GLP-1 Side Effects, Risks, And Who Should Actually Be Using It | Dr. Christle Guevarra

Throughout various parts of my life, since I can't figure out this whole calories fat loss thing down, I am just going to focus on weight and find, you know, joy in taking ownership of the fact that I can lift something heavy. It gave me a lot of confidence that I couldn't get from hunger, fat loss, you know, losing weight. We are alive at a time that the landscape of medicine has changed. GLP1s have been around for a long time, but they haven't been used. They have not been FDA-approved for weight loss. There has never been something more effective than these medications. I feel like there's still a lot of a disconnect, especially with the way medicine traditionally is set up. Sometimes it can get a little hard to help with the behavior change aspect of the GLP1 use. And so I find that there are still a lot of people who are struggling with how do I eat, how do I exercise. It seems like we could do a little bit better in providing that support when it comes to the behavioral change part. What are some of the biggest challenges that they come in and say they've struggled with? When somebody's eating to get in as much fiber to feel satiated and they still don't, I have to wonder, is that... Dr. Christel, welcome to the show. Thank you so much for having me. Now, you're a family physician and you also train in sports medicine. You are educating a lot on the use of GLP1s, which we are going to talk all about that. We're going to talk all about fat loss. And you're very interested in muscle preservation as well as performance. Correct. That is correct. Take me through what you are seeing right now in the landscape. GLP1 use, it seems like there's a lot of good things happening and there's a lot of things that I'm like, who we could do a little bit better. There's a lot more emphasis on resistance training across the board, which is obviously I... That's always awesome. And so women, I'm seeing a lot more women in the gym, physically. So that is also amazing. And a lot more patients are just receptive to the fact of like, oh, I don't want ozempic butt. So I'm going to get into the gym and lift something and challenge myself. I feel like there's still a lot of a disconnect where, especially with the way medicine traditionally is set up with clinic, with checkups once every four weeks, three months. I think sometimes it can get a little hard to help with the behavior change aspect of the GLP1 use. And so I find that there are still a lot of people who are struggling with, how do I eat? How do I exercise? I just take this shot and I kind of, I have these side effects and I'm going to wait X amount of weeks till my next follow-up appointment to bring them up. And so the medical system in which we're kind of in the traditional practice model just doesn't seem like, it seems like we could do a little bit better in providing that support when it comes to the behavioral change part. And you've actually been really public on your Instagram, social media, talking about your own journey with GLP1 news. Do you think that obesity, five years from now, not even 10, do you think we're still going to be struggling with obesity? I think we're going to be struggling with it a lot less so. I think there are still going to be people who are hesitant to take these medications just because of whatever, you know, this, it still feels like too good to be true because we have a longstanding history of diet medications that have not been so healthy for us and, you know, have been recalled by the FDA back in the day, the rainbow pills in the 1950s and 1960s. So, you know, people still have that hesitation towards, you know, drugs that are, you know, FDA approved and people, you know, will still hesitate. But I think overall population-wise, I think that obesity is going to decrease. And again, you train in sports medicine, family medicine, you were on the front lines. There has never been something more effective than these medications. Correct. This is a new, this is, you know, a new breakthrough and it's only going to get better, especially with the drugs that are still in clinical trials and they're coming down the pipeline. But, you know, after semaglutide, ozempic, Wagovie came, you know, became FDA approved for chronic weight management, it's just been, you know, it's just only going to go up from here. And I think that brings us how many generations are waiting now, so that we're in, is this now we're into the third generation? I think so. Right at true tide. Right at true tide. Yeah. And that's in phase three trials. Correct. And what I understand. Correct. The GLP ones have been around for a long time, but they haven't been used, they have not been FDA approved for weight loss, but they were used for diabetes. What was what was it FDA approved for? It was for diabetes, right? Originally it was for type two diabetes, and that was in 2005 with Bayetta. And that was a twice a day injection. The, and if you take a look back, they were noticing some changes in weight loss, but it was somewhere along the order of five pounds in the air. If you look at actually look at the graph in the, in the paper, the error bars are just all over the place. And it was not nothing spectacular. And I think it was sexendo. That was in 2014. That's right. But again, the weight loss aspect was also still not that impressive and you had to inject every day. So we use sex on it in our practice when that came out. It was again, it was the best that was available, but it was not, was nothing like the GLP ones. Every simple time I tried to get that approved insurance just denied it. So I just stopped eventually trying at least and you've been someone who's been fit and training. Have you been fit and training your whole life? I've had some periods where I was not so, not so mindful of my diet and exercise and, but overall over the course of what the last 40 something years, yeah, I've always at love sports. I was always very competitive. So, you know, whether it's in the classroom or in sports, so I've always been active for the most part, you were doing competitive, you know, competitive powerlifting. How was that? It was good. It gave me a chance to start lifting weights and throughout various parts of my life, adult life, I felt like, okay, since I can't figure out this whole calories, fat loss thing down, I am just going to focus on lifting weights and, you know, I get my confidence or find, you know, joy in taking, you know, taking ownership of the fact that I can lift something heavy. I'm competitive. I'm okay at this. And I'm having a really good time with meeting all these people, you know, at these different meets and training, posting my training online on these forums and meeting people. So it gave me a lot of community and it gave me a lot of confidence that I couldn't get from, you know, hunger, fat loss, you know, losing weight, you know, because I couldn't get that part of the equation down. So I'm just going to focus on this for a really long time. As a fellowship trained physician, it was hard for you to get your macros on your nutrition under us. It was the calories. It was a big thing. Yes. And compared, so you who were so highly trained and you're doing a fellowship, for you, it was difficult. I can only imagine what someone who didn't have your education, the resources, how difficult it's been for people. Yeah, I almost felt like even more guilty about it because yes, you are, I am, you know, I'm in medical school. I'm doing all these things. I'm taking care of patients. This seems really easy. Why can't I do it? Like what is wrong with me? So I took it, I literally for decades took it as like this moral failure on my part. Like I'm just not trying hard enough. I must be doing something wrong. And maybe if I do this XYZ thing, you know, maybe this will help. But I've dieted myself to to the point where I failed medical school anatomy the first time and I had to retake it in fact in the early. Okay, wait, tell me more. Tell me more. Oh gosh, I was working with a coach who, you know, gave me my meal plan instead of macros and it kind of was around 1100 calories, five 45 minute sessions of cardio a day. We're humming five, five a day or no five a week. Okay, by the way, I was like, there's no no, no, no, no, excuse me. That would be impossible for anyone lifting four times four four times a week. And and then yeah, eating this X amount of calories. And at some days, there were no no carbs. So it was just protein and fat. And I, you know, I felt like garbage. I did not and I had entered medical school. Summer anatomy, it was the and of course it was summer anatomy for all of the overachievers who wanted to take it first. And then in the fall when the rest of the med students come in, you can be a TA and you can put it on your resume and get paid. And of course, I was going to do it. I couldn't