SPEAKER_05 0:03

Welcome back to another episode of Vitals and Values. And we are now about to be back on our normal routine of podcast episodes on really the topics around what vitals and values is really about. Don't kid yourself. The values of marriage, the values of travel, the values of living and quality life, all that stuff sits. Um, so I wouldn't say that was completely off the rails, but getting back to some different talking points that are very effective right now. So this episode is on the top five things you need to know before starting. Danny is with Dr. Nadolski at Vineyard, and he had an incredible transformation years ago. Vineyard is a uh doctor and team supported obesity transformation online company.

SPEAKER_03 0:58

Yes.

SPEAKER_05 0:59

Uh so they help with uh prescriptions of GLP1s, the dietetic side, the fitness side, all in kind of one encompassing system. And we were just having this conversation because and I get it, the world lives in this kind of back and forth. When you push one way, someone pushes pulls back the other way. And because of the massive explosion of GLP ones all over everywhere, and a lot of freaking uh people are promoting and selling compounded pharmacy GLP ones with on obesity, which is a really gray area of we should be doing that or not. There's this huge movement of people who've lost a bunch of weight that did it without weight loss medications, and now they constantly just belittle and look down upon people who have used the drug to help support their weight loss.

SPEAKER_00 1:54

It's fascinating to me. I don't understand that.

SPEAKER_05 1:55

Oh, it's and it's all this passive aggressive stuff. And I was talking to Danny about it, and it's just it's so funny to me because again, I'm not I it's not about my story, and but it is fascinating when you've when people that are in the middle of a transformation or have a transformation and they have this just ego about it all. I've been down 200 pounds in body fat for like 13 years now. Most of these people that are talking shit have maybe been down the weight for two or three. And do they really understand it? Like, do they really get it? And the ego behind it. And it's funny to me because yes, I've did this whole transformation without weight loss surgery, weight loss surgery or medications, but I support it. It's just freaking biology. And this idea that just because I've been able to maintain this for this amount of time without drugs and surgery, who cares? I don't get why we live in this day and age where, oh, you just gotta, you just gotta work harder, Billy. And it's like, yes, it's funny because the sheer majority of people on these medications don't disagknowledge the importance of lifestyle and fitness and all this kind of stuff. Just learning the biology behind the benefit of these medications.

SPEAKER_00 3:11

And I mean, this is a great example from today. So I saw a patient today who you also know, and he has been on a GLP one for a couple months now, and I truly feel it is transformational for him. 100%. We talked about it. Yeah, it's amazing what that medication is doing for him. And it's not that he hasn't tried before. It's not that he doesn't work hard. He's incredibly hardworking. And to see how he even stated it was so freeing for him to not be consumed by thoughts of food all the time.

SPEAKER_05 3:50

The food noise, the obsession of food, uh people that have never dealt with it have a really hard time understanding that it's one thing that if you just had a couple bad behaviors and then you fixed it and you didn't really have a food noise problem. You just drank too much sugary pop, you just did a couple things and made a couple tweaks. But there is a population out there that this nauseating food noise where it's hard to sleep. I mean, Lara has seen it with me, like especially I get it at night on occasion, where I just turn into a bear at 10 o'clock and I it's hard to turn off.

SPEAKER_00 4:26

I think this is where it's so important of knowing people's stories and not making assumptions about them because unless you've had these conversations with multiple people and know these people personally and their struggles, I don't think you should be ever commenting on their choices for their weight loss because it's incredible what these medications can do for people.

SPEAKER_05 4:47

100%. And you sit there and go, it's funny because we don't sit there, this person's uh blood pressure is 118 over 78, and you're going, well, he's on lysinopril.

SPEAKER_00 4:56

I know no one ever looks down on people for that. And I think it is funny that so, I mean, so many of my patients are asking for a medication or they're just kind of interested in them, but I feel like it's almost like they're slightly embarrassed to bring it up because I feel like they feel that stigma about taking the meds, and I just don't understand it and I wish it wasn't there.

SPEAKER_05 5:19

100%. Well, from a from a vitals check, I think it's kind of important to keep to work into um why this conversation matters right now. So kind of walk me through that.

SPEAKER_00 5:28

Yeah. So the GLP one use just continues to grow. And I saw um I saw a study from 2024 that said there was about 6% of you, uh United States um individuals were using the medications. And then uh the more recent research is a little bit hard to find, but it looks like it's somewhere around 11% of US adults are taking GLP ones. Um, and upwards of 15% of people have at least tried them. So that's not a small percentage of the population.

SPEAKER_04 5:55

Very large.

SPEAKER_00 5:55

Um so it's in especially the timeline. Yeah, it's been fast. And these uh we only have two really approved currently for weight loss. And there's gonna be more. Like research is ongoing, and so I'm sure this is just gonna continue to rise. So uh that is uh growing. Um there we use here in our practice at Concierge Medicine only the brand name versions, but there are still some compounded versions out there, and uh the cost of these medications is constantly changing, and so it used to be like I don't think any of my patients could afford it hardly. And that has slowly come down, and so it's still not cheap, but it is more accessible and I from a cash pay perspective. From a cash pay perspective. Um, and because really, pretty much all my patients are on cash pay because insurances just don't cover it. Um, and uh, but I think it is very exciting that Medicare just launched a program that is going to cover it for certain individuals that meet certain criteria. So that is exciting, and hopefully we will get that with other insurance companies. And hopefully the costs come down so more people can get these that need it.

