Latest / The Antisocial Doctors Podcast / Episode 23: Is Tracking Body Composition Actually Helpful?

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Episode 23: Is Tracking Body Composition Actually Helpful? · The Antisocial Doctors Podcast

• 1:27
  Sonia Singh MD: You're listening to The Anti-Social Doctors Podcast hosted by me, Sonia Singh, a board-certified internal medicine physician with a master's in nutrition and a special interest in health anxiety.
• 1:38
  Rebecca Berens MD: And me, Rebecca Behrens, a board-certified family medicine physician with a special interest in disordered eating.
• 1:43
  Sonia Singh MD: We're also millennial women, anxious moms, and curious humans navigating social media.
• 1:48
  Sonia Singh MD: We've seen firsthand how these platforms can be powerful tools for education and connection, but can also make us unwell.
• 1:56
  Rebecca Berens MD: This podcast is meant to be the antidote to your doom scrolling, a solve for the anxiety, stress, guilt, shame, and confusion that comes from social media's messaging around health.
• 2:05
  Rebecca Berens MD: In each episode, we discuss a health-related topic trending on social media with curiosity, nuance, evidence, humility, and compassion.
• 2:12
  Sonia Singh MD: This is not your average debunking podcast.
• 2:15
  Sonia Singh MD: We wanna explore not just what is trending on social media, but why.
• 2:18
  Sonia Singh MD: Why are so many people drawn to this?
• 2:20
  Sonia Singh MD: What is the nugget of truth here?
• 2:21
  Sonia Singh MD: What are the facts?
• 2:23
  Sonia Singh MD: What can we learn from this as patients and doctors?
• 2:25
  Sonia Singh MD: No shame, no blame, no snark.
• 2:27
  Rebecca Berens MD: We're so glad you're here
• 2:41
  Sonia Singh MD: Hi, Rebecca.
• 2:42
  Sonia Singh MD: Hi, Sonia I'm really excited to talk about this topic with you,'cause we've actually both been talking about it offline for a long time, and it's becoming, I think, very relevant to a lot of the other topics we have discussed on this podcast.
• 2:57
  Sonia Singh MD: So- Absolutely tell us a little bit about the patient story that inspired today's topic.
• 3:03
  Rebecca Berens MD: Okay, so this is probably something familiar to a lot of people now, but I had a patient that told me they were regularly checking their body composition with a machine at their local gym so that they could monitor their metabolic health and track their progress with their workouts.
• 3:17
  Rebecca Berens MD: And the other reason I wanted to do this topic is I've also had some conversations with some obesity medicine physician specialists that have talked about the importance of body composition measurement and even that it should be considered a vital sign and be done as a screening measure annually for everyone 18 and older.
• 3:37
  Rebecca Berens MD: Which I did not agree with, but I was like,"Let me actually investigate,'cause maybe I don't know." So that's what drove me to do this topic today.
• 3:48
  Rebecca Berens MD: Didn't you just get a body composition machine in your practice?
• 3:52
  Rebecca Berens MD: I did.
• 3:52
  Rebecca Berens MD: Okay.
• 3:52
  Rebecca Berens MD: And we will talk about that.
• 3:54
  Rebecca Berens MD: I
• 3:54
  Sonia Singh MD: believe I got an email- So to be clear- as a patient saying that- I did you had an exciting new body composition machine.
• 4:00
  Rebecca Berens MD: And I am going to talk about that, because I don't want to indicate that I am anti body comp machine.
• 4:07
  Rebecca Berens MD: 'Cause I'm not.
• 4:08
  Rebecca Berens MD: But I think we have to be aware of the appropriate uses, limitations, and potential harms.
• 4:16
  Rebecca Berens MD: And so that's why I wanted to dig deeper into this topic today.
• 4:20
  Sonia Singh MD: Okay.
• 4:21
  Sonia Singh MD: I appreciate that,'cause I have actually...
• 4:22
  Sonia Singh MD: It's been on my wish list.
• 4:23
  Sonia Singh MD: I have been wanting to get a body composition machine for my practice.
• 4:26
  Sonia Singh MD: So having this conversation with you may help me clarify whether that's the right choice or not, or at least how to use it wisely if I end up getting one.
• 4:33
  Sonia Singh MD: Yeah.
• 4:33
  Rebecca Berens MD: And I think that's the key thing and what I wanna make sure we're talking about.
• 4:37
  Sonia Singh MD: Okay.
• 4:38
  Sonia Singh MD: So tell us a little bit more about what's the claim...
• 4:40
  Sonia Singh MD: What are the claims around body composition machines?
• 4:44
  Rebecca Berens MD: Yeah, so a lot of things that I've seen, at least, there's a lot of ads or influencer marketing around the importance of body composition testing how it can show you your metabolic age, quote, unquote, and give you information to help you personalize your health plan to optimize your health.
• 5:02
  Rebecca Berens MD: Optimizing, as we are- always talking about it.
• 5:04
  Sonia Singh MD: Always optimizing.
• 5:05
  Rebecca Berens MD: And so it's, it's basically the more information you have, the better, and you can use this to kinda tweak your plan, right?
• 5:11
  Rebecca Berens MD: I think also there's discussion of Skeletal muscle mass is so important as you age, which true and can be tracked as a marker of your longevity, which not so sure that's as accurate.
• 5:23
  Rebecca Berens MD: And then I think the other piece is, there's a lot of discussion of oh, you should not do these bioimpedance bioelectric impedance analysis scales versus a DEXA scan because there's some variation between the two that could drastically change your approach to your health.
• 5:40
  Rebecca Berens MD: Which I think is an interesting claim that we'll talk about.
• 5:42
  Rebecca Berens MD: But basically, you know- indicating that one is better than the other and all that.
• 5:48
  Rebecca Berens MD: So we'll talk about that.
• 5:50
  Sonia Singh MD: I guess this is an inherent claim, but my impression or what I think about when I think about getting the body composition information is that I'm getting more of a breakdown and more detail than what I just see on a scale.
• 6:02
  Sonia Singh MD: Like- Absolutely right now all I have is a scale.
• 6:04
  Sonia Singh MD: And so-
• 6:05
  Rebecca Berens MD: Absolutely.
• 6:06
  Rebecca Berens MD: Absolutely
• 6:06
  Sonia Singh MD: for me, I feel this would...
• 6:08
  Sonia Singh MD: I have patients who embark on all these lifestyle changes, and then they come back and they're disappointed that the scale does not show that.
• 6:15
  Sonia Singh MD: And- Part of me believes that something is changing in terms of their composition, and I wanna prove it to them.
• 6:20
  Sonia Singh MD: So to me it's like part of the claim is it will bring...
• 6:25
  Sonia Singh MD: it will give you additional data points with which to evaluate changes that you're making, and that might help guide or motivate you to make further changes.
• 6:35
  Rebecca Berens MD: Yes.
• 6:35
  Rebecca Berens MD: And that's something we're gonna talk about.
• 6:37
  Rebecca Berens MD: And I think that is definitely relevant.
• 6:40
  Rebecca Berens MD: I guess I don't necessarily...
• 6:41
  Rebecca Berens MD: I guess I have seen some stuff on social media around that.
• 6:44
  Rebecca Berens MD: But I feel like a lot of the stuff I see on social media is more the optimization and the- Got it thing you can buy from me that- Okay.
• 6:55
  Rebecca Berens MD: Yeah.
• 6:55
  Rebecca Berens MD: So going into that, we'll go into why I think it's viral.
• 6:59
  Rebecca Berens MD: So as we discussed, a lot of this comes back to optimization culture.
• 7:03
  Rebecca Berens MD: How much more information can I have so that I can, perfectly tweak my routine to improve my health span and all of these things?
• 7:10
  Rebecca Berens MD: And I think that, of course is something that comes up on a lot of our episodes and is a big viral discussion on social media right now.
• 7:18
  Rebecca Berens MD: I think the other thing is, and we talked about this in our MRI episode, is the patients get a really nice color-coded printout that says you're normal, you're borderline, you're not normal on various metrics.
• 7:32
  Rebecca Berens MD: And it's a simple easy-to-read thing.