sleep because the hunger pangs were so intense, I could hear my stomach growling. And then I would come into anatomy lab, just a zombie trying to figure out what muscle is what. And I'm just like, I don't know because I'm exhausted. And you know, my neurons are just arguing over the last calorie. And so yeah, I failed by a couple of percentage points. And I just remember feeling like, wow, I can't die. I'm nowhere even close to being lean. My, you know, lifts are all in the tank. And I just felt like I had to willpower my way through it. And I failed anatomy. Like this is like the worst way to start off my medical training. And so yeah, I learned a whole lot of things from that experience. But for somebody to say that, Oh, you just didn't try hard enough. I just want me like, let me tell you, we tried, we really tried. It's interesting though, because we are seeing two sides of the story. And what do I mean by that? People will say the people that don't use GLP lines are saying, okay, well, if you use it, you're cheating. And as someone who was struggling with it and who tried, I mean, is that your perspective? Oh gosh, no, I think it's, it's an amazing tool to you and we have in the toolbox. And it has allowed not just for myself to thrive so many other people, couldn't find, they just were struggling to even get out of bed and get to the gym and found that, you know, some days, like after starting this medication, yeah, their, their weight started to go down, but they also found the motivation to make it to the gym and start doing the things that everybody's telling them to do, like, we need to eat less, you need to move more. Well, some people are still so stuck in a loop of, you know, dysregulated hunger, feeling depressed, depressed and guilty, because why can't I just do this thing? And here is this medication that shuts off that food noise that persistent, like, drive to think about food, that they can actually focus on the tasks that they need to do, their quality of life just goes up and it only goes up from there. And it's amazing. And the other part that I think that we're seeing online is who gets it? Who deserves, for lack of a better term, to be able to utilize it? Yeah. And, you know, I'm so glad we're having this conversation now and not what four years ago when the shortages were, you know, apparent. And so you had people with type two diabetes, you had people with obesity kind of fighting over like who really deserves it. The, you know, the technical FDA cutoff is over BMI over 30, you know, and then BMI over 27 plus, you know, some comorbidity, like blood pressure, high cholesterol, the kid syndrome X, right. And sure, like that makes sense. There is a little bit of wiggle room, because I think a very common question I get asked is like, what about, you know, somebody with a BMI of 26 or, you know, because it's overweight, but it's not in, you know, normal BMI calorie who might be struggling. I think there is some gray room. And, you know, in medicine, there's, you know, there's the, there's an arc to it. So you have to think about somebody's diet history. And then why did they fail? Why did they struggle? And, you know, are they having persistent food, you know, thoughts about food? Like what happens, you know, 10 weeks down the line or 12 weeks during a diet? Like, do you, you know, do you just stop working out? Do you, you know, are you binge eating or whatnot? Like you have to ask these detailed questions about why it is, you know, why did these other things not work? And so, you know, it's not just a numbers game whatsoever. I mean, totally agree with you. We also know that BMI doesn't tell us anything about the body composition. For those of you who are listening, you all know what BMI is, body mass index, it's really used or had been traditionally used for insurance to determine outcomes potentially, but it doesn't say anything about your body cut percentage. Yeah. And your percentage of muscle mass, both of which are much more relevant. Yeah. When it comes to assessing health outcomes. And then the other thing is as physicians, who is it to say for us to say if a patient wants to try something? Yeah. And they might not meet the criteria from our perspective or from a BMI number or even a body fat percentage. Right. And I'm not saying that their body fat percentage is 18%. Yeah. But let's say they have struggled with the same five to 10 pounds. And it is causing them so much grief. And it is consuming them. Yeah. How is that for us to say, well, continue for another five years to try X, Y and Z, but this person who is 20 pounds overweight, they deserve to have it. Exactly. And that's the part that's, and I've had somebody ask me that before. And I didn't have a really good answer. And I was like, that is actually a really good point because we don't, it's not like, oh, your A1C is 6.5 therefore, you definitely deserve. I think there is a gray room because there's a lot of people, a lot of the things that I have picked up from the fitness space, make sure you get tons of fiber or make sure you eat lean protein. Well, when somebody's eating a whole bag of frozen strawberries and a whole bag of frozen broccoli to get in as much fiber to feel satiated and they still don't. And they're still trying to pretend like this food, like they're not persistently thinking about food. I have to wonder, is that person, would that person benefit from a GLP one versus trying to employ all these other things? And I don't know. So if it were me, I would say yes, they would, even if it's not to the full dosing, right? There's ways in which we use medications off-label all the time. And then we're starting, I'm sure you're starting to see the data emerge that is helping with addiction with alcohol usage. Yeah, anecdotally, and yes, I have started to see that. Anecdotally, I find that people are just not really wanting to drink, or if they do, it's a lot less than what they used to consume. And it's hard to say whether or not that comes with the, also all the other behavioral changes or not, at least in my patients, because that it's all in one. I can't separate the two. Cigarette smoking, anecdotally, seeing a lot of people who are like, eh, I don't really want that as well. You might be wondering, why are you wearing a robe? Well, thank you to one of our sponsors, Cozy Earth. And when we talk about health, everybody wants to jump straight into training and nutrition. But why wouldn't they? But let me ask you something. How are you sleeping? How are you recovering? What does your environment feel like when the work is done? Because that, my friends, is where real restoration happens. And I'll be honest with you, I didn't think a robe and slippers would be part of my performance strategy, yet here we are. 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I mean, it's pretty extraordinary. Again, think about we are alive at a time that the landscape of medicine is changing. When I was doing my fellowship in nutritional sciences, the big thing was bariatric surgery. They were doing bariatric surgery because these medications, so part of the job is a fellow in church, I mean, you've had to work games and what was so you guys listening in fellowship, each fellow is responsible for it's typically a clinic within that specialty. And for nutritional sciences, because I did a combined nutritional sciences geriatric fellowship, for the nutrition part, I had to run, I got to it was actually amazing, run a weight management clinic. It was a weight management clinic. And this was 2015. Mm hmm. JLP ones were not approved for weight management. Oh boy. These people struggled so much, yeah, that many of them would end up doing bariatric surgery. Oh, the outcomes for bariatric surgery, whether it was banned or ruined, why they're not good. Yeah, I mean, the immediate weight loss is impactful. But the secondary complications with gastric emptying with nutritional deficiencies, it seems as if a lot of people end up reverting back. These medications were not FDA approved or used. Now, we're in an entirely new landscape that is taking away, I mean, if someone were to choose bariatric surgery or a GLP one, I mean, this is a new landscape now. Yeah, the approval process, the surgery, like surgery itself is a risk factor. And especially for somebody who is obese, the anesthesia, you know, having to intubate them to get surgery, all of that has complications. And so yeah, I would, I would honestly have them recommend, you know, let's see what all these medications can do first. And then if all of that fails, which I know, I haven't come across a patient yet, where medication has complete, like we have a couple of different choices other than GLP ones, where we need to start thinking about surgery, something a little bit more extreme. Do you think that meaning they failed GLP ones? Correct. How often do you see that? I don't see that quite often. The more typical