SPEAKER_05 7:08

Absolutely. So now the five things you should know before starting a GLP one.

SPEAKER_03 7:17

Yes.

SPEAKER_05 7:18

Preface because contrary to popular belief of pretty much what most of the internet tells you, we have way more liability. So would you like to use the classic uh legal disclosure here? Because I think it's very important we hit it early.

SPEAKER_00 7:32

So, yes, this is not do not consider anything we say on this podcast as as medical advice. Please consult your own doctor for your own health concerns.

SPEAKER_05 7:40

And there may be some crossover because contrary to public belief, health influencers can pretty much say whatever they want and not be held liable for the most part. And uh Lara here can lose her license, go to jail, all types of problems if she starts doing egregious uh statements on the internet. So there's a big difference there.

SPEAKER_00 8:01

All right, and so these top five, I mean, I would say these are things that I cover with all my patients before I prescribe the medication, maybe not quite in a list of five, but these are all important things for people to know before the medications are prescribed. So do you want to start us off with number five, David?

SPEAKER_05 8:17

Yeah, because this one uh we had conversations of constantly. I think I have a feeling we talked about this before even a lot of your patients kind of leaned in on it. And you were like, that can't be real. And then more and more of your patients were coming to you with this question or doing this, which is sourcing matters. Number five, sourcing matters. Compounding isn't automatically safe. And right now, roughly one in five current GLP1 users are using some type of non-FDA approved compounded medication. And I think it's it's you kind of want to unpack that. Cause because I when I when we talked about this, you're like, wait, really? And I was like, What? That's true. That's so funny. 100%. We talked about it early. And you're like, people are just buying it off the internet. I'm like, yeah, people are just buying it off the internet.

SPEAKER_00 9:08

Really, how long ago we talked about this?

SPEAKER_05 9:09

Yeah, like it happened right because our first before our first date, yeah, you were at uh the in Chicago for that event that talked about GLP1s. Um, and I remember bringing that up in one of our first dates, going, Oh yeah, the this momentum of people just buying it from compounded pharmacies on the internet, it's getting out of hand. And you were like, Wait, what? That's so interesting. You can just buy it, and then sure enough, like 18 months later, now all your patients are, hey, can I you know?

SPEAKER_00 9:38

Interestingly enough, I think compounding, at least in my patient population, I feel like more people were doing it probably last year. Um, and now that the medications are no longer in a shortage, there is less availability of compounded options. And so I feel like there's less of it. But uh the compounded versions are the so semaglutide and terzepatite are the names of the medications that are approved for weight loss. Uh, they are um uh there are compounding pharmacies that actually make these rather and it's they're mixing it themselves in their own formulation. They are not using the original, it's not from the original drug companies. And so these are not FDA approved. They have not gone through the same safety scrutiny, through the same research that the actual FDA approved medications have, and they're not generic. Um, and the vast majority, I think, of the of most physicians are not recommending these to their patients due to just that we just don't know enough about them. And we as physicians are uh usually uphold the part of the Hippocratic Oath that says do no harm. And so there is concern that these medications could do harm. So I think that's a big reason that most physicians are worried about them.

SPEAKER_05 10:52

And uh I think that's always one that it was a big craze last year with the shortage. Now that it's not becoming that issue and the prices are coming down, it's less of a of a talking point, but it's still there quite properly.

SPEAKER_00 11:05

I mean, I just had a patient recently start on one on her own and she hasn't noticed any changes in her uh in her weight and ability to lose weight yet. So we shall see.

SPEAKER_05 11:16

Well, because she could be getting water.

SPEAKER_00 11:18

She could because we have no idea what's in there. We have no idea what's in it. So um, and I would say I was having some patients come to me on the compound aversions, and I would always ask them how much are you paying for it? And a lot of them were paying more money for the compound aversion than I could get it to them for the FDA approved drug. Yeah. And so I did switch several people over just for that reason. And now there's the approved one. That is a much safer option, in my opinion. Wow. So if you use compounded, there's lack of standardization. There is you don't know what the quality is, dosages may be off. There are always different dosages. So I'm never I can't tell people what they should be doing with it because it's not the same. Um, and so uh if you do that, just realize that it is at your own risk. Are some of them safe? Probably, but we just don't know.

SPEAKER_05 12:09

Number four.

SPEAKER_00 12:11

Number four. So there are things that you should know before you start one that if you have certain family history, personal history, you should not take these. Um, it's not a lot of common things, though. So um if you so they're absolute contraindications, so things that you cannot have um to take this medication is a personal or family history of medullary thyroid cancer. So that is a specific type of thyroid cancer, not all thyroid cancer. Uh, if you have a personal or family history of multiple endocrine neoplasia, type number two, you cannot. Now, this is not common. I can't say I've ever had a patient with this, but if you are one of those rare people that knows somebody with it in your family, just be aware. Um, if you're pregnant or if you have a history of hypersensitivity, which is always very obvious, but they always have to list it. So those are reasons you should not take this medication. So, really, what I take from that is most people can take it. Now, if you have a history of gastroparesis or you've had prior gastric surgery, gastric bypass or baryotic surgery, um, you should not, you should be cautious. Um, and if you use insulin or a sulfur urea, which is a type of medication, both are those are types of medication. Diabetes, you should be cautious as well, uh, because it can lower your uh blood sugar. So to answer your question, Brunember.