• 7:34
  Rebecca Berens MD: A lot of them also use a score at the end that's"This is your metabolic age," or,"This is your total body score." And who doesn't wanna get an A+?
• 7:42
  Rebecca Berens MD: A grade.
• 7:43
  Rebecca Berens MD: I know.
• 7:43
  Rebecca Berens MD: Or a gold star at the end of the day, but I think, again, we've talked about this before the confusion that results from getting these medical reports full of jargon or going to the office and getting your weight and you're just like,"What does this even mean?" Versus getting this breakdown of information.
• 7:58
  Rebecca Berens MD: And that really appeals to people.
• 8:00
  Rebecca Berens MD: And then, like I said, a lot of the content that I've seen is often an influencer or even an ad that is selling a direct consumer body composition, a DEXA scan or doing a a gym will advertise it like,"Oh, you can do your body comp at our gym and track your project." So there's just, there's a lot of underlying advertising behind it.
• 8:22
  Rebecca Berens MD: And particularly in the gyms I think a lot of times they do it and then they have a sales package afterwards.
• 8:28
  Rebecca Berens MD: "Oh, this is your body score, and y- you can buy this program and use this supplement that we sell, and then you'll improve your body score," right?
• 8:36
  Rebecca Berens MD: And so-
• 8:36
  Sonia Singh MD: It's an entry point to, Yeah the rest of the things they're gonna sell you.
• 8:39
  Sonia Singh MD: Yeah.
• 8:40
  Sonia Singh MD: Yeah,
• 8:40
  Rebecca Berens MD: absolutely.
• 8:41
  Rebecca Berens MD: And so I think that is a lot of the things playing into the virality.
• 8:45
  Rebecca Berens MD: What else do you think?
• 8:46
  Rebecca Berens MD: What have you seen?
• 8:47
  Sonia Singh MD: No, I think people just have this deep desire to understand themselves and their bodies better.
• 8:52
  Sonia Singh MD: And l- I, like you said, I think we in medicine are really dropping the ball on presenting that information in a way that people find useful and perceive to be valuable.
• 9:02
  Sonia Singh MD: So someone showed me recently one of these reports where it was, a 3D, model of his body and then, all the fat and all the percentage.
• 9:11
  Sonia Singh MD: It was so detailed.
• 9:12
  Sonia Singh MD: And, I can see how me and my little scale just can't- Yeah.
• 9:17
  Sonia Singh MD: compete with that.
• 9:18
  Sonia Singh MD: So yeah, I think we as a society are desiring more data.
• 9:22
  Sonia Singh MD: And so I think the desire for more concrete data is probably driving this.
• 9:27
  Sonia Singh MD: I think we desire to understand our bodies.
• 9:30
  Sonia Singh MD: They feel mysterious to a lot of people, and sometimes we don't make them any less mysterious in medicine.
• 9:36
  Sonia Singh MD: Yeah, I think this gives you that sense of having a more than surface level view into your health and how you're doing.
• 9:42
  Rebecca Berens MD: Yeah, absolutely.
• 9:44
  Rebecca Berens MD: Okay.
• 9:44
  Rebecca Berens MD: So what is the nugget of truth?
• 9:46
  Rebecca Berens MD: So as we just said, body composition is providing a lot more information and context than, a height and weight BMI calculation.
• 9:56
  Rebecca Berens MD: I've mentioned this many times on this podcast, I think the BMI is kinda stupid.
• 10:00
  Rebecca Berens MD: It was never intended to be a marker of individual health.
• 10:04
  Rebecca Berens MD: And really, it should be used more as a screening tool to then have a discussion about metabolic health risks and things like that.
• 10:11
  Rebecca Berens MD: But but on an individual level, it's kinda stupid.
• 10:15
  Rebecca Berens MD: And so a body composition is a direct measurement of that individual, right?
• 10:20
  Rebecca Berens MD: So you are getting a lot more information that is specific to that individual rather than just on the percentiles of humans, you're here.
• 10:27
  Rebecca Berens MD: It just, it's not- Like you said it's not satisfying to the patient and also it's very stigmatizing.
• 10:34
  Rebecca Berens MD: Yeah I think the other thing that's interesting is that, you can have someone who has a, quote unquote,"normal BMI"- but still has, sarcopenia, meaning a low muscle mass, which has implications for their functional capacity and for their metabolic health.
• 10:48
  Rebecca Berens MD: And they may have increased visceral fat, which we know is related to overall metabolic health and cardiometabolic disease.
• 10:55
  Rebecca Berens MD: And you're maybe missing that in an individual that's a normal BMI and I think this, this goes a lot to like- when we talk about diet culture, I think people who look thin naturally are perceived as healthy, and people who are larger naturally are perceived as unhealthy.
• 11:13
  Rebecca Berens MD: Yeah.
• 11:13
  Rebecca Berens MD: And that is probably not true in many cases, right?
• 11:17
  Rebecca Berens MD: And it may be useful to delineate on, in an individual if there's more to discuss, much better than the BMI.
• 11:23
  Rebecca Berens MD: I think also as we know, if people who have a higher BMI can have a higher BMI because they have a lot of muscle.
• 11:31
  Rebecca Berens MD: And it doesn't necessarily mean that they have a lot of visceral fat just because their BMI is high.
• 11:36
  Rebecca Berens MD: And so it's going to better classify the health risks for that individual patient compared to what the BMI says.
• 11:43
  Rebecca Berens MD: And again, talked about this many times on the podcast, weight and BMI are not an accurate measure of your individual health and are very stigmatizing numbers many times.
• 11:53
  Rebecca Berens MD: And again, it is a little bit more precise to that individual and and maybe more actionable in that way.
• 11:59
  Rebecca Berens MD: The other thing is, DEXA is the gold standard for body composition.
• 12:03
  Rebecca Berens MD: And so there is some truth to the fact that DEXA is a little bit more accurate than the BIA which is the bioelectrical impedance analysis.
• 12:11
  Rebecca Berens MD: I'm just gonna say BIA from now on'cause it's...
• 12:13
  Rebecca Berens MD: That's a mouthful.
• 12:13
  Rebecca Berens MD: So that
• 12:13
  Sonia Singh MD: would be like a InBody type scan?
• 12:15
  Rebecca Berens MD: Like an InBody, or what I have is a seca.
• 12:17
  Rebecca Berens MD: And so yeah we'll talk about that because there are varying degrees of BIAs.
• 12:22
  Rebecca Berens MD: There's like home grade, and then there's gym grade, and then there's medical grade, right?
• 12:27
  Rebecca Berens MD: So Not every BIA machine is equal.
• 12:29
  Rebecca Berens MD: But all that to say with the DEXA, you're maybe getting a bit more information.
• 12:34
  Rebecca Berens MD: I think the other thing with DEXA is DEXA is also used to measure bone density.
• 12:39
  Rebecca Berens MD: And so that is not something that is measured with BIA.
• 12:42
  Rebecca Berens MD: However, the direct to consumer body composition DEXAs are measuring total bone mass, not bone density at the medical level that would be required to delineate like osteopenia or osteoporosis.
• 12:56
  Sonia Singh MD: Oh, okay.
• 12:57
  Sonia Singh MD: When you say direct to consumer, what does that mean?
• 13:01
  Rebecca Berens MD: So there's all kinds of places where you can walk in and pay for a DEXA body comp.
• 13:06
  Sonia Singh MD: So you're telling me that those DEXAs are not the same as like a DEXA at an imaging center that I would send my patient to?
• 13:13
  Rebecca Berens MD: So in terms of the...
• 13:15
  Rebecca Berens MD: Because with this, it's always like the software and stuff that they're applying.
• 13:18
  Rebecca Berens MD: They are not evaluating the bone density in the same way that a medical grade DEXA is.
• 13:24
  Rebecca Berens MD: Oh, okay.
• 13:25
  Rebecca Berens MD: Now, it is still a DEXA machine.
• 13:26
  Rebecca Berens MD: Yes.
• 13:27
  Rebecca Berens MD: But with DEXA, it matters how the machine is programmed- Okay and the software that's being used.
• 13:32
  Rebecca Berens MD: And you're not getting the same information.