scenario that I do see is insurance, you know, comes in and says, we're not covering this or we're only covering this partially or your insurance has changed. Congratulations. So let's figure it out. Are your patients maintaining the use of GLP ones? So some of the recent data that I've been seeing is that the typical person will stay on a GLP one for two years and that 70% come off after two years. I have seen some of my patients come off of it mostly because of insurance reasons. And they're still able to maintain. It is definitely a lot more a bit more of a challenge than when they were on it. But they, you know, the behavioral change part, the lifestyle part is so important. And having that support system is also, I think, is pretty much key to maintaining that and keeping regular follow-ups. So and I've seen other other people who've shared their stories with me online where they've come off of it because they wanted to and are still thriving and still doing great. So it's not like you are doomed for life, but for some people, you know, even for myself, I probably will be on it for life. And I'm okay with that. It's not a moral failure because it's improved your quality of life so much. Yes. Gosh, it's not and it's not just the physical aspect of it. It's a lot of people when they describe the like the first time you start on the medication, it's like this light bulb went off in my head and everything just went quiet. And now I'm able to have a conversation with you. Like if we would have had a conversation five or six years ago, I wouldn't be able to pay attention to you because I would be thinking, gosh, I'm so hungry right now. The lights are so bright. But like I don't I'm really embarrassed. I don't want to admit that, you know, I have a problem thinking about food all the time. And it would just be like this spiral of despair going on my head. And I would just smile and nod and be like, everything's okay. And everything's not okay. And so it's really given me the space to think about how I want to show up in this world, how I want to live my life. Who am I talking to? How am I talking to you? And just really gave me a chance to do a lot of self reflection. Is that why you were able to be more public about it as opposed to not necessarily share your story? I think it was a combination of that. And just being in in my 40s and, you know, perimenopausal, I think there's also that shift to where it's like, I just don't like, you just stop caring what other people think. And I think about all the struggles that I've gone through, trying to lose weight over the course of decades. And if I can help one person, you know, not feel so alone in, you know, in all of this, like, I feel like it was worth it. It was worth whatever it is, the, you know, internet has to throw at me. Hopefully good things. And also, at this point, it's if it's good, if it's bad, it's this is the new world that we live in. But one of the things that I really respect about you is that you are a trained physician. Now, it's also what we're seeing in research that there's a lot of filler information. People don't know where to go for good information anymore. Someone could have a doctor in front of their name, and it might be deeply misleading. Maybe there are, I don't know, a doctor, a botany or something. And there is something to be said for a trained medical provider that has studied general health, family medicine, sports medicine to be able to make informed decisions. There is something to be said about having that base time in the clinical hours. Because if there's one thing that I took from family medicine, my and sports medicine training is there is just this deep intuitive sense that you don't get until you get, you know, face to face time. And the times where I have nailed a zebra diagnosis or, you know, some like life or death situation is not because I had the answer, like I memorized the book, or I read some, you know, study on PubMed. It's because I looked at that person, I was listening to them. And it was like something just seems really off. And I'm not sure why. So let's get this ultrasound, let's get this MRI and let's go from there. And, you know, sure enough, you know, some athlete with a leg clot, a blood clot or something like that. And it's just something just is telling me that like this, you know, this isn't normal unconscious competence. Yeah, the unconscious competence. You mentioned perimenopause. Yes. How is that changed your perspective on hormones for yourself for your patients? Oh, my gosh. So that was definitely an experience that has really got me thinking about, you know, all the other physicians in the forefront of hormone, merit peri, metapausal hormone therapy, just because I had no idea it sort of blindsided me. And I was like, what is going on? All of these symptoms were some of them. She's like, what? What were they? At first, it started off really just sort of I didn't, I wasn't feeling like myself. It just the word forgetfulness. And it was very similar to the word forgetfulness I had when I took, when I was prescribed a medication off label for weight management. Topomex. Is that limit? That's limital, right? No, toparamate. Toparamate. Yeah. Very similar to that. And I was like, I'm not on that medication anxiety that worsening anxiety, I would wake up and just feel like the world is coming to an end. That's called parent. That's five, 45 in the morning. Let me just tell you insomnia, the hot flashes. And then I would get this awful like neck rash on top of it, eczema in my eye that just never appeared. And then finally, the genital urinary symptoms was like the last straw. That was when the work out for the thyroid, the heart, all of it came back normal. And at the time my provider said, you know, everything's normal. And there's nothing I can do for you. Those were the last words. And I just remember thinking, oh gosh, well, I still have all of these symptoms and all of this other stuff is normal. So we're not going to do anything. And I think as a provider, especially as somebody who is a primary care provider, but if everything came back normal, sort of my response would be like, let's figure something else out. Absolutely. Let me send you to a specialist. Absolutely. If I don't know if it's this, let's send you to a specialist. And so I really, I thought about that. And then I remember, gosh, I can't remember, for those Rachel Rubins, big podcast talking about this and thinking about it in terms of sending grandma to the hospital with your osepsis. And I just thought of all the admissions that I had to do as a resident, you know, grandma with, you know, altered mental status from a UTI and thinking about how many times could I have prevented that? I think that for me was the kicker. And I was like, I need to get my CME up. I need to start really like, hey, we need to just be vigilant and thinking about these things. Early late 30s and just asking those questions, how are you feeling? And, you know, if it's not this, then we need to find other answers. But again, this is the changing landscape because before the Women's Health Initiative, from what I hear from the older providers, they were all prescribing hormones. Yeah, there wasn't any reason why people weren't, for the most part, it was very ubiquitous. And then of course, the Women's Health Initiative came out and it seemed as if overnight people stopped prescribing hormones. Yeah, I didn't, I was not really a thing when I was being trained as a family medicine physician. And so now I'm like, I got to catch up, which is great because I think they put it in such a way that like, we are physicians, we have prescribed medication before these are not, these are not scary medications. In terms of fat loss and weight loss, what is the rate for your, your patients that come in and you're like, okay, we're going to go and we're going to try to lose X number of pounds in totality. Or do you do it that way? Do they have a goal for if they're going to lose 20 pounds and how they're going to do it? So I, it really, it does depend on what they're starting, what we're, what we're starting with. But I do tell them that like, if the goal is 20 pounds, and that seems like a reasonable goal, we may not do it all in one shot. Because I also want to make sure that we are thinking about what happens after the diet. I also want to make sure that I'm not missing any diet fatigue markers, like poor sleep, poor performance in the gym, because that can come crashing down depending on what their life situation is like. And so I don't want them to feel like I have to burn, I have to get this off, you know, now, I want them to start thinking about this in terms of, this is going to be a lifetime thing. So it didn't take you, it took you a long time to get to this point, like there is no rush. I want to really get people feel as if they have to rush, get it done, do it right now. And the reality is, many