SPEAKER_05 13:28

Yeah, I mean, it's uh it's always fun because like I hate to say it, it's pretty much standard. It's it's not many people.

SPEAKER_00 13:35

Pretty much most people can take it. Um, so that is number four. Anything else on that one? I think that's pretty straightforward.

SPEAKER_05 13:42

Yeah, I mean, that makes sense. Uh honestly, with number three, I think you gotta stay with it too, because this is above my pay grade.

SPEAKER_00 13:49

So, okay. Uh, you have to know about side effects. And I mean, people are usually good about asking this, but the vast majority of these side effects that we see in these medications are GI. It can be stomach pain, nausea, it could be constipation or diarrhea. Um, but they're not uncommon. I would say most of the patients that I see don't have a huge issue with these symptoms. They may have some mild nausea, some mild uh upset stomach for a few weeks when they were initially starting the meds. But usually that improves and they can tolerate it fine. Though I have had some people just not able to take the medications at all because of side effects. Typically, um, like I said, they go away. And then this is why, if you've ever started one or look into it, there is a very specific dose titration of these medications. You cannot jump to the top dose because you will feel terrible. Like I don't think anyone could tolerate that. So you have to go slow. You have to start at the lowest dose and move up each month to the maximally tolerated dose.

SPEAKER_05 14:49

Now, this is always an interesting one because this actually goes into titration a little bit. We've had this conversation, so it's a little tangential, but it's similar, which is one of the things that was always a gripe with me with these medications, since it's been out for longer than you think, and and talking to different people. One of the weaknesses in the traditional healthcare system is you're seeing patients every six months, if you're lucky, four to six.

SPEAKER_00 15:21

That would be that would be probably a lot.

SPEAKER_05 15:23

Four four to six. And so, all right, you put somebody on one of these medications, uh, you got someone who's 150 pounds overweight, haven't seen them for six months, they come back, they're down 90 pounds. And 90's a little higher. It's a little aggressive, but we'll say we'll say 50. 50 in six months. No, because that's reasonable. That's that's upper reasonable. So we'll say it we'll say 85, 90. Yeah. And a lot of doctors, because they're so ecstatic over the fact that they lost the weight, they're just gonna run with it, and they're not going into the secondaries of like, ooh, is this too high of a dose in the sense that they're starving themselves, X, Y, and Z. And I've met a lot of people, because it technically is going against what the protocol is, but if you're seeing sustained weight loss at a good level, why just go up in dose? And that one always annoyed me, which was like, okay, someone's on second dose and they're dropping on average a pound and a half a week. And then the physician goes, Well, the protocol is next month, double your dose again. And it's like, they're doing great. Why are we jumping dosages if they're just seeing the great results? So, from your standpoint, what is your general protocol if someone's at losing a sustained weight? Do you jump them or do you kind of keep them consistent?

SPEAKER_00 16:39

I mean, I always talk to the patient about what their goals are and how they're feeling. And I have a lot of patients that are like, I'm happy with my weight loss, I'm happy to stop at this dose. Um, while there's others that are happy to go to the max dose. And I think it does really matter of what weight we're starting with. So if you're starting at 400 pounds, I feel like it's very different than if you're starting at uh say you need to lose 50 pounds or something. Because um I think most patients, and I am more aggressive on those patients that are 400 pounds. Yep. Um, and so I but it's this is a this is this is the patient's, in my opinion. This is their life, this is their health. I am here to help guide them through this, but I I am not going to tell them what to do if they feel uncomfortable with it. Now I can tell them, hey, you may benefit from more weight loss or faster weight loss or whatever it may be for these reasons, say your uh your high blood pressure, your cholesterol, those types of things. Um, but it is always a conversation uh with the patient.

SPEAKER_05 17:43

Yeah, because I I just know I've had conversations with people in the past where they're like, I feel like I'm at a great place, I'm moving right along, I'm losing a pound and a half a week, I feel great. And they go to see their primary and they go, Oh, well, you're doing great. Let's double your dose again. And they kind of hesitate and they're like, but I'm doing great. And they and then all of a sudden they get stoned while they were doctor going, No, you really should go up a dose. And I'm like, I don't Yeah, I mean, I don't understand that either.

SPEAKER_00 18:07

I think, I mean, if you talk to the drug reps, they tell you gotta go to full dose. Well, the thing is, the studies were done. They were trying to get Everett to max dose. So that's what they tell you to do. Now, is I just don't understand that either. It doesn't make sense. Of course, if you can get people to max dose and it's great for them, great. But yeah, they're losing weight at a lower dose.

SPEAKER_05 18:26

What's what's the goal? Top dose, or is the goal sustained fat loss? I would argue that the goal is sustained fat loss.

SPEAKER_00 18:34

Their goal is max weight loss. That's what the drug reps are looking for. Yeah.

SPEAKER_05 18:39

And so I I I I'll push back on the pharmaceutical angle and stuff like that.

SPEAKER_00 18:43

Like I just think it's I don't know, but I would say the most physicians I know were are not gonna push that to the max dose if people are doing fine. I could be wrong, but that's my perspective.

SPEAKER_05 18:56

Well, and that's and again, these are flame of a couple of conversations I've had with people where they just ask my opinion.