• 13:34
  Rebecca Berens MD: So your bone mass could say one thing on your DEXA bone density, but that has nothing to do with if you have osteopenia or osteoporosis.
• 13:42
  Sonia Singh MD: No, but would they call that bone density then, or would they just call
• 13:45
  Rebecca Berens MD: it bone- They call it bone mass.
• 13:46
  Sonia Singh MD: Okay.
• 13:47
  Rebecca Berens MD: But I think it's easy for a patient- To misunderstand that information, because like you're hearing bone mass.
• 13:55
  Rebecca Berens MD: Is that different than bone density?
• 13:56
  Rebecca Berens MD: My bone mass is good, so everything's fine.
• 13:58
  Rebecca Berens MD: But like we know like-
• 13:59
  Sonia Singh MD: Interesting the
• 13:59
  Rebecca Berens MD: bone quality could be affected, right?
• 14:02
  Rebecca Berens MD: And so I think this is just something important to know in terms of when we're talking about the truths behind these things.
• 14:09
  Sonia Singh MD: Yeah.
• 14:09
  Sonia Singh MD: But- That's so interesting,'cause I definitely do have people who I feel like they've told me"Oh, I went and got this at my gym, and like they told me my bones were normal, so like I don't need a bone density or something." So those may not actually have been true screenings for osteoporosis.
• 14:24
  Rebecca Berens MD: They were not, I can assure you.
• 14:26
  Rebecca Berens MD: Yes.
• 14:26
  Sonia Singh MD: Okay.
• 14:27
  Sonia Singh MD: All
• 14:27
  Rebecca Berens MD: right.
• 14:27
  Rebecca Berens MD: Because- Good to know yeah, we have to have the appropriate equipment and appropriate radiologist to interpret the program data.
• 14:35
  Rebecca Berens MD: This is way above my ca- pay grade.
• 14:36
  Rebecca Berens MD: I don't mean to say like I know everything about DEXA.
• 14:38
  Rebecca Berens MD: But the point is, if you got it done at a gym or a random place, it's not checking your bone density.
• 14:43
  Rebecca Berens MD: A wellness
• 14:43
  Sonia Singh MD: center.
• 14:44
  Rebecca Berens MD: Yeah.
• 14:45
  Sonia Singh MD: Actually, I gotta look up...
• 14:45
  Sonia Singh MD: I'm gonna look up this report actually at some point, because I th- I...
• 14:48
  Sonia Singh MD: This patient, I thought it was all on one page where it was like her body composition and the bone density, and it was all in the same report.
• 14:54
  Rebecca Berens MD: Mean, unless they had a true medical grade machine that could do that type of calculation differently than, more like a medical grade one.
• 15:05
  Rebecca Berens MD: But I've never seen that.
• 15:06
  Rebecca Berens MD: I could guess that it says bone mass, and that was reported as"Oh, it's normal, so your bone density's normal." I could see that being interpreted in that way, but I don't think that's probably what was meant.
• 15:18
  Rebecca Berens MD: Okay.
• 15:18
  Rebecca Berens MD: We will analyze this.
• 15:19
  Sonia Singh MD: Yes.
• 15:20
  Sonia Singh MD: Awesome.
• 15:21
  Sonia Singh MD: Okay, go on.
• 15:22
  Rebecca Berens MD: So I think also there is increasing support amongst expert opinion and guidelines around the use of body composition monitoring over time in certain contexts.
• 15:32
  Rebecca Berens MD: For example, if the, someone has a condition that is prone to muscle mass loss cancer, malnutrition, using a GLP-1, having bariatric surgery There is more expert opinion coming out that this is something we should be monitoring,'cause these are known risks of this treatment or this condition, and measuring it might help us intervene or adjust the treatment depending on the needs of the patient.
• 15:57
  Rebecca Berens MD: But we'll talk about whether there's actually evidence behind that later.
• 16:01
  Rebecca Berens MD: Going to what are the facts, I think Like we talked about in pre- previous episodes, when we're talking about evidence for any sort of intervention, whether it's a screening or a treatment, we need to be looking at what is the purpose, in what patient population are we studying this, what is the strength of the data, and then I would also add what are the risks and benefits, and when you weigh those risks and benefits, is it worth doing?
• 16:26
  Rebecca Berens MD: Because if there's potential harm and little potential benefit, maybe that's not worth doing, but if there's a good amount of benefit and little harm, that's something that maybe that calculus is a little bit different even if there's not as much strength of evidence behind it- potentially, right?
• 16:42
  Rebecca Berens MD: So anyway, when we're talking about in this case and answering the question, like should the general population be doing body composition screening and monitoring over time, is there any evidence that actually improves any of their outcomes, and then are there any potential harms to that?
• 16:58
  Rebecca Berens MD: So
• 16:58
  Sonia Singh MD: I just wanna pause and point out that a lot of non-medical people, and even a lot of medical people, would not even get to this layer of the conversation because for a lot of people they just perceive more information as better Yeah.
• 17:10
  Sonia Singh MD: So they're like,"Why would I not want also my body composition in addition to our weight?" So to clarify, why are we even going the step further and looking at this is like this is how we make decisions in medicine, especially for populations of people and recommendations that we're making on a population level.
• 17:27
  Sonia Singh MD: We're not making the decision for you or I, like whether you or I- Yeah wanna get this.
• 17:31
  Sonia Singh MD: We're talking about, does this make sense as something that we should be recommending to our patients, and- Yeah,
• 17:36
  Rebecca Berens MD: in
• 17:36
  Sonia Singh MD: general that requires...
• 17:37
  Sonia Singh MD: Yes, and that requires a higher burden of proof to say, whether this additional data is actually helpful or not helpful, or whether there's some unintended harm from checking it.
• 17:47
  Sonia Singh MD: Yes.
• 17:47
  Sonia Singh MD: So yes.
• 17:48
  Sonia Singh MD: Okay.
• 17:49
  Sonia Singh MD: So let's move on to a deeper dive on the facts and the context.
• 17:53
  Sonia Singh MD: I have a lot of questions popping up in my mind, but I'm gonna withhold them and see if you address them.
• 17:57
  Sonia Singh MD: Okay.
• 17:57
  Rebecca Berens MD: Hopefully I can answer them.
• 17:59
  Rebecca Berens MD: Okay.
• 17:59
  Rebecca Berens MD: Okay.
• 17:59
  Rebecca Berens MD: So first, I wanna talk about the most common types of bone density technology that are used.
• 18:06
  Rebecca Berens MD: So there are multiple types.
• 18:07
  Rebecca Berens MD: You can do it with DEXA, with a BIA, MRI, CT.
• 18:11
  Rebecca Berens MD: So there's a lot of options.
• 18:13
  Rebecca Berens MD: I'm gonna focus on DEXA and BIA today because these are the ones I saw come up the most in studies, and also are certainly the ones that are coming up the most on social media and are available direct to consumer.
• 18:25
  Rebecca Berens MD: Like- I've never seen a direct to consumer MRI or CT specifically for bone density.
• 18:29
  Rebecca Berens MD: Although maybe, I don't remember from our MRI discussion if that was something they report.
• 18:34
  Rebecca Berens MD: Maybe I'm misremembering.
• 18:35
  Rebecca Berens MD: But anyway, all that to say I'm gonna go over BIA and DEXA specifically.
• 18:39
  Rebecca Berens MD: So I'll start with BIA.
• 18:41
  Rebecca Berens MD: So how does BIA measure your body composition?
• 18:45
  Rebecca Berens MD: So basically, it's measuring the movement of a electrical charge through the body, and lean tissues like muscle and blood contain high amounts of water and electrolytes, so they conduct well, versus fat and bone tissue contain very little water, so they're poor conductors and they slow down the current.
• 19:04
  Rebecca Berens MD: And so then the device based on a calculation, taking into account height, weight, age, sex, and waist circumference, uses that current information to calculate an estimated fat mass, and fat-free mass, and visceral fat mass, and muscle mass, et cetera.
• 19:22
  Rebecca Berens MD: And the reason that someone might use this, or pros and cons this is very quick.
• 19:26
  Rebecca Berens MD: Like I said, I have a Bod Pod machine.