people struggle for years, take a step back, going a little bit slower, reorienting ourselves to wherever the goal is, makes a ton of sense. Yeah. And I find that it's a lot, a lot more sustainable. You know, getting to the gym, lifting weights, meat, you know, cooking, meal prepping, cooking, whatever it is, and figuring out how is that going to look for you? How is that going to look for your family? How are they going to be involved in the process? Are you prescribing JLP ones? Okay. Yeah. Take me through your decision making process. Again, we understand that you're not the listener and your patients are listening, but again, we're not giving medical advice. And here she is. But there's going to be some decision making protocol that you go through in your mind as opposed to, okay, a patient comes to you and is like, Hey, I want to go on JLP one. Yeah. Tell me, tell me why and tell me through, take me through your, you know, like diet history, have you tried losing weight without a medication before? How has that been for you? And what are you currently doing right now? Take me through your day. Because I find that that is a much better way of trying to get some information, because I find that patients are very well intentioned. They really want us to, you know, to not judge them because it's a very sensitive topic. And so I get a lot of, you know, I just don't understand. I'm eating chicken breast, you know, and I'm eating fish. And then, you know, for dinner, like I don't snack. And I'm like, Okay, that's really awesome. What was your last meal? Like before you, you know, before we had this conversation, take me through that. And then take me what happened, what did you do when you woke up? And so the conversation then becomes, you know, I'll start thinking about like, what are the major themes of, you know, why things didn't work? Is it because, you know, Oh, I had, you know, this life event that happened, or am I having persistent thoughts about food, you know, at a certain point, or do you think, how often do you think about food? Is it like something that's, you know, ongoing in your head? Like how do you feel like, you know, it's impacted your quality of life, your job, your relationships from there, just thinking about like, you know, if that is the case, maybe we can start thinking, I think a medication would be very helpful. What are some of the biggest challenges that they come in and say that they've struggled with? I would say this doesn't come up as soon as they walk in. I think after a while, I start to see themes of, I take care of everybody else, and I put myself on the back burner. And it's not just with the kind of physical aspect part, but emotional. They have seemed to be providing for everybody else, whether it's financially, whether it's relationships, whether it's emotionally, and trying to find the words to kind of stand up for themselves and say, like, I'm not okay with this, or I'm not really comfortable with this conversation, or I don't appreciate being spoken to like that. Those come out later. But you have to stack up these little wins for them to get the confidence to branch out and think about how is this relationship kind of affecting me? And is this now net positive now that I start, I'm starting to take care of myself, and I really like myself, and I really like this new me, this new life, this new identity, right? It's so transformative for people. And again, if you're listening to this, we're not saying that you have to use a GLP on or you don't have to use a GLP on, but just as a very broad overview, it allows people to choose as opposed to before oftentimes, and again, I ran a weight management clinic, they didn't have a choice. And what do I say they didn't have a choice? It appeared that food was running their life. No matter what they did, they couldn't get ahead. And so these medications now allow people to step into a new version on themselves. And then their life's changed. So there's two things that I see to experience with the patients is that on one hand, they are uncomfortable with their weight loss or uncomfortable with just this new version. And they might sabotage themselves. That's one group. And again, it's not Black or White. And then the other group is they really transform their lives and their relationships change, their friend groups change, everything it's almost as if they're on this rocket ship where now they get to make these choices. Yeah. 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 self. 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. 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What the science versus hype in terms of GOP ones, you'll hear GOP one medications. At any moment in time, you will hear about all the negatives. Right? Oh, yeah, they're gonna get pancreatitis, thyroid cancer. It's gonna stop your gastric emptying. Okay, so tell me about some of the the actual risks versus the perceived risks. The pancreatitis thing is a very low absolute risk. And anecdotally, I will say I have a colleague whose patient did end up going to the hospital from pancreatitis and still managed to text, going to the hospital for pancreatitis, GLP one is still worth it. But honestly, though, when we talk about quality of life, the person is still clearly having a very serious event and is still making that choice of like, this is still a net benefit overall. So, and who am I to argue with, with somebody who says that? But again, the risk is low. It's serious, but when it happens, but it is very low, most commonly nausea, vomiting, constipation, diarrhea, or the most common symptoms, and those can be managed with expectations, with making sure to not crash die and making sure to stay hydrated. And they tend to go away over time. How long does it take for some of the symptoms to reside? For some people, it can take, you know, weeks. For some people, it can take a few months. And I think it's really, I don't have enough of a kind of, you know, general enough of a kind of N to generalize like how often, but it can vary. Yeah, we see that in our, our clinics, we have a telemedicine clinic, it's called Strong Medical, which because obviously muscle is the most important organ, although we've had urologist on the podcast, they think that it's something else, muscle and fat regulation and the use of these GLP ones. This is again, more of a conversation. Do you want to touch on the rate of muscle loss or muscle loss with GLP one medications and counterbalancing? You know, the rate of muscle loss and with these GLP ones, I'm not too entirely familiar with the, the exact numbers on it. Honestly, with the, as long as you are actually resistance training and keeping your protein intake reasonable, you can really avoid all of that. And you can actually, for somebody who's relatively new to resistance training, and actually get some pretty decent recomposite body recomposition in ways that I'm just like actually sort of like even more surprised to myself because for somebody who's never gone to the gym, I will give them something very easy to do, like three sets of 10 to start off with and only because 10 is an easy number to count to and watching them sort of progressed from there. And as long as they're consistent, you can get a whole lot out of for a while before you have, you know, start thinking about like, let's move on to like a more, you know, advanced protocol or start thinking about all these other chains. Like, no, you can just, we can just stay here for quite some time and milk these sort of newbie gains out before we need to start thinking about anything else. Meeting in terms of adding more complexity. I would rather have somebody go to the gym consistently, then really start thinking about like, oh, do I need to be on this program or do I need to be on that program? Yeah, we could talk about that. Let's build up some, you know, consistency first, and then let's think about, you know, something a bit more advanced. What was the biggest or what has been some of the biggest surprising features in the use of JLP1 and training? The way in which it calms down sort of this persistent thoughts about food in a way that's completely different from a stimulant like Fen Fen or using caffeine. A fedra. Yeah, a fedra. It's just, it's so different. It really is just like, you know, there are times you have to be a lot more intentional about your nutrition, because you, people can't, and I've done this a couple of times where it'll be 3pm and like, oh, why am I, why am I lightheaded? Oh, I haven't eaten. I should really think, you know, and I, next day, I'm like, I really breakfast, breakfast and make sure I eat that and make sure it, you know, I fuel myself so I don't end up in this situation. But so many people have ended up in that sort of similar situation when you have to think about your food consciously versus, you know, before the medication when you've got, you know, food