SPEAKER_00 19:01

And sometimes I'm like, uh, well, did you tell the doctor that you were happy at your dose? Because there are people that their doctor tells them, well, go up in dose. And they don't let the doctor know that they are happy where they're at. And so it has to be a good conversation.

SPEAKER_05 19:14

Yep. Now, number two, this one I will hammer home. Me too. Because as much as I just said how important medications and surgery can be for supporting someone's weight loss and building sustainable health and all this kind of stuff. Number two is essential, which is nutrition isn't op isn't optional just because you're eating less calories on these medications. This one drives me nuts. Yes, it suppresses appetite, so you control calories easier, so you build a deficit, and so you lose weight. No one denies that. That's the primary mechanism behind GLP1s. The problem is, is there is a too high of a population that gets excited that they don't feel hungry anymore, so they just starve themselves. And that's a problem. So walk me through kind of how you unpack how you talk to your patients on nutrition behind GLP1s.

SPEAKER_00 20:14

Well, I mean, I talk to my patients who are doing a GLP1, uh, I talk to them about their nutrition honestly, almost the same way I talk to all my patients about it, because I don't think it matters whether you are on a GLP one trying to lose weight or not, because I think the principles of nutrition are still so important to all those people. However, like you said, I do stress the importance of maintaining regular food intake. Like let's eat meals throughout the day, let's not completely just stop eating because you just don't feel like it because you're not feeling full or because you're feeling more full. Um, and I really hammer home protein intake for these patients uh because um I don't want them to lose muscle mass. And we know that weight loss is going to result in some loss of muscle mass, but we can try to mitigate this with uh and push it towards more fat loss, which is what people want, anyways, um, by encouraging them to continue to eat a solid amount of protein. Um and along with that, if we can get them to resistance train, that's ideal. That's icing on the cake. I really talk about that with all my patients as well.

SPEAKER_05 21:24

Well, that's the whole I can't tell you how many conversations I've had with people where they take these clinical studies on uh GLP1s and they see the massive muscle loss in some of these studies. And the the primary reason is people the the drugs work too well and people just starve themselves into extreme weight loss. It's not that the drug is magically making you eat your muscle. And I think that's that that becomes like the classic argument that people that are against these drugs always use, where it's like, Well, you're gonna lose all your muscle because you're on these drugs. It's like, no. Any starvation diet that lacks protein and compound lifting and extreme deficits leads to muscle loss. Like that's just the way it is.

SPEAKER_00 22:12

All therapies for weight loss and obesity treatment result in muscle loss. Not just the medications.

SPEAKER_05 22:18

And what it's actually kind of crazy, and I I don't fully know all the data on it, but it's actually, I mean, uh the the state these third level of weight loss medications are getting crazy with the IGF one and all that kind of stuff.

SPEAKER_00 22:30

And the new ones that aren't approved yet?

SPEAKER_05 22:32

Um but my whole point, like the reason why pretty much all the studies show that you lose muscle mass is not inherently because of the process itself, because you can actually, contrary to popular belief, we have small studies on it. You can gain muscle in a calorie deficit. But you can sp there's only two populations that can really get away with it, which is number one, more people that are extremely obese, and number two, people who are novice lifters. And so my joke, I've said this for years, is if you are significantly overweight and you've never strength trained, you're actually super saiyan because you're one of a very small, like it's actually a large group of people, um, but like a small, unique population, even though it's a large population, that can gain a considerable amount of muscle mass in a calorie deficit is people who are considerably overweight and compound that with don't have a lot of strength training in their background. Because you it's called newbie gains and it's it's consistently shown. And so, yeah, there's pop like if you can put on some big muscle in a calorie deficit if you do it intentionally. The problem is from a from a controlled trial perspective, it's very hard to get people to make that big of a shift. I could believe it.

SPEAKER_00 23:50

It's hard to get people to do one change.

SPEAKER_05 23:52

Yeah, and so a lot of change. But yeah, and so like that one's I mean, you can't go wrong. Like you can't undervalue the importance of nutrition with these medications.

SPEAKER_00 24:01

Yeah, nutrition, uh, healthy nutrition is not not eating. Which I think sometimes that's almost what people are thinking.

SPEAKER_05 24:08

Yeah, it's like 90s thinking too.

SPEAKER_00 24:09

Yep, yes, diet culture at its finest.

SPEAKER_05 24:12

Yep.

SPEAKER_00 24:13

All right, anything else on that one?

SPEAKER_05 24:14

Uh no, I think we hit it pretty good. Final, number one.

SPEAKER_00 24:17

All right, down to number one. So we kind of hinted at this at the beginning, but being on a GLP one does not make you weak. Not mean you're cheating. It's really understanding your biology and using a tool to help.

SPEAKER_05 24:31

It's just it's it's so funny to me. It's like the same people that love talking science and mechanisms and all this kind of stuff on how weight loss works and from like a calories perspective and a macronutrient perspective and like all this kind of stuff. They love leaning on those mechanisms. And then the mechanism behind hunger and satiety and how that makes you feel is just like, that's just weakness. And it's like, wait, wait, wait, wait, wait, wait, wait, wait, wait, wait. So, you're gonna talk about hypertrophy and muscle protein synthesis, and you're talking about all these metabolic pathways, but when we talk about uh ghrelin and leptin and all these metabolic pathways, we're gonna ignore it and call it just lack, it's like lack of discipline. Uh-huh. Like, oh, shut your mouth. And so, yeah, I hear this one all the time. Yeah.