• 19:27
  Rebecca Berens MD: It takes 24 seconds.
• 19:29
  Rebecca Berens MD: It is painless.
• 19:30
  Rebecca Berens MD: There's some of them that are home almost just a scale that's portable.
• 19:36
  Rebecca Berens MD: Again probably not as accurate as medical grade ones, and the one I have in my office is portable.
• 19:41
  Rebecca Berens MD: You roll it room to room.
• 19:43
  Rebecca Berens MD: There's also some that are larger and don't move around, but they're certainly smaller than a DEXA scanner.
• 19:49
  Rebecca Berens MD: Yeah.
• 19:49
  Rebecca Berens MD: So this is something that could be actually implemented at the point of care in a regular medical office- versus these other DEXA, MRI, CT.
• 19:58
  Rebecca Berens MD: No one's just doing that in their office, especially for a quick office visit.
• 20:02
  Rebecca Berens MD: It's just not happening, right?
• 20:04
  Rebecca Berens MD: And so this is a point of care tool that's available.
• 20:06
  Rebecca Berens MD: And it actually is not so far off of DEXA.
• 20:09
  Rebecca Berens MD: Different machines have different, different levels of accuracy compared to the DEXA.
• 20:15
  Rebecca Berens MD: I actually chose the seca specifically, and I'm not getting paid by seca here, but because it had better- concordance with DEXA compared to some of the other options I considered.
• 20:23
  Rebecca Berens MD: So anyway, all that to say there's different levels of accuracy, but overall, it's a better point of care tool than these other options.
• 20:32
  Rebecca Berens MD: However, cons, the accuracy is affected, of course, by your hydration level.
• 20:36
  Rebecca Berens MD: Because it's- Well, that makes sense it's charged through water.
• 20:39
  Rebecca Berens MD: Yeah.
• 20:39
  Rebecca Berens MD: And so if that has changed, especially significantly since maybe the last time that you got it measured, if you have food in your stomach, if you're cold or warm, if you exercised recently, all of this is gonna cause- shifts in fluid that will impact the results.
• 20:54
  Rebecca Berens MD: And certainly the direct to consumer, home scale versions you just stand your feet on it.
• 20:59
  Rebecca Berens MD: There's nothing you're holding, so the charge is not being transmitted as properly as it would be in a machine where you're holding the grips and you're standing on the scale part.
• 21:09
  Rebecca Berens MD: And the gym machines are not the same accuracy as the medical grade ones.
• 21:14
  Rebecca Berens MD: So you know, l- different layers of accuracy depending on the type of BIA that you're using.
• 21:21
  Rebecca Berens MD: And then of course also these situational limitations.
• 21:25
  Rebecca Berens MD: And then with the DEXA again, it is the gold standard.
• 21:28
  Rebecca Berens MD: It is high precision, but again, software based.
• 21:32
  Rebecca Berens MD: There can be variations between different machines including the manufacturer, the model, the type of software or whatever that they're using.
• 21:41
  Rebecca Berens MD: And so you would have to be using, again, the same machine over time if you were gonna be tracking this over time, because a different machine would maybe give you a different result.
• 21:53
  Rebecca Berens MD: And so even though it is more accurate than a BIA by a little bit there's still the limitation of using the same machine.
• 22:01
  Rebecca Berens MD: And again the situation, like fluid changes and all that still will impact it somewhat maybe just to a lesser degree than a BIA.
• 22:09
  Rebecca Berens MD: The other thing to note with DEXA is it does expose the patient to a small amount of radiation.
• 22:15
  Rebecca Berens MD: Now, it's very small.
• 22:16
  Rebecca Berens MD: It's nothing like a CAT scan and, we do these all the time for bone density screening, and it's not something we particularly worry about.
• 22:23
  Rebecca Berens MD: When I was reading about it, the effective radiation dose was reported as similar to the normal background radiation received over one day at sea level.
• 22:31
  Rebecca Berens MD: So not a huge dose of radiation, and not really different than your day-to-day.
• 22:35
  Rebecca Berens MD: But, certainly if you were doing these every week, I imagine it could start to, to build up maybe over time.
• 22:41
  Rebecca Berens MD: So yeah, that's, the summary of how those two types of body composition work.
• 22:46
  Rebecca Berens MD: And those are be- gonna be the ones we're mostly talking about in the studies I'm gonna talk about
• 22:52
  Sonia Singh MD: Okay.
• 22:53
  Rebecca Berens MD: Okay.
• 22:54
  Rebecca Berens MD: I, I wanna get into the data I did find, and then we're gonna talk about the data I didn't find,'cause that's a lot.
• 23:03
  Rebecca Berens MD: So the first one that I wanna talk about was a systematic review and meta-analysis of randomized controlled trials, so this is a pretty strong level of evidence.
• 23:13
  Rebecca Berens MD: And this was looking at many studies that evaluated specifically lean mass changes using incretin therapy, which is like the GLP-1s, versus lifestyle interventions.
• 23:23
  Rebecca Berens MD: Is there a difference in lean mass loss between these two things?
• 23:26
  Rebecca Berens MD: And it was a huge meta-analysis, lots of studies.
• 23:29
  Rebecca Berens MD: And so you have 20 RCTs comprising over 15,000 participants.
• 23:35
  Rebecca Berens MD: And it did show that with total weight loss, whether you're using a medication like a GLP-1 or doing lifestyle interventions to cause weight loss there is a comparable proportion of lean mass loss between the two.
• 23:50
  Rebecca Berens MD: So in both cases- if you're losing weight, A percentage of that, of course, is gonna be lean mass and that wasn't necessarily different between the two.
• 23:57
  Rebecca Berens MD: Okay.
• 23:57
  Rebecca Berens MD: And lifestyle plus resistance training was the best for managing weight loss.
• 24:04
  Rebecca Berens MD: So again, there maybe is a difference- For maintaining muscle mass when you're doing...
• 24:07
  Rebecca Berens MD: if you're adding resistance training to these- there may be more of a difference between the two than just like in general, if that makes sense.
• 24:13
  Rebecca Berens MD: And so again, in both cases, there is significant, lean mass loss when there is significant weight reduction.
• 24:21
  Rebecca Berens MD: But it's comparable between the two if the same amount of weight is lost.
• 24:25
  Rebecca Berens MD: And so again, ensuring you're integrating resistance training, protein intake.
• 24:29
  Rebecca Berens MD: And and they recommended body composition monitoring at the end of this.
• 24:34
  Rebecca Berens MD: And I didn't see a whole lot of evidence as to why.
• 24:38
  Rebecca Berens MD: But that was what they were using, of course, to measure...
• 24:41
  Rebecca Berens MD: that's what these studies were using, was to measure the- Yeah body composition changes, was body composition.
• 24:46
  Rebecca Berens MD: But I- I don't know that this actually studied that- As, as like- So the question- an actual change of outcome.
• 24:52
  Sonia Singh MD: So the real question we would want answered is does monitoring people's body composition over the course of this weight loss attenuate or change the outcome?
• 25:02
  Sonia Singh MD: Yeah.
• 25:03
  Sonia Singh MD: Does that- Yeah help people maintain more by showing them that they're losing it and having them, adjust their treatment or their lifestyle accordingly?
• 25:11
  Sonia Singh MD: Yeah but
• 25:12
  Rebecca Berens MD: yeah, that was about it.
• 25:12
  Rebecca Berens MD: 'Cause I don't think anyone is disagreeing that lean mass is lost when you lose weight.
• 25:16
  Rebecca Berens MD: Like- Right that is established.
• 25:18
  Rebecca Berens MD: I don't think anyone disagrees with that point.
• 25:21
  Rebecca Berens MD: But my main question going into this was, does measuring the body composition- routinely make any difference in that outcome.
• 25:29
  Rebecca Berens MD: So that was my-
• 25:30
  Sonia Singh MD: And I think the reason it's more relevant now with GLP-1s is just'cause it's so much easier for people to lose a large amount of weight in a short- Yeah amount of time.
• 25:39
  Sonia Singh MD: Whereas with just the lifestyle changes, that same amount of weight loss may have happened over a longer period or just not been possible.