is just taking up all that space in your brain. In terms of the protection of muscle mass, the data doesn't show that there's something inherent to the JLP1 that's negatively affecting skeletal muscle mass. Honestly, if you look at some of the other bigger data sets, I think it improves muscle quality by decreasing this intramuscular adipose tissue, this intramuscular fat. Again, you get that from training. Yeah. But there's something, I think we're going to begin to see more positive effects on muscle versus any kind of negative effects. Do you always talk about training with your patients and, and or provide them with some kind of protocol? Yeah, I do. I, it's one of the very first things that is like part of the kind of things that I tell Dr. Crystal, even get jacked. We're going to at least, we're going to at least do our best to be always talking about how important resistance training is. And I think it's also because a lot of people just have busy lives. So, you know, versus cardio, there's nothing wrong with cardio. I love cardio. How much cardio are you doing? Am I doing personally? She's like, none. I, well, I do train jiu jitsu. I do a lot of nogi. So it's a little bit more faster paced, a lot of like wrestling takedowns. And so you do need to be in some a lot more of a cardio shape to handle that kind of sport. So I do that twice a week, but one of the days is a two a day. And so I'd say one, two, three, four, about five hours of that a week. Amazing. And that's what you use for cardio. I do. When you are using a JLP one, and obviously you're a macro intake is probably much lower, your total caloric intake is lower. Do you find, and you also work with the athletes as well? I do. Do you find that their performance decreases with JLP one use? I think it really depends on what their diet is looking at what their diet is all about, because not everybody who's on a JLP one is necessarily like trying to lose fat. There are times where people are on a JLP one and trying to maintain whatever their body weight is. And I find that, you know, if they're in maintenance, they're, they do just fine. There are some very mild mild trade-offs deficit and trying to do a sport or, you know, or whatnot, but overall, it really depends on the calories and not necessarily like the drug itself. That's an excellent point. There is somewhat of a discussion that people seem to be either for or against, such as the way of the world now it is, but it's either they're just really on board with JLP ones or they're not. And it's the decrease in potential performance is not necessarily related to the drug, the mechanism of action is to what this drug is doing to tendons or flexibility or any of these other, you know, markers of fitness or the requirements of fitness, but the decrease in total calories. Who would you not recommend having these medications? I mean, somebody who I'm concerned with anorexia, but that seems pretty, that seems obvious. I, yes. But also, it can never be too obvious. It can never be too obvious. The, I'm trying to think of all of the concerns from the social media community about, you know, what to look out for for eating disorders, thinking about somebody who is excessively exercising, somebody whose calories are already pretty low. That would make sense. Yes, but it seems to make sense. I'm just really struggling to find, you know, maybe that population just hasn't, I haven't come across to any people in that population group. We don't actually get those patients either, but then again, we much less likely to prescribe some of those kind of going down that resistance range is a non-negotiable career. When you have patients on the JLP ones, what are the markers that you are seeing change the most or that you're looking to see change in terms of blood work? Total cholesterol, LDL typically goes down. I do see improvements in A1C for, you know, I do have some people who have, you know, who are, I prescribe it for weight management, but also they have diabetes. So I am seeing improvements in their blood sugar. Their sugar, sugar logs overall, just with the resistance training alone has been a huge help. And so I think that's, you know, really about it. I don't pay attention too much with any labs beyond that just because whether it's an insurance issue or whatnot, because I start having to thinking, I see, so you're very strategic in terms of the cost. I see the profile. We see changes in triglycerides. We see decrease in fasting blood sugar. We see changes in insulin sometimes we see lower levels of insulin. People of A1C, what else? You know what else that we're seeing anecdotally? A decrease in inflammatory markers. So I think we're both in favor of JLP ones. So maybe it's a bit biased, but also we've also worked, I mean, I've worked in weight management and we've seen medicine for, I don't know, I started studying nutrition almost 20 years ago. Yeah. And I will admit, I do have a bias because of my own experiences struggling with this. I am biased in the sense that I probably would lean more towards prescribing this medication than trying to gatekeep just because of what I've experienced both there and then also in the fitness space trying to do all the lifestyle things, which are important. It's non-negotiable because the medication can quiet the noise that affects the brain, decreases gastric emptying, can improve insulin sensitivity. However, you can't just go eat Cheetos and drink Rippets. Oh gosh. Now I feel like people who've actually done that have ended up getting sick and then you're like, okay, this is a learning lesson for sure. Like we need to start being way more intentional about our nutrition. And there are times where I've had to act more, like I feel it more like a mom, a nagging mom than I do a doctor where it's like, hey, let's get some goddamn fiber in here. Let's get a fruit. Let's get a vegetable in here. How can we make this? Dr. Dubey is just, she's driving the hammer. What is the minimum amount of protein that you recommend for your patients? So what is it? The 0.8 to 1 gram per pound of ideal body weight? We say 100 grams. Yeah, less than 100 grams. Yeah, I guess so. That really does turn out to be such that. And then from there, I'll try and figure out what meals or how do you actually cook your meals and then trying to figure out what can I swap in or give them sort of, here are some proteins to choose from. And let's start there. How does this go? And sometimes they'll text me from the grocery store like, hey, how does this look? I'm like, patients, you better not be texting Dr. Crystal because you just better not be doing that. I'm kidding, my patients. What about supplementation? Do you utilize supplementation, especially with the use of GOP ones? And if calories are down, total food consumption is down. I think especially at first, the overall food is down because they're thinking about the nausea and whatnot. Eventually the food volume does go up, the hunger sort of returns. I keep it very simple, especially for resistance training. I'll have them try creatine. How many grams? Gosh, five, five grams. My dad's really big into creatine right now. We usually recommend between three and five for muscle and then 10 to 12 for brain help. Okay. Okay. My dad's like, I mean, listen, my dad's major placebo and he does listen to this podcast. But anyway, what we're seeing is that for cognitive function also perimenopause. Yeah. So creatine is one. Creatine's one, a multivitamin just to make sure you're covering your bases. And then from there, it really becomes what can you afford? What are you interested in? And then becomes a conversation because I do find that I want to be very mindful of financial costs as far as risk-benefit, pros and cons. Have you always been like that with the patients? I have. And I think my personally just coming from a child of immigrants, I just am always thinking, I bet it is always something that I'm thinking about. How can I make this work on a shoestring budget? So there are times in medical training where I've tried to shop, like, see how few dollars I can spend, whether it's chicken breast versus chicken thighs, whether it's oatmeal as a source of carbs, thinking about frozen fruit because fresh can sometimes go bad, thinking about what is available through SNAP, you know, EBT. Which by the way, what is going to be available is changing now. Yeah. What do you think about this new food guide, food guidelines? The, I'm still really can't get past the destruction of my plate. I'm still very like, it was just very easy for me. And I have, you mean, you could still use so in, you could, you could. You saw that forever strong. I know, I did. And I was like, the plate plate plate. Right. We kept the plate because, you know, from our perspective, the, you're laughing, but we see patients. And so, first of all, I love the new guidelines. And also Don Lehmann and some of my colleagues wrote the