SPEAKER_00 25:19

And well, interesting. And uh, so mo I we have a lot of patients that want to start these meds and then they're like, but they want to get off them one day. Like that the and I'm like, okay, I mean, that's a reasonable, that's fine goal. Um, but there is some studies out there that show that most people who stop the meds will gain about two-thirds of their weight back. So, okay, you're still gonna come out better than you were when you started, but people don't want to gain that back either. And so, interestingly enough, um, while my sister was on vacation, one of her patients reached out and wanted his GLP one refilled. Um, he had been on the five milligram dose, and then she he had told her, you know, he was doing pretty good. So we wanted to go 2.5 milligram dose. You know, he was gonna work his way off that med. Well, so he messages after he's been on it. Well, guess what? He gained five pounds. And he's like, Can we please go back to the five? I was like, Yes, we sure can. So, and I think, I mean, I think if you want to try that, that's totally fine. But I think some people may not be realizing what the medication is actually doing for them, and that if you stop it, those effects are going to be gone. It's not like it just helps you for a while and then okay, now I got it. That's not how it really works.

SPEAKER_05 26:29

100%. There's there's still there is still some benefit because that's where sometimes I will argue that okay, so right now, uh, what is it, 50% of Americans are clinically obese, 80-ish percent are overweight, total it's like 90% between overweight and obesity is clinic, like it's just a massive number. Do I believe that say 50% of the American population should be on a GLP one because of genetics between hunger and satiety? No, absolutely not. I think there is a potential, there is a large percentage of that population that if they knew the power of prioritizing protein and getting close to your goal, body weight and protein per day, prioritizing whole foods and fiber, building a better relationship with food, that you're not using it to cope with stress, you're not using it for all these reasons. A large percentage of the population could get off one of these medications and build sustainability because the hunger and and all that problem goes away. With that being said, there is a population that probably should be on a GLP one for the rest of their lives. Is that a problem? No.

SPEAKER_00 27:47

Absolutely not. I don't really know why people find it such a problem. It's interesting.

SPEAKER_05 27:54

Yeah, it's it's it's weird. But I think it's important to talk about because there is a pop there's people out there, you get some of these endocrinologists and stuff that are just like champing the GLP ones, and they sometimes undermine the value of the nutritional side and how that's affecting hunger and satiety, the emotional side and how it's affecting a hunger and satiety. And they just basically are promoting only GLP ones. And it annoys me because I'm just like, that's not true. I never see that.

SPEAKER_00 28:23

You see endocrinologists do that? Weird.

SPEAKER_05 28:26

There's a woman out of, yeah. There's a woman out of, I can't remember her name. Um it's just, it's one of these things where she there's a population of people that tend to lean the political way that as soon as you have any inclination of bootstrap, it's victim blaming.

SPEAKER_00 28:45

But what do you mean by bootstrap?

SPEAKER_05 28:48

You are playing a role in the reason why you're hungry. So, like I'm speaking out both sides of my mouth right now. I'm saying GLP1s and weight loss surgery have their place. Some people should be on for the rest of their lives. They're promoted. However, I also just said of the 50%-ish of clinically obese Americans, a large percentage of them do not need to be on them if they learn the power of all that kind of stuff.

SPEAKER_00 29:13

So we've had this conversation, I think, in the past.

SPEAKER_05 29:15

Yes.

SPEAKER_00 29:15

So, how, though, is this different than telling someone who's got diabetes that they just need to eat less sugar and drink less pop? I don't want to give you the med because you just have to change these habits.

SPEAKER_05 29:28

No, but that's the whole point. It's like it's a duality of the importance of both. And it's and the the importance that there's nuance and context into this. So share the reality of the pathophysiology of the genetic variants in hunger, satiety, leptin, all this kind of stuff, and the disease state, which is always on a bell-shaped curve. And then going into also the disease state you're dealing with compared to the actual genetic disposition of where you're at, are not aligned. Now, someday we're gonna find out, we're gonna be able to look at the genome and look at the stuff to a so level that we'll be able to see that to that level. What I'm saying is, is there's a huge population out there that all they do is eat fast food, drink a bunch of regular sugar, do everything wrong so they're hungry. But if they just made these changes, they wouldn't be. But there is a population that is doing everything right. They're eating primarily whole foods, they're eating primarily, they're eating a large prop uh a protein pop like of calories. They're doing everything right, and their hunger is still through the freaking roof, and that that food noise just doesn't go away, which is why those populations should be on the medications and they'll probably be on the rest of their lives.

SPEAKER_00 30:50

But are you saying that other populations shouldn't be?

SPEAKER_05 30:53

I'm saying that they could get off of it and not need it anymore because of once they learn the proper nutritional behaviors.

SPEAKER_00 31:00

But that's hard.

SPEAKER_05 31:01

See, I disagree. Like I still think there, like that, but that's the whole thing. There's nuances. It is. I'm not saying it's not, but that's but that's a part of the that's but if we're want if we want to be intellectually honest based upon the variables at pay, based upon everything in beh in what comes into being an individual, you have to take that into consideration. And sometimes these endocrinologists, they just play the one card, which is well, food noise, hunger, food noise, hunger. You're right. You're right. It absolutely plays. But then simultaneously go, yeah, if you're it, if this population is eating hostess cupcakes all day, is it is it the genetics of their hunger and food noise? Or they have never taken fundamental uh decision making of, you know, I should really start eating more whole foods.