• 25:46
  Sonia Singh MD: Absolutely.
• 25:46
  Sonia Singh MD: Okay.
• 25:47
  Sonia Singh MD: Okay.
• 25:47
  Sonia Singh MD: Yeah.
• 25:47
  Sonia Singh MD: So that's one bit of data, although it doesn't really answer the question in a way.
• 25:51
  Sonia Singh MD: Yeah, does not
• 25:52
  Rebecca Berens MD: answer the question.
• 25:53
  Sonia Singh MD: This is useful.
• 25:53
  Sonia Singh MD: Okay, what else you got?
• 25:55
  Rebecca Berens MD: The next one I just thought was, this was an interesting one.
• 25:58
  Rebecca Berens MD: So this was a study of older adults, and it was studying aerobic resistance exercise or both in dieting obese older adults.
• 26:08
  Rebecca Berens MD: So that was the population.
• 26:10
  Rebecca Berens MD: And my first question was,"Why are these older adults dieting?" But anyway, we'll get into that.
• 26:15
  Rebecca Berens MD: So it was a 20-week, it's a 26-week study randomized, and there were four groups.
• 26:21
  Rebecca Berens MD: There was a control protocol where they were not on any specific, weight management based diet or doing any sort of exercise intervention, just like their usual situation.
• 26:31
  Rebecca Berens MD: There was an aerobic group that was in a diet-based weight management program, and the diet-based program was the same amongst the next three groups that I'm gonna talk about.
• 26:41
  Rebecca Berens MD: It included a, quote-unquote,"balanced diet" that provided an energy deficit of 500 to 750 calories per day.
• 26:48
  Rebecca Berens MD: Ooh.
• 26:48
  Rebecca Berens MD: Yeah.
• 26:48
  Sonia Singh MD: Big def- big energy deficit.
• 26:50
  Sonia Singh MD: Yeah.
• 26:50
  Sonia Singh MD: Okay.
• 26:51
  Rebecca Berens MD: For a...
• 26:52
  Rebecca Berens MD: Th- these were all patients over 65, by the way.
• 26:54
  Rebecca Berens MD: I don't think I said that yet.
• 26:55
  Rebecca Berens MD: Ooh, okay.
• 26:56
  Rebecca Berens MD: Which I thought was interesting.
• 26:57
  Rebecca Berens MD: And contained approximately one gram of high quality protein per kilogram of body weight per day.
• 27:02
  Sonia Singh MD: Okay.
• 27:03
  Rebecca Berens MD: So- Reasonable decent amount of protein.
• 27:05
  Rebecca Berens MD: There is a calorie deficit in all of these non-control groups.
• 27:09
  Rebecca Berens MD: So one was aerobic exercise, one was combined aerobic and resistance exercise, and one was resistance exercise alone.
• 27:19
  Rebecca Berens MD: So essentially resistance, aerobic, or the combination of the two.
• 27:23
  Sonia Singh MD: Okay.
• 27:23
  Rebecca Berens MD: And they were all meeting with a dietician regularly to discuss balanced diet and general diet advice, but only the ones in the testing groups were given a specific plan to reduce a calorie deficit.
• 27:36
  Rebecca Berens MD: So the control group was just receiving like education about balanced diet.
• 27:40
  Rebecca Berens MD: Okay.
• 27:41
  Rebecca Berens MD: And yes, so the people included were 65 or older.
• 27:44
  Rebecca Berens MD: They were considered obese, meaning a BMI greater than 30, and they were sedentary, meaning regular exercise less than an hour a week.
• 27:51
  Rebecca Berens MD: And their body weight had been stable with stable use of medication for the last six months.
• 27:57
  Sonia Singh MD: Okay.
• 27:58
  Rebecca Berens MD: All participants had mild to moderate frailty, which was defined as a score of 18 to 31 on the modified physical performance test.
• 28:07
  Rebecca Berens MD: So basically this is a, a test to see what can they actually do.
• 28:09
  Rebecca Berens MD: Functionally- how functional are they, right?
• 28:11
  Rebecca Berens MD: Most of the participants were women, were white, and were well-educated.
• 28:15
  Rebecca Berens MD: So important to note this is not- necessarily generalizable to the whole population.
• 28:20
  Rebecca Berens MD: Yeah.
• 28:20
  Rebecca Berens MD: And anyone who had a significant cardiopulmonary disease, neuromuscular problem, anything that would impact their ability to do the exercise or significant cognitive impairment or using a drug that affected their bone metabolism, all these people were excluded, of course, which makes sense.
• 28:36
  Rebecca Berens MD: So the reported outcomes from this study were that adults 65 and older indicated that weight loss plus a combination of aerobic and resistance exercise improved their physical function and reduced frailty more than weight loss plus, plus aerobic exercise or weight loss plus, plus resistance exercise.
• 28:58
  Rebecca Berens MD: So basically the combination was better than either exercise intervention alone.
• 29:04
  Rebecca Berens MD: But- Okay the thing that I thought was interesting, and was buried in a table'cause, body composition change was like a secondary outcome of this.
• 29:11
  Rebecca Berens MD: And I couldn't actually see how they were measuring it.
• 29:13
  Rebecca Berens MD: They were measuring it based on thigh muscle, which makes me think it was ultrasound based on some other things I read.
• 29:18
  Rebecca Berens MD: But anyway.
• 29:19
  Rebecca Berens MD: The control group actually had improved thigh muscle and performance scores compared to all of the other groups in this time period.
• 29:28
  Sonia Singh MD: The control group that just got generic diet advice and did not do any exercise.
• 29:32
  Rebecca Berens MD: Yes.
• 29:34
  Rebecca Berens MD: So- That was fascinating to me,'cause it was not really- discussed in the discussion.
• 29:39
  Rebecca Berens MD: But I'm just like, why are we going for a decrease here for what reason?
• 29:46
  Rebecca Berens MD: I didn't understand that.
• 29:47
  Sonia Singh MD: Interesting.
• 29:49
  Sonia Singh MD: But was that because the control group just didn't lose any weight, and everybody else
• 29:53
  Rebecca Berens MD: did?
• 29:53
  Rebecca Berens MD: They did not lose any weight, no.
• 29:54
  Rebecca Berens MD: They did not lose any weight, but their performance score increased, not just...
• 29:58
  Rebecca Berens MD: And their muscle- actually increased.
• 30:01
  Rebecca Berens MD: So it wasn't just that their weight was stable.
• 30:02
  Rebecca Berens MD: Maybe they just started getting
• 30:02
  Sonia Singh MD: adequate protein.
• 30:04
  Rebecca Berens MD: And so that's my thing is did just, getting some dietary counseling and maybe, I don't know if they...
• 30:10
  Rebecca Berens MD: I don't think they measured what did they actually do with that information, but they were getting just sort of general dietary counseling.
• 30:16
  Rebecca Berens MD: Maybe that alone was enough to help with some of these things.
• 30:19
  Rebecca Berens MD: And do we really need to be pushing weight loss and monitoring body comp in these patients when instead we could just leave them alone?
• 30:30
  Sonia Singh MD: Let's see.
• 30:31
  Sonia Singh MD: Okay Your argument would be, like y- they didn't prove that these people even needed to do an intervention.
• 30:37
  Rebecca Berens MD: Yes.
• 30:38
  Rebecca Berens MD: And- That is my argument.
• 30:40
  Sonia Singh MD: But we don't know about all these people.
• 30:42
  Sonia Singh MD: We don't know- you know- We know they're, we know they're frail, so they're not very functional
• 30:46
  Rebecca Berens MD: yeah, but the control group went up in their functional capacity.
• 30:50
  Sonia Singh MD: I see what you're saying.
• 30:51
  Rebecca Berens MD: It just, it's,
• 30:53
  Sonia Singh MD: you know- So you're saying the objective or the goal of the study should that have been the goal in the first place?
• 30:59
  Rebecca Berens MD: Yeah,'cause I think they were just like, how do we reduce the impact of the loss of lean mass in these frail adults when they're dieting?
• 31:09
  Rebecca Berens MD: And I think the underlying assumption was these people need to lose weight.