guidelines. I am completely biased. However, all the signs is available. So good. Meaning if you go to the website, you can see that where they chose the data is transparent. It's not epidemiology. They only use randomized control trials for you guys listening or watching this at home. Why that's so important is because in the past, it's always been epidemiology, which is low quality data, which should only be used to pose a hypothesis, not to make broad public generalizations and implications on public health. So I'm very excited. I heated to cut you off there, but no, no, no, no. Tell you about him, which I love these dietary guidelines. The dietary guidelines are great. I am very upset. I think I'm way, way too more upset than I need to be. And it's just, I have so much emotion. It's just, I couldn't, I was like staring at the screen, like, where is, where's the cutoff with the lean meat and the oil? And I just couldn't see that. Is it, can we touch on that? Because that is, do you want to share what your perspective is on that? And I will definitely love to share. I just, I literally just, I have a really terrible eyesight in general. And so I was in the club growing more lutein and Zia's anthins and vitamin A. We're all in trouble. So, yeah, I don't know if you have any insight on who designed the graphic. So that part I don't. But what I can say is that the 10% saturated fat is, we need more data. We need more research. Should it be 10% saturated? There's no evidence that it should be 10, that should be 15. We just don't have a lot of data. And I think that it is a challenge because the 10% has been there for so long. So basically the food, the new food pyramid, the upside down pyramid keeps saturated fat at 10%. What that does, however, is we'll number one, we don't have data to change that higher or lower. We had Dr. Tom Brenna on the show. He wrote the, he's been on the last three guidelines. He wrote the fat part. We'll have Kevin Mackie, he's been on the shows coming back again. And these are fat, these are fat experts. There needs to be more research. And I will say something else that blew my mind is that the saturated fat recommendation came from a hydrogenated whale blubber during times of war when they needed to feed people. It wasn't meant to be used. This hydrogenated oil wasn't meant to be used, but the studies in the 60s grouped this hydrogenated whale blubber and called it saturated fat. Oh gosh. That they were then subsequently saying that that's bad, but hydrogenated whale blubber isn't saturated fat. I just wanted to throw that out there that again, this goes back to us believing, hearing something, no matter how many times we hear it, we believe it's true. Yeah. Even though there is an evidence for that. I don't have too much of an opinion on the new dietary guidance. I do like the increased protein recommendation. I just, for the patient sitting in front of me, how is that? That is when I think of how is that going to affect the person sitting in front of me? And I can't really think of too many things that I would change when it comes to how I approach my patients with these new guidelines. But the good news is you've always been interested in nutrition. Yes. But most physicians are not really providing nutrition care, which it seems a bit counterintuitive, especially primary care. Typically family medicine, primary care, we see kids, we see all ages. And we're not trained typically, the training doesn't involve nutritional science training. But if you think about things like elevated levels of triglyceride, this is a carbohydrate problem. Elevated levels of cholesterol. This, for some people, it's a fat problem. For some people, it's a calorie problem. And for some people, it's genetic glucose. There's all these direct relationships to nutrition. And the training has to increase. And there have been times where protein, like plant-based, meaning just eat plants and pay no mind to the protein. So I know... Said nobody ever. Some people have it. Why are we doing this? Protein is an important part of this. And so I think that's why this pendulum kind of swung me other way with like, we have to put protein in everything. Protein on our popcorn, protein on this and that. Very misleading, isn't it? Yeah, exactly. And I find that I think that it's going to shift once again, because I think social media is now tired of protein stacks and everything. Crystal, it's so disappointing. So we've spent 20 years talking about protein. Now people are caring about it. And now it's getting a bit overblown in the way that protein should be in coffee and popcorn. And it's ridiculous. And it's a protein dilution, because it's not, number one, it's not a threshold amount. Number two, you're just getting extra calories from protein. Okay, fine. So if that causes the pendulum to swing the other way, it's we're going to be constantly doing this back and forth. That sets us up for failure. Yeah. I still think it's the most important macronutrient. I do too. And there are times where people can't get to a quality meal, healthcare workers. We're actually technically not supposed to be eating while we're at our desks, but we buy them. Is that true? I wonder why they kept kicking me out. No, it's good. There were times at the hospital where we had to hide our food, because we weren't allowed to eat the desk and type our notes at the same time. Oh, I remember that. Wait, wait, you did your residency. Where did you do it? The Philadelphia suburbs. Okay. So right outside of Springfield, which is right outside of Philadelphia. And then one of the clinics was in Upper Darby, which is you got to go through West Philadelphia to get there. Is that unsafe? I wouldn't go walking around there at night. So who's she got her maids, right? I mean, that's legal there, but I live in Texas. So there's all kinds of things that are legal here. And then your fellowship was in Vegas? Yes. Tell me about that sportsman instant fellowship. That was right when COVID was happening. So wow, we had sports. They were just a little truncated. And then all the rest of the sports from fall were sort of pushed into spring. And so got to work, you know, still managed to have a really good year working with football players, working with all the collegiate athletes, you know, some pro athletes as well. And then I was thinking about, you know, I have all this free time, free time. Let me start looking at and looking at EKGs and athletes pre and post COVID to see if there was anything significant. Because I know that when COVID first came out, we were really worried about the effects on the heart and all this other stuff, at least for very healthy athletes. I'd have to go back and look at that paper. But I don't think we saw anything too, you know, concerning, because you're already starting with very young, healthy athletes. COVID, you know, it was a very is a very serious disease. But in that population, it's like, you're already at, you know, you're healthiest, you're young. And so as expected, you know, didn't really see any too many changes. That really kicked everything off. Yeah. In a very interesting way that I don't think anyone has seen in decades and decades. I'm thrilled to announce one of the new sponsors of the show. And that is the Carol Bike. Now, if you've listened to the show, you know that I believe muscle is the organ of longevity. And of course, you need resistance training, but you also need high intensity interval training. And I would say nothing improves cardiovascular fitness, like a targeted program and tool. And that is why I'm so excited about the Carol Bike. It is an AI powered stationary bike that delivers, get this, a scientifically validated, reduced exertion, high intensity interval protocol in just 20 seconds to 20 second, all out sprints, all of this in under five minutes. And this isn't random hit. It's resistance that adapts in real time to your output. So you get precise and personalized stimulus to improve your VO2 max, which is one of the biggest predictors of mortality. And listen, we've all cheated ourselves, our efforts on the treadmill, and maybe we didn't push as hard as we could on the rower. But with the Carol Bike, there is no cheating. For those of you prioritizing muscle, this allows you to focus on cardiovascular training that complements strength work instead of competing with it. It is efficient. It is evidence based, and it respects your time. So it allows you to get visit Carol bike.com and use code lion for $100 off your Carol bike. That's C A R O L B I K E dot com and use the code lion for $100 off your bike. GLP ones and athletes, should they and are they allowed to use GLP ones? So as of now, I believe GLP ones are on the bottom monitoring list. So it's not a banned substance, but they are monitoring athletes who are on these medications to see whether or not there is a performance benefit, whether it can help them, whether it