SPEAKER_00 31:56

But how can you determine which person is in which group?

SPEAKER_05 32:00

That's gonna take time.

SPEAKER_00 32:01

Well, that's what I think, because you can't make an assumption. Correct.

SPEAKER_05 32:04

But it it's it's not being able to say, I know Billy Bob's just being lazy and I know John's being, he needs it. It's just knowing from an epidemiologic standpoint of 50% of Americans, there's no way 50% of Americans even have GLP1 for the rest of their lives. I just don't buy it.

SPEAKER_00 32:20

Unless they can't make behavioral changes. But see, I'm like, why, like, why is that not a good enough reason?

SPEAKER_05 32:27

Because the because what happens is some of that population is the same population that's not gonna do too right no matter what they do, and they lose bone density, which is nutrition.

SPEAKER_00 32:37

Right.

SPEAKER_05 32:37

So that's the whole point. So, like, so so we can't take that out of the mix. So, like, that's that's why these GLP ones aren't gonna fix every single problem.

SPEAKER_00 32:46

I agree with that. I and I'm just playing the devil's advocate here because I'm I'm thinking like you, it's you can't make an assumption about what people are gonna do. And it's not like you well, you can't have it because you have to do these things first, and you're okay though on this side.

SPEAKER_05 33:01

My my angle is it was probably long-term, it was longevity. It was like, do you need to be on the drug for the rest of your life versus use it as a catalyst to start dealing with your hunger cues? There's a difference in my from my point of view, and knowing like you can't take that variable out of the mix. We have it at number two. And so, how many of these, how many, how many people out there that say you could you could use it from even some of the potential patients you have that uh they want to use it to starve themselves out of five more pounds of of weight loss. They try to they just want to eat less and less and less. And it's that same fundamental going, there's a psychological issue. It's not mechanistic based upon hunger. It's like that's I agree with that. That's what I'm saying.

SPEAKER_00 33:52

And like and my question would be just as you know, in general, does that mean those people shouldn't have it? That's the question, I think, right?

SPEAKER_05 34:03

Well, the argument would be that if they don't take a handle in nutrition, we have plenty of studies showing the ramifications. Sure, but it's not like loss, muscle loss because they're doing the they're they're still only eating Reese's peanut butter cups, but they're building a calorie deficit. And so it's leading to a whole cascade of future problems.

SPEAKER_00 34:23

But that's also assuming that everybody that wants to lose the last five pounds.

SPEAKER_05 34:27

No, this isn't just five pounds.

SPEAKER_00 34:28

This is this is obesity, this is No, but I'm saying the group that you're saying just like wants to lose that last few pounds and starve themselves out of it. That's making the assumption that all those people are just gonna be, you know, they just don't want to make any of these final changes to their nutrition.

SPEAKER_05 34:44

No, I mean it it's just the idea that physiologically and psychologically are two different like I agree. Yeah. And so and and so going off of that point with number two, the import like you can't undermine the importance of proper nutrition and how it helps in the in someone's health.

SPEAKER_03 35:04

Yes.

SPEAKER_05 35:05

And while yes, GLP1s, weight loss surgery are absolutely beneficial and supported for a slew of clinical studies and all this kind of stuff, it's not the end-all be-all. And it's not, it's not the reason it's not gonna be the you could put the entire country's population on GLP ones, there's still gonna be health nutritional problems. Well, that's true. And that's and like so that's why but it's so fascinating to me some of these endocrinologists, they just oh, you need weight loss? GLP one. And I'm like, wait, wait, wait, wait, wait, wait, wait, wait. Yes, weight loss is absolutely beneficial and should be supported with this, but you have no information on all the importance of nutrition. They don't talk about nutrition at all because it almost seems like if you talk about nutrition, it seems like you're blaming the individual for not making good food choices. And that, like I I've seen some of these endocrinologists do that. They, as soon as you even attempt it to go, like, hey, can we talk about nutritional choices based on these people as well? They go, no, no, no, no, obesity is disease. And so it's just drugs.

SPEAKER_00 36:12

No, okay, but it drives me nuts. The people that are these endocrinologists that are seeing people that are having these conversations.

SPEAKER_05 36:19

This is social media, endocrine.

SPEAKER_00 36:20

Well, right, but are these because I mean, most people, at least, you know, in this community, that are going to an endocrinologist have an endocrinological problem. Like they're not being referred to endo for obesity. If I tried to do that, I can guarantee they would ref deny the referral.

SPEAKER_01 36:36

Yeah.

SPEAKER_00 36:36

They have to have a thyroid problem, uh, they have to have diabetes, they have to prediabetes, they have to have some other adrenal problem, like whatever it is. But so that is a completely different population than the average person that just wants to lose weight. So I think you have to look at it. Like, what is the population that these endocrinologists are seeing?

SPEAKER_05 36:52

Well, you're this is also timeline. This was like three years ago. But still, like it doesn't change what endocrinologists are doing. No, because endocrinologists were the correct me if I'm wrong, endocrinologists were the first to start using these medications.