• 31:13
  Rebecca Berens MD: But it was not discussed that the control group- The people that they didn't do much with actually was fine.
• 31:17
  Rebecca Berens MD: Yeah.
• 31:17
  Rebecca Berens MD: And I don't know.
• 31:18
  Rebecca Berens MD: Okay, maybe there's other metabolic things that were not discussed here, right?
• 31:22
  Rebecca Berens MD: 'Cause this was primarily based on functional capacity and body composition measurements and things like that.
• 31:26
  Rebecca Berens MD: I didn't see anything about blood pressure, cholesterol, blood sugar, you know, all these things.
• 31:31
  Rebecca Berens MD: But I don't know.
• 31:33
  Rebecca Berens MD: To me, I was like,"Maybe you just need to leave these people alone."
• 31:35
  Sonia Singh MD: Wait, but so did functional capacity improve in the intervention groups?
• 31:39
  Rebecca Berens MD: That is a great question.
• 31:40
  Rebecca Berens MD: I
• 31:40
  Sonia Singh MD: don't- Because that's, that's what would support their whole f- study.
• 31:43
  Rebecca Berens MD: It did.
• 31:43
  Rebecca Berens MD: Yes, it did but not as much as the control group.
• 31:50
  Rebecca Berens MD: There was an improvement in the control group, but actually, no, I was wrong.
• 31:54
  Rebecca Berens MD: The the increase was better with the intervention groups.
• 31:58
  Rebecca Berens MD: And so let me go back.
• 32:00
  Rebecca Berens MD: Let me just do that again.
• 32:01
  Rebecca Berens MD: So the control group did have less of an increase in their functional capacity compared to the others, but the others were doing exercise that the control group was not doing.
• 32:12
  Rebecca Berens MD: So is it possible that if we just added the exercise to the control group- Ah.
• 32:16
  Rebecca Berens MD: Without the calorie deficit-
• 32:18
  Sonia Singh MD: I see
• 32:18
  Rebecca Berens MD: that it would improve more?
• 32:20
  Sonia Singh MD: Okay.
• 32:21
  Rebecca Berens MD: So it did- That was not tested
• 32:22
  Sonia Singh MD: So they didn't even, yeah, they didn't even bother doing that arm Of exercise alone without calorie deficit.
• 32:27
  Rebecca Berens MD: Yeah.
• 32:28
  Rebecca Berens MD: 'Cause I truly wonder, I'm like, if their, muscle mass in the the thigh muscle actually improved and, their functional capacity didn't go down, so if we had just added exercise alone to the control group- would that have actually made them- Out- outperformed the other interventions A better
• 32:48
  Sonia Singh MD: outcome.
• 32:48
  Sonia Singh MD: Yeah.
• 32:48
  Sonia Singh MD: Yeah.
• 32:49
  Rebecca Berens MD: But we didn't, but we didn't test that.
• 32:50
  Rebecca Berens MD: So anyway,
• 32:51
  Sonia Singh MD: Interesting.
• 32:52
  Rebecca Berens MD: Okay.
• 32:52
  Rebecca Berens MD: But again, none of these studies that I found they're studies of how body composition can be changed by various interventions, but none of them are addressing the question of does monitoring that body composition actually change any outcome?
• 33:12
  Sonia Singh MD: I'm sure you can also find studies, though, linking a higher percentage of fat mass and a lower percentage of muscle ma- I did a little bit of that for the protein episode where, like- Yeah lower muscle mass and sarcopenia is associated- Yeah with all kinds of bad out- outcome
• 33:26
  Rebecca Berens MD: Absolutely.
• 33:27
  Sonia Singh MD: So in the same way that we might check a lab that tells us that somebody's at increased risk for developing diabetes or something.
• 33:34
  Sonia Singh MD: In my mind, it makes sense of okay if we know that, lower muscle mass is associated with badness down the road and we check that thing, I am identifying now a risk factor for progression to that bad outcome.
• 33:49
  Rebecca Berens MD: Absolutely.
• 33:50
  Rebecca Berens MD: And that is what all the experts say.
• 33:53
  Rebecca Berens MD: And I agree with that to an extent.
• 33:55
  Rebecca Berens MD: I think that- If you are someone that is at risk of some sort of metabolic health problem and, or has a metabolic health problem, and we check the body composition, does that maybe help us understand the overall risk level?
• 34:11
  Rebecca Berens MD: Maybe.
• 34:12
  Rebecca Berens MD: Maybe it does.
• 34:12
  Rebecca Berens MD: Maybe it helps us to better understand that individual risk profile.
• 34:17
  Rebecca Berens MD: But does it actually change that?
• 34:20
  Rebecca Berens MD: Does measuring it change the outcome we've identified the risk factor, but did, did it make anything different- By measuring it?
• 34:28
  Rebecca Berens MD: And that's my question, because I think all of the counseling that we normally do is what we would still say once the body composition was done.
• 34:38
  Rebecca Berens MD: I just, I don't know that it would actually change anything that we do.
• 34:45
  Sonia Singh MD: So you and I have had this conversation about checking insulin levels, yes.
• 34:48
  Sonia Singh MD: And also about checking some hormone levels in perimenopause, where these are situations where typically checking those numbers does not change anything about our plan or our management.
• 34:59
  Sonia Singh MD: But we have come to the conclusion that in some cases we might offer those things as, almost a gesture or as part of the art of medicine of building trust and getting the patient to accept or, to feel that they understand their diagnosis better or their treatment plan and they feel more comfortable with it.
• 35:22
  Sonia Singh MD: So I, I guess I'm putting this in a little bit of the same category where yes, my doing of it may not be based on robust data, but again, perhaps in that art of medicine bucket we can say that information might be used to motivate or to, help a patient in some way.
• 35:44
  Rebecca Berens MD: Yeah.
• 35:45
  Rebecca Berens MD: And that was the conclusion I also came to.
• 35:47
  Rebecca Berens MD: And I agree.
• 35:47
  Rebecca Berens MD: I think does it change our medical management?
• 35:49
  Rebecca Berens MD: Probably not.
• 35:50
  Rebecca Berens MD: But I think what we talked about with that insulin conversation was does it change the patient's management?
• 35:55
  Rebecca Berens MD: Does that motivate them to do more of this stuff that we've been talking about anyway- now that they have some data?
• 36:02
  Rebecca Berens MD: And, I feel on the fence about that because part of me is are we paying it, playing into this like data obsession- By doing that, right?
• 36:10
  Rebecca Berens MD: Versus, moving away from you must know every ounce of data about yourself, and let's focus on enjoying your life and doing healthy behaviors that we know are healthy for you, right?
• 36:21
  Rebecca Berens MD: That's the piece that I feel uncomfortable with, is like I don't wanna be feeding into it.
• 36:24
  Rebecca Berens MD: And yeah.
• 36:26
  Rebecca Berens MD: So-
• 36:26
  Sonia Singh MD: But by d- by not providing that data, are you then pushing them back to be relying on the, just the number of pounds on the scale or the BMI, which you hate both
• 36:36
  Rebecca Berens MD: of, right?
• 36:36
  Rebecca Berens MD: I do.
• 36:36
  Rebecca Berens MD: So what I,
• 36:37
  Sonia Singh MD: I, in my practice- So this feels better than those.
• 36:40
  Rebecca Berens MD: In my practice, I'm looking at behaviors and labs.
• 36:47
  Rebecca Berens MD: And in my mind, that's what matters.
• 36:52
  Rebecca Berens MD: If there's disease on labs, like we have to intervene and treat that.
• 36:56
  Rebecca Berens MD: Even with the fasting insulin, like I talked about this.
• 36:58
  Rebecca Berens MD: I do order a fasting insulin with a fasting glucose, and we estimate do you have some insulin resistance even though your glucose is normal?
• 37:04
  Rebecca Berens MD: And then we talk about"Hey, this is a risk that you have.
• 37:06
  Rebecca Berens MD: Here are some behaviors that could mitigate that risk." But I don't know that adding this data- adds anything else to the table.
• 37:16
  Rebecca Berens MD: And again, I have one of these.
• 37:17
  Rebecca Berens MD: So I'm obviously doing it, right?