can hurt them. What about for something like wrestling? You're thinking about a weight based. Yeah, my immediate reaction would be like, okay. So my dad was a collegiate wrestler. He went to Penn. He wrestled, he was captain of the wrestling team. Patty was up for all American total over a year. Now he's a mountain man like sleeps outside. He's hilarious, but also very smart. He would talk about cutting weight. And so I think maybe the question and if you guys are out there who are involved in wrestling or any weight based sport and love to hear everyone's opinion, because is part of a weight based sport, the ability, the discipline, the mental challenge to do, I mean, I don't know, in my mind, it would be part of it. And I'd also have concerns about the weight cut, even of itself. I already have like, should we even be cutting weight for, you know, sports like wrestling and MMA as a performance enhancing drug in a weight based sport? I would say that it is, it can be very much a performance enhancer. And I wouldn't be surprised if at a certain point, it ends up becoming a performance enhancing drug for certain sports like wrestling. So but I don't make the rules. But you should. I'm not on that committee. I don't have any athletes in our practice that are on a GLP one. But hormones is a whole different story. Yeah. Anabolic agents are very helpful for muscle, for sarcopenia, for burn, for catechia, for wasting syndromes. I don't know what the landscape holds. I know what I hope would happen. You know, as another physician who prescribes medications, do you find it odd that someone could go to their doctor and say, I need a medication that can't lose weight? The physician will say, sure, okay, totally can appreciate that. But if someone goes to their doctor who's like, hey, I need a medication that's going to help me build muscle, the stigma is no, oh my God, that's cheating, cheating for what we're talking about, maintaining muscle mass. It's just a very interesting dance because from my perspective, optimal health would be at least 50% of your body weight is muscle, body fat percentage, again, some people are leaner than others naturally. There shouldn't be necessarily restriction. Again, we're not talking about abuse. We're not talking about quote, steroid abuse. We're talking about if you're undermuscled, it is very difficult. People will say, listen, I mean, how long have you been trying to get bulky? Oh, me personally? Yeah, last 40 years. Yeah. Yeah, 30 years just trying to put on muscle. It's not, you know, from a natural training perspective, it's very difficult, especially as they age. I mean, your parents are what in their 60s or 70s. Yeah. Yeah. And there are, you know, especially with hormone replacement, menopausal hormone therapy, kind of now be like, are you corrected yourself? Yeah, I know, like friends were old physicians, like they didn't even, they didn't even call, we call them hormone replacement therapy. I know the correct term. Yeah. Yes. So menopause replacement therapy. No. Okay. They're just from my perspective, I haven't seen patients for a long time, giving them hormones, progesterone, testosterone, they are not, you're not going to really change on curious to your perspective. I don't see a changing body composition. You have to do the nutrition and you have to do the resistance training. Do, does hormone replacement do a whole bunch of other things? Yes. But does it inherently change someone's body composition? I haven't seen it. There may be some mechanisms that don't necessarily translate to human clinical trials. So the idea that we're going to be able to really build, maintain, address sarcopenia, we have medications that can help lose body fat. Yeah. Why would we have a stigma against medications that could then be anabolic agents? I'm not sure. I also think the landscape is actually changing in terms of how people view. I think when you say anabolic agents, people do think of the nineties, they think steroids are bad and legal, but the things that I'm starting to see now, even amongst physicians, is the peptides, the overall peptide space. And so we went from steroids are bad to what kind of peptides are you on. And GLP's unfortunately gets lumped into that category, but they start listing off all these other agents that some of them are on the water list for performance enhancing. They're listed as a performance enhancing drug. And so I feel like this anti-anabolic agents are, I think it's slowly starting to chip away because people are starting to be more mindful or starting to think about like, what do I want my quality of life to look like? What do I want, 10, 15 years down the line? I don't want to be sarcopenic. I want to be strong. I want to do all these things. I'm doing the training. I'm doing the nutrition, but I'm also in my fifties and my sixties, and I still have decades left to go. It's not like it's 60, like lights over. What do I want the next couple of decades to look like? And I, you know, they're starting to ask these questions. And I think the landscape is changing. It's not very as much like taboo as it once was. Are you concerned about the lack of randomized control trials for peptide? Have you thought much about the usage of peptides, the efficacy, the evidence of where they are? I have. And I am not an expert on all of those other kind of peptides that most people are talking about, particularly for tendon healing, for all these other BPC, 1500. That is a whole nether ballpark that I just haven't really kind of kept my ear here and there, see what people are doing, but I'm not. So you're not using them? No, no, no. Like please go somewhere else. Like I'm just not an expert. Please. It's very honorable of you. But yeah, no, it would be nice to see randomized control trials to see what is the case because it sounds like from what I had heard that it's all just rodent data, nothing. I have heard that there are, that there is collective human data, but we still have to put it to the tests and the rigors that we would anticipate, which I think are going to start to come out. And then on the other hand, there is data for anabolic agents that work with various populations. And I do think that we've accepted this GLP one years as we are not or that we're going to address body fat, but we also conversely have to address skeletal muscle. I personally think that it's from a health standpoint, even more important, but from a cognitive standpoint, GLP one, if I were to think about, okay, so what's the list of priorities? GLP one years is an absolute priority for the psychological reasons that you're talking about. And I think that that is absolutely where the landscape is going. What do you want patients or people to walk away with knowing after hearing our interview? A couple of things. One, if you are having persistent food noise, persistent thoughts about food, especially when you're dieting, it's you are not broken. There are things available at your disposal tools in your toolbox that are able to help with all of that. And asking for help or even considering having that conversation does not mean you're broken. You did not fail at life. We have all sorts of modern technologies that are available to us in YouTube, cars, air conditioning, deodorant, exactly. It really just depends on your situation and how you decide to proceed. If you decide to proceed with it, resistance training is always going to be the most important thing in my book, just because everybody has so many other things that they got to take care of, families, jobs, et cetera. If I had to pick one thing to do, please pick up something heavy, challenge yourself and call it a day, live the rest of your life. Three days a week. Three days a week. Three sets of 10. Full body. Get some, get after it. And you'll be surprised at how much you can get out of that if this is your first endeavor in the weight room. And it's not a scary place. I promise you a lot of bodybuilders, many bodybuilders are really kind and awesome. New beginnings, right? Earlier you are to training the more impactful the outcome in that condensed window. So for example, if you've been training for, I don't know, 20 years, you change up your program, good luck. You're going to make incremental changes. But if you're new to training, and especially the women listening, the number one obstacle that I hear from women, and I'm curious as to what your patients say is only a bulky. Yes, that is correct. And I tell them, I start showing them pictures and saying, you need to really try hard. And other anabolic agents likely are coming into play when you're thinking about that. And how tall are you? You're my size, right? I'm 11. Oh my gosh, I've never been on an abacus. I'm taller than you. I am taller than you. This is amazing. I don't think I've ever been taller than you. This is a first. Actually, my sister, I'm taller than him. Okay, so I'm five one. And you and I trying to put on muscle, it's going to take us, listen, I've been trying to get bulky for, you know, 30 years, man. Not that long, where this 20. Yeah. So ladies, it's not, it's not going to happen. No, it isn't. And talking about the weight itself, especially when you're new to resistance training, you the scale might not reflect. Good point. Okay, talk to me about that. That is another definitely one of the first things. And I keep having to harp on it because I find that with a slow, not just the slower rate of fat loss compared to, you know, whatever it is they were doing before they get really discouraged. And so I encourage them to take a before picture, take, you know, make note of your clothing size. And a before picture with clothes on. Yes, with clothes on. Yes. Please. Oh my gosh. Because there will be times where a lot of times they feel a lot very discouraged. And I'm like, look at you, send me a new picture. Like great point. And you compare the two. I'm like, did you just like, you know, six months ago, you've only lost like what five, 10 pounds, but the body recomposition, you are down to sizes. Everybody at your work, like doesn't believe you when you say you've lost five to 10 pounds, because they're like, no, it's got to be more, you look waste, like way more leaner now. And so those are things that I definitely harp on very early on. And I keep repeating because it's, it's hard because you want to see the scale drop alive. Basically, what you're saying is you're getting ahead of your seeing that the train goes down the track. And you're getting that's now friends, this is a very smart physician. That is a very smart physician move is you see what is coming because you've had enough clinical experience, enough reps to hear what patients struggle with. And if they struggle with weight, for example, that they're actually putting on muscle and losing fat, but the scale is not changing, then they're going to be like, I'm done, even if their body looks better. Yes. So you are getting ahead of that. I hadn't thought about discussing that on this podcast. That is a really good point. Do you like your patients to weigh themselves? I do. And I want to do it in such a way that the scale becomes a neutral place and not a place of like where their emotions run and, you know, where the scale actually determines their worth. So, and that takes all been there. And I've been there too. Yes, 100% I have been there too. 100%. Did you gain weight in residency? Oh my gosh. Same. Oh, same. Oh, gosh. Yeah, especially during sports men fellowship and COVID, it was, it was a time it was ICU baby for me. It was the ICU rotation. Seriously, and it was just like, ICU ER, not sleeping. I was up at the nurses station eating peanut butter and ground crackers. Oh, yeah. Oh, yes. Even, even remember the applesauce roast? That was me. I saw it. Peanut butter, peanut butter, jelly sandwiches. Disgusting. Yeah. I was like, oh, disgusting, terrible idea. Where is it? And so we've all experienced that. And I will tell you that was a period in my life where I just felt so bad about myself. I wasn't sleeping. I was eating at the nurses station and just not that it's a bad thing, but it kind of is a bunch of junk food. It is. Let's just call it a spate. It is. It's a bunch of junk food. Tastes terrible. Stop bringing the Krispy Kreme donuts. But when you've been up for 24 hours, anything tastes so bad. Exactly. 48. It changes your blood sugar regulation. Oh, yeah. It makes it harder to lose weight. It's just, and again, the scale is a really good thing for context. I'm five one. My normal weight is 110 pounds. Give or take me a moment a little bit later. Sometimes in residency when I was sitting, I see you, guess how heavy I was? 125. 135. No way. Oh, well. 135. It was almost 25 pounds heavier than I am right now. Oh my gosh. I was a size between the size four, maybe like, and again, you guys might be listening to this like, oh, whatever. But where I'm, yeah, tiny and my natural weight is small. There is something to be said for being able to track and my diet wasn't on point. I was exhausted. I was so stressed out. I'm like, you know, you're looking at x-rays and trying to figure out what the zipper line is and what's this patient's, you know, eye on gap. I don't know. Oh, thanks. I don't want to. I was terrible. Right? So we call the resident, there's coes running. Remember that? Oh, yes. Terrible. Oh, yes. And yeah, I didn't, I just felt so terrible about my relationship to food at the time, my relationship to weight. And I can only imagine that, you know, thank God that that was a short term experience. But I'm sure that that happened to you too. Oh, yeah. When I was, when I was a resident, I, I made sure to get my protein in and I made sure to get my lifting in. That was the one thing that like, same. No matter what. No matter what. The calories were all over the place. I would eat the crusted donuts that have been sitting there for a day and a half. Like I just did not care. But I would at least make sure I hit my protein and I went to the gym three to four days a week. And if I was on night float or some other shift, like I would stretch out my like the last week of my training cycle to a week and a half to two weeks. Were you competitive at the time doing powerlifting? My last competition was I was a second year resident in that. And then I hung my hat, you know, up and I was like, I'm done with powerlifting. I'm going to switch to bodybuilding to give my joints a break. And then also because I'm, you know, obviously in a calorie surplus, let's see how much muscle I can put on, like screw it, like I'm just going to, you know, eat. Was that on purpose or were you, was it a way of coping with the coping the stress that you were like, if I'm going to put on muscle? So sure. Can you do? Oh, yeah, no, totally. Oh, yeah, I just realized so at times where I was like, I'm just going to, you know, I'm like, I think a 411 and around that time and somewhere between, I think I competed at 72 kilos, like 158 pounds. And so I'd fluctuate somewhere between 160 and 170 at 411. And I was snoring, my joints hurt. And I was like, I'm feeling a little beat up from powerlifting, but I still want to keep training. I still think that that's important. Were you thinking a ton about food at that time, even if you were in, oh, yeah, 100 high calorie during my calorie time? Yeah. So this was really, this was not food addiction, but you were just consumed. Yeah, the the the times were I like at 165, 170 and 411, like it was manageable. But I would definitely have to keep snacks on me at like every two to three hours, just so I wouldn't turn hangry, you know, in the hospital. But yeah, I decided to switch up my whole training, just give my joints a break and just increase my reps, focus on, you know, more bodybuilding style, because yeah, I realized that I wasn't going to get to be lean. And that's okay. Like I also realized that residency sucks. And the fact that I'm doing something is better than nothing. So let's just see how much muscle I can put on or during this time. And then once train, you know, medical training is over, let's see where the chips fall and what my life looks like outside of that and kind of go from there. It's tough. And you're just like trying to get your the wall ends, right? You want all women to lift weights? I do. There's no other way. There's no, right now we don't have, you know, a medication that can just be like, here you go, take this pill and magically grow muscles. And then also, I don't know if it's going to help with the tendon issue. So like how strengthen your tendons. And yeah, even if you have all sorts of medical conditions, there are ways around it, like there's plenty of athletes who end up getting ACL surgery who's like, Oh, I'm just not going to go to the gym. And I'm like, Uh, you did not get you have your other leg and you had a whole upper body, like we can, we can work around this, like you can get your, you know, turn around and get back into the gym and let's figure something out. They are very unpopular. What is next for you? What are you working on now? I'm just working on a lot more content. I did mention at some point, I think writing a book, awesome, food noise and how that has shaped kind of my entire life and the decisions I've made and see how that goes. So I'm thinking that's the, you know, kind of a little bit further down the line, but yes, content and then the book. Well, Dr. Crystal Guavara sooner, rather than later, the book is needed. Let me know how I can help expedite that because I think people hearing it from someone who is a highly trained physician, family medicine, plus sports medicine who also struggled and then, you know, I really think you're normalizing it for people and that is very valuable because this way it, it kind of breaks that fourth wall. So thank you so much. Thank you so much for having me. Thank you.