SPEAKER_00 37:06

In diabetics. Yeah. Like they weren't just seeing average people and then putting it on them.

SPEAKER_05 37:12

That is true, but it's kind of a a a scapegoat because as we both know, obesity lead is a leading factor into diabetes.

SPEAKER_00 37:23

Right. But they're probably already diabetic if they're seeing endo, is my point.

SPEAKER_05 37:26

But that that may be true, but it's again, it's But then if they have diabetes, guess what?

SPEAKER_00 37:32

These medications are indicated. Not for weight loss, but for diabetes.

SPEAKER_05 37:36

Aga this is but this is the point. It's not that we're going you're you're still focusing on a singular aspect of it. It's going back to no, it's going back to this idea that, okay, fifty percent of America is clinically obese. Okay. And you more than most are very intentional with what goes in your mouth. Correct? Correct. How often are you getting McDonald's and you're slurping? We got from a friend of ours, we got a a sugar Gatorade because there wasn't any sugar free. How long has we been sipping on that in the refrigerator?

SPEAKER_00 38:11

Uh several days.

SPEAKER_05 38:12

Several days, because we understand what it's doing. There's a lot of people out there, whether it's ignorance or they just don't care or whatever, they're making every behavioral food choice wrong, which is leading towards the cascade of effects of hunger and satiety. That regardless, if you it's it's not, they're not obese because of these the genetic dispositions to actual hunger. It's they're making behavioral decisions wrong.

SPEAKER_00 38:44

But I I st we could keep going in circles here, but I still don't know why that matters that much.

SPEAKER_05 38:49

Because that is a important variable that has to be correlation versus causality. It it is a causative variable that if you actually want to help the most amount of people, there's plenty of people out there that because they have adverse effects of the medications won't take a GLP one. So they don't have, but they don't have the ability to change or have have benefits if they knew these five, seven things that'll help them with their hunger and satiety without the GLP one.

SPEAKER_00 39:20

But you can keep changing conversations here, but because I'm just because someone hasn't made the lifestyle changes, the medications may help their health more if they just got on it. Because do you know how important those things are for metabolic health and for the people? That's very true. That's very true.

SPEAKER_05 39:38

100%. No one's I'm not saying that's not true. The the point is there isn't there is absolutely no need to put 50% of Americans on these medications.

SPEAKER_00 39:49

You don't know what the you don't know the details of 50% of the health care uh people in this country. It's making a lot of assumptions about people and their health and how easy it is for them to lose weight or not.

SPEAKER_05 39:59

No, because because coming down to it, if like okay, because when you go through this like aspect, the amount of the population that is not making fundamental good quality decisions matters. How is it how is it that we're able to have people lose weight without medications, then?

SPEAKER_00 40:21

What do you mean? If if we have I didn't say you have to have these medications to lose weight. That's not what I'm saying.

SPEAKER_05 40:27

That's what this point, that's the whole point of my argument is correct. That's that is correct. They are supportive, but they're not essential.

SPEAKER_00 40:36

Well, yeah, that's I don't think we have any disagreement on that.

SPEAKER_05 40:39

Then then walk through your point. Because the point I'm making is 50% of Americans are clinically obese. Okay. Does a population probably need to be on throughbacks for life because of genetic dispositions, all this kind of stuff? Absolutely. It's not essential. That and if you decide to do it, that's fine. It's not the point. The point is there is a population of endocrinologists and doctors at B that all they talk about is the drug, and they don't talk about the other causative variables that influences someone's quality of health.

SPEAKER_00 41:12

I mean, I don't hear these endocrinologists because I'm not seeing the same people you do. All I'm saying, what I'm hearing you say is there's two types of people that want the med. There's people that have this genetic predisposition, and there's people that aren't making good lifestyle choices. Is that what you're saying?

SPEAKER_05 41:27

No, I'm saying there's a bell-shaped curve between all of it. Well, sure.

SPEAKER_00 41:31

But then what's the how do you relating that to these meds? Are you saying some should be on and some shouldn't?

SPEAKER_05 41:37

Yeah. I'm I'm saying some people, some people do not need to be on them if they made the hunger problems they're dealing with are not are not completely out of their control. It's because they're eating 42 grams of protein a day. They're primarily eating, they're drinking three large uh sugar drinks that are umpteen hundreds of calories of sugar. They're doing everything wrong, which is why they lack satiety and their calorie density is high.

SPEAKER_00 42:12

So are you saying those people should not be on these meds? Is all I'm asking.

SPEAKER_05 42:17

No, what I'm saying is they don't necessarily need to be on long term. They may be beneficial in the short term to start building because they they've had such a struggle with that. But once they make the change within the drugs, with or without the drugs, don't care. Once they make the change behaviorally, those same chronic hunger cues that who we're talking about struggles with don't happen in him, that person. So they're taking something that is completely unnecessary because they think, because they're they're taking correlation versus causality versus like you're sitting there. It's like this, it's it's like the the woman I just dealt with today on Facebook, that the low carb community. This this woman was part of one of the old Mediterranean diet studies back in the 19 the early 1990s, early 2000s, and they were in a clinical trial of 100 people, 80 per 80 people out of the 20 or out of the hundred gained all the weight back after the study. So these studies don't work. And when I did keto, I've built sustainability. It's keto. Do you not hear what you just said? Like, no, it comes down to calories and protein. And whether you choose a lower carbohydrate approach, a higher carbohydrate approach, with like with whole foods, medicine, it doesn't matter. You think the cause was low carb. No, no, no, no, no, no. That process helped you build sustainability to build a calorie deficit, and you enjoyed that modality better, which is fine. But when you make claims that you can't burn body fat at a high insulin state and it's this and it's this mechanism, it's this mechanism, no, no, no, you can't do that. Because you don't actually know the hard hard mechanism. All I'm saying is out of the fifty uh this population that are being put on these drugs right now, do they all have to be on it based upon this specific mechanism?

SPEAKER_00 44:13

No. Okay, uh if you're saying they don't have to be on it, are you saying they shouldn't be on it?

SPEAKER_05 44:19

It depends. What's what's the cascade of the negative effects if they're, say, just drinking regular pop, but they're b but they're only drinking a few things and now they have bone density loss, they have all these other problems.

SPEAKER_00 44:31

Right. But I think there can be people doing all the wrong things that would still have a better outcome if they took the med. And there's There's truth to this. Because the medications are used, they're indicated for more than just weight loss. And so I think that's the thing. It's like you can't look at somebody who's taking the med and not making the right choices and make the assumption that they're making a bad choice.

SPEAKER_05 44:52

But you're creating a very specific one-sided person. When I'm talking about 50% of the American people, I don't think this I don't think this is one-sided.

SPEAKER_00 45:01

I think there's a lot of people out there like this. Do you know how many people have liver disease, have kidney disease, have high blood pressure, have metabolic problems, that they would benefit from these medications regardless of how they change their lifestyle because it helps those problems. I mean true. Not all those problems, but some of them.

SPEAKER_05 45:17

True. The byproduct being weight loss.

SPEAKER_00 45:20

Uh no, but there is there is plenty of evidence for benefit that it is not correlated with weight loss.

SPEAKER_05 45:26

Yeah.

SPEAKER_00 45:26

So that's the thing. It helps cardiovascular reduction, liver disease reduction. These are not related to weight loss always.

SPEAKER_05 45:34

That is true. But again, you're you're getting into the weeds. We're spoken, we're space, we're specifically talking about weight loss. Yeah. You're throwing out these secondary uh claims. Well, because I'm not sure. We're talking about weight loss and hunger. You can't just throw, no, no, no, no, no, no, no. You can't throw a secondary uh benefit when we're talking about weight loss.

SPEAKER_00 45:54

I can when we're talking about weight. No, no, no, no, no, no.

SPEAKER_05 45:56

We're talking about hunger and weight loss. We're talking about hunger and weight loss. Stay on topic. Hunger and weight loss. Yes or no. Hunger and weight loss, yes or no.

SPEAKER_00 46:05

For what? What you're doing.

SPEAKER_05 46:06

Cardiovascular reduction, you threw other things in there that this whole conversation was about lifestyle-induced hunger.

SPEAKER_00 46:13

Oh, I don't agree with that. That is not how we start.

SPEAKER_05 46:16

That's how this whole conversation started. No, we're not. 100%. Because I said 50, we'll go back to the beginning. I support these medications. I'm going to stay the same quote from the beginning. If anyone says otherwise, comment down below if my if my context has changed. 50% of Americans are clinically obese. Are like for example, should we support people on these medications? Absolutely. Is there a population that should probably need to be on these drugs for the rest of their lives? Absolutely. There's nothing wrong with that. Do I believe 50% of Americans that have obesity problems, which is a calorie problem, need to be on these drugs for the rest of their lives because they have a genetic disposition to hung. That is not how we started. That is how this started. We did not I promise you, everyone watching this, watch this whole episode, comment down below if I if I've been incongruent with my statement at all. You are the one that started adding secondary benefits. No, no, no, no. You are the one that started changing things.

SPEAKER_00 47:12

Okay, we did not start this podcast saying we are talking about only the people with a genetic predisposition to wait. That was not how we started it.

SPEAKER_05 47:20

No, but but when I made my claim, my statement about 50% of Americans being clinically obese and that process, obesity being primarily uh an a calorie thing, which is primarily a hunger thing, which food noise, all this kind of stuff, that was the important and I and my whole comment setting.

SPEAKER_00 47:38

Maybe that's how you felt, but that is not how we started this podcast. Absolutely not.

SPEAKER_05 47:42

I'm not talking about the talk total podcast. I'm talking about when I made my statement. I don't agree. I do not agree. I'm looking forward to this. Um guys, if you think I said something different than what I said, I'd love to hear it. David Bottenberg, I know you're gonna watch this whole episode. Whose side are you on right now?

SPEAKER_00 47:58

Because I think David starts talking about other examples, and then it's just as confusing.

SPEAKER_05 48:03

No, you're the one that threw secondary benefits of liver, fatty liver disease, and cardiovascular.

SPEAKER_00 48:08

So we're talking about who should be on these medications, and you have to do it. That is a part of it.

SPEAKER_05 48:15

That's but that's the lens what I'm talking through. I do not agree with you. I'm right. Nope. All right, beautiful people.

SPEAKER_00 48:22

My dad's all right.

SPEAKER_05 48:24

It was a beautiful episode. Hope you guys got some great value out of it. We'll talk to you soon.

SPEAKER_00 48:29

Bye.