• 37:19
  Rebecca Berens MD: But I'm not- I
• 37:20
  Sonia Singh MD: know.
• 37:20
  Sonia Singh MD: I kinda wanna come to the office and get mine done.
• 37:22
  Rebecca Berens MD: Anytime.
• 37:23
  Rebecca Berens MD: But
• 37:24
  Sonia Singh MD: To be honest, I would like to know my body composition.
• 37:26
  Rebecca Berens MD: Yeah.
• 37:26
  Rebecca Berens MD: So you know, anytime you can come.
• 37:27
  Rebecca Berens MD: But I think my, my point behind this is does it reach the level of recommendation that this is a vital sign?
• 37:36
  Rebecca Berens MD: I think that's maybe a stretch
• 37:40
  Sonia Singh MD: I don't know.
• 37:40
  Sonia Singh MD: I just keep thinking about the patient that is exercising and weight training and doing all the things they're supposed to do, and I'm like,"Yes, you go, girl." And then they're like,"But nothing's happening on the scale." And I'm like,"The scale is not the, the be-all, end-all." Yeah.
• 37:55
  Sonia Singh MD: I know your body composition is changing.
• 37:57
  Sonia Singh MD: Yeah.
• 37:57
  Sonia Singh MD: But I can't prove it to them.
• 37:58
  Sonia Singh MD: To me, that would be a really valuable use of this, and for sort of the metabolically unhealthy but thin population- Yeah that's"I'm fine.
• 38:07
  Sonia Singh MD: I'm okay," and I'm like,"No, you're not, actually."
• 38:10
  Rebecca Berens MD: Yeah.
• 38:10
  Rebecca Berens MD: And I do agree.
• 38:11
  Rebecca Berens MD: When I talked about that at the beginning I do think if you're seeing someone who has a normal BMI but they're, not eating a balanced diet, they're never exercising- You can tell them"Hey, you need to do these things even though your weight is normal." Because I think that's a, that's another societal problem.
• 38:27
  Rebecca Berens MD: We only tell people who are at a higher weight to do these things.
• 38:31
  Rebecca Berens MD: We never harass genetically thin people about doing all these things.
• 38:36
  Rebecca Berens MD: We only do it to larger people.
• 38:37
  Rebecca Berens MD: I
• 38:37
  Sonia Singh MD: mean, I feel like I do, but
• 38:39
  Rebecca Berens MD: Sure.
• 38:39
  Rebecca Berens MD: But okay, in a typical doctor's office, right?
• 38:42
  Sonia Singh MD: Yeah.
• 38:42
  Sonia Singh MD: The amount of time that is spent- You go in, they get your weight, and
• 38:44
  Rebecca Berens MD: they're like- discussing it"You're fine."
• 38:46
  Sonia Singh MD: Yeah.
• 38:46
  Rebecca Berens MD: And there's no discussion of any of this.
• 38:48
  Rebecca Berens MD: And, but the,'cause the EMRs do this, right?
• 38:50
  Rebecca Berens MD: Bas- based on the BMI, you'll get a pop-up flag that's"You need to talk to this patient about nutrition and exercise- because they're overweight." And we should just talk to every patient about that, regardless of their weight.
• 39:01
  Rebecca Berens MD: But it's this, this societal sort of push that we have to these patients"You're not doing everything right." But if someone's weight is normal, we don't harass them about it.
• 39:10
  Rebecca Berens MD: And I do think it pa- perhaps in that situation, maybe that, that is a motivation for those patients- To be like,"Hey, even though your, your weight and BMI is technically in the normal range by," whatever criteria someone made up you still have increased risk for some of these things.
• 39:26
  Rebecca Berens MD: And you would benefit from making these behavioral changes.
• 39:30
  Rebecca Berens MD: So I...
• 39:30
  Rebecca Berens MD: like I said, I think there is a role for what we're talking about in terms of- helping to motivate a patient in a way that the general counseling maybe is not.
• 39:41
  Rebecca Berens MD: But we haven't proven that works.
• 39:44
  Rebecca Berens MD: There's- no proof that- giving them in- this information actually changes their behavior.
• 39:48
  Rebecca Berens MD: Changes their behavior, and I think we need to talk about the harms next, so I'm gonna-
• 39:52
  Sonia Singh MD: Oh, okay.
• 39:52
  Sonia Singh MD: We haven't talked about the harms yet.
• 39:53
  Sonia Singh MD: Yeah.
• 39:54
  Sonia Singh MD: Yeah,
• 39:54
  Rebecca Berens MD: I'm
• 39:54
  Sonia Singh MD: talking- Oh, okay.
• 39:55
  Rebecca Berens MD: Okay.
• 39:55
  Rebecca Berens MD: So- Talk
• 39:55
  Sonia Singh MD: to me about the harms.
• 39:56
  Rebecca Berens MD: So one thing that I wanna talk about is the...
• 40:01
  Rebecca Berens MD: This is a article called The Methodological Standards for Body Composition Assessment: An Expert-Endorsed Guide for Research and Clinical Applications, Bioimpedance, DXA, CT, and Ultrasound Methods.
• 40:12
  Rebecca Berens MD: Okay.
• 40:13
  Rebecca Berens MD: So this is a super long article.
• 40:15
  Rebecca Berens MD: I'm gonna be honest, I did not read the whole thing,'cause it was very long.
• 40:18
  Rebecca Berens MD: It was, a very detailed summary of all of the research, okay?
• 40:21
  Rebecca Berens MD: But basically, the conclusion that they came to using BIA specifically for longitudinal body composition is it's problematic.
• 40:33
  Rebecca Berens MD: Okay.
• 40:33
  Rebecca Berens MD: Because there's wide limits of agreement between the reference standards, and the ability to detect changes, especially more subtle changes, may not be picked up.
• 40:45
  Rebecca Berens MD: Because again, like- Water in- water intake and food- Yeah and, like, all these things can affect.
• 40:50
  Rebecca Berens MD: So you could maybe have a patient, and this could be counterproductive where they've been doing all these things, and they're like,"I wanna see my progress," and then it hasn't changed, and then they're, super frustrated.
• 41:00
  Rebecca Berens MD: Like- Okay"Oh, all this was not worth it, and I'm a terrible person." Yes.
• 41:04
  Sonia Singh MD: Okay, yes.
• 41:04
  Sonia Singh MD: So you're...
• 41:05
  Sonia Singh MD: Like, a, the response to my argument of"What about my lady who's doing all the right things?" Yeah.
• 41:09
  Sonia Singh MD: "And I wanna show her that it's working," it's it might not actually show her that it's working."
• 41:13
  Rebecca Berens MD: And it, and but it, but we know that it is helping, right?
• 41:16
  Rebecca Berens MD: We know that this is helping, and so that's my concern about relying so heavily on measurements and data.
• 41:22
  Rebecca Berens MD: Because it's really unmotivating to people.
• 41:25
  Rebecca Berens MD: Just like it's unmotivating when they see the scale hasn't changed.
• 41:29
  Sonia Singh MD: Okay, this
• 41:29
  Rebecca Berens MD: is- Numbers are unmotivating
• 41:30
  Sonia Singh MD: this is really interesting,'cause I have a real-world play out of this, where I have a patient who works in healthcare and has her own body composition, access to a body composition machine where she works.
• 41:41
  Sonia Singh MD: And so she gets a lot of...
• 41:43
  Sonia Singh MD: She tests it often.
• 41:45
  Sonia Singh MD: And she has never been able to get to the body fat percentage that is her goal, that she thinks would be healthy.
• 41:51
  Sonia Singh MD: And I personally think she's healthy, but she's very much like,"No, but I cannot...
• 41:55
  Sonia Singh MD: I am doing all the things and I cannot get to this number." And now she's working with a weight management physician, and she's doing a GLP-1, and I still am not completely convinced that is necessarily the right thing for her.
• 42:07
  Sonia Singh MD: But if we're believing this body composition data, and we're believing that this is a risk predictor of metabolic disease, then maybe.
• 42:16
  Rebecca Berens MD: And was this visceral fat or total body fat?
• 42:19
  Sonia Singh MD: It was total body fat
• 42:21
  Rebecca Berens MD: So visceral fat was not a concern?
• 42:23
  Sonia Singh MD: I can't remember her exact numbers, but I do recall total body fat was the thing that she was most- Yeah like she had a number in her mind of what she wanted that to be, and it w- Was
• 42:33
  Rebecca Berens MD: that number healthy to you?
• 42:35
  Rebecca Berens MD: Or was it lower than
• 42:36
  Sonia Singh MD: it should've been?
• 42:37
  Sonia Singh MD: It seemed reasonable to me, but looking at her, I just felt I think this is just how you're built.
• 42:43
  Sonia Singh MD: Like I don't think- Yeah I think you're doing- and that's the thing- all of the right things, and all of her numbers were otherwise fine.
• 42:48
  Sonia Singh MD: So I, it was a hard call.
• 42:50
  Sonia Singh MD: Yeah.
• 42:50
  Sonia Singh MD: But I did not I tr- if I felt like it was medically indicated, I would've prescribed the GLP-1, but I was like,"I don't feel comfortable with this," so I had her see somebody else too.
• 42:58
  Rebecca Berens MD: Yeah.
• 42:59
  Rebecca Berens MD: Do a full workup.
• 42:59
  Rebecca Berens MD: And, I think, like- The subcutaneous fat is not the problem.
• 43:08
  Rebecca Berens MD: It's the visceral fat.
• 43:09
  Rebecca Berens MD: And so like that's what's contributing mostly to the cardiometabolic disease.
• 43:15
  Rebecca Berens MD: And And that's I'm gonna get into my next harm that I was gonna talk about is Is this a new obsession for people?
• 43:20
  Rebecca Berens MD: First we have the scale.
• 43:22
  Rebecca Berens MD: People are wanting to get to a certain number, and they're doing any means necessary to get there.
• 43:26
  Rebecca Berens MD: Now they have a whole lot of other targets- that they wanna hit.
• 43:30
  Rebecca Berens MD: Are we just giving more numbers to perseverate on and try to optimize, and I, and that's my concern with playing into this, because it's pushing people in a direction that I'm not sure makes a difference for their health, and maybe they're using extreme measures to try to get their numbers where they want it to be.
• 43:48
  Rebecca Berens MD: And that's actually less healthy for them than if they just did the behaviors and don't care what any of this stuff says.
• 43:55
  Rebecca Berens MD: And I will also say, was so when I got my body comp machine, I did it every day for two weeks because I wanted to see what is the margin of change that could happen when clearly my body composition did not change in two weeks.
• 44:08
  Rebecca Berens MD: Like- there's nothing that could've...
• 44:10
  Rebecca Berens MD: And, it changed in a way that I think could freak someone out.
• 44:13
  Rebecca Berens MD: Some things looked worse.
• 44:16
  Rebecca Berens MD: Rarely did anything look better, actually, which,
• 44:18
  Sonia Singh MD: it only got worse
• 44:19
  Rebecca Berens MD: after two weeks.
• 44:19
  Rebecca Berens MD: I was like,"Oh, I'm just deteriorating over here." Again, it's like- You're deteriorating by the day my body composition did not change in two weeks.
• 44:24
  Rebecca Berens MD: That did not happen.
• 44:26
  Rebecca Berens MD: I could see that if you only have two data points, say you have one data point and then six months later you got another data point, and there's not a substantial improvement, does that actually mean nothing improved or does that just mean it was two different days?
• 44:39
  Rebecca Berens MD: Because, it...
• 44:40
  Rebecca Berens MD: The other thing that when you do the serial monitoring, gives you the body score at the end, and it gives you arrows for each thing, like up or down.
• 44:50
  Rebecca Berens MD: And so when things are getting worse and your body score goes down- It's down down arrows it's very upsetting.
• 44:55
  Rebecca Berens MD: Yeah.
• 44:56
  Rebecca Berens MD: And I'm doing this as a trial.
• 44:57
  Rebecca Berens MD: I'm not doing this to treat myself here, but, it did hurt my feelings a little bit.
• 45:01
  Rebecca Berens MD: It's like, why am I getting so much worse every...
• 45:03
  Rebecca Berens MD: But logically I know this is not relevant, but I could definitely see how for a patient that becomes so frustrating.
• 45:12
  Sonia Singh MD: Yes.
• 45:12
  Sonia Singh MD: I think you have to know yourself deeply to understand, how you are going to react to this type of information because I definitely have patients that can self-identify themselves and be like,"I don't wanna be weighed.
• 45:24
  Sonia Singh MD: I don't wanna see this number." Yeah.
• 45:26
  Sonia Singh MD: "I don't want, I don't want more data.
• 45:27
  Sonia Singh MD: I don't...
• 45:29
  Sonia Singh MD: Please don't make me track my gluco-" they- they know that they will become obsessive over those numbers, and they're like,"Please don't even put me on that side." Yeah.
• 45:35
  Sonia Singh MD: But I think a lot of people don't have the awareness of how obsessive they can get.
• 45:38
  Rebecca Berens MD: And especially if you are, moving on a disordered eating pathway.
• 45:42
  Sonia Singh MD: Yeah.
• 45:42
  Sonia Singh MD: Y-
• 45:43
  Rebecca Berens MD: your brain wants that.
• 45:45
  Rebecca Berens MD: Your brain's becoming competitive with itself.
• 45:47
  Rebecca Berens MD: And so that's my concern, is those patients are being missed anyway.
• 45:50
  Rebecca Berens MD: And now are we just feeding into it by giving them all this data?
• 45:54
  Rebecca Berens MD: Cause there, there's more targets for them to try to hit.
• 45:57
  Sonia Singh MD: So that's the interesting part, is I feel like a lot of my patients who should not have more data'cause they become obsessive over it and they already have too much data, are always the ones who want more data.
• 46:07
  Sonia Singh MD: Yes.
• 46:07
  Sonia Singh MD: The ones where I'm like, I would like to give you more to get you excited or motivated or whatever," are the ones that are, least interested in doing and, having more.
• 46:17
  Sonia Singh MD: So I guess I like the idea of having it be a little bit...
• 46:21
  Sonia Singh MD: right now it's like you have to seek it out, and I kinda like the idea of having it incorporated in some way so that it's just there.
• 46:28
  Sonia Singh MD: And maybe everyone gets it on- once a year or something, but, I don't know.
• 46:32
  Sonia Singh MD: I'm-
• 46:33
  Rebecca Berens MD: Yeah.
• 46:33
  Rebecca Berens MD: I'm gonna talk about at the end how I do it,'cause obviously- Okay I wanted to do this in a not harmful way, and so I've thought a lot about it.
• 46:42
  Rebecca Berens MD: But the last thing I wanna talk about as another potential harm is weight stigma and psychological distress, which we kinda just talked about.
• 46:48
  Rebecca Berens MD: But, again- I didn't find anything specifically around body composition and psychological distress or weight stigma, but there is a lot of data out there about how weight stigma affects people's, health-seeking behaviors and psychological health in risk of depression, anxiety, all of these things.
• 47:10
  Rebecca Berens MD: And there's a lot of data out for that.
• 47:11
  Rebecca Berens MD: I just, I pulled one.
• 47:13
  Rebecca Berens MD: This was a systematic review and meta-analysis, weight related stigma and psychological distress.
• 47:17
  Rebecca Berens MD: And There were 30 studies, and there was nine, over 9,000 participants experiencing weight-related self-stigma, meaning applying that to yourself and feeling bad about yourself related to weight, and then over 15,000 expe- experiencing weight-related perceived stigma.
• 47:34
  Rebecca Berens MD: In social interactions, feeling that they are being stigmatized based on their weight- which of course probably contributes to self-stigma.
• 47:41
  Rebecca Berens MD: Self-stigma.
• 47:42
  Rebecca Berens MD: And there was moderate associations between weight-related self-stigma and psychological distress and between perceived stigma and depression.
• 47:50
  Rebecca Berens MD: Okay.
• 47:51
  Rebecca Berens MD: Which makes sense, right?
• 47:52
  Rebecca Berens MD: If you're feeling bad about yourself, that's psychologically distressing, and if you are feeling, A lot of stigma related to external factors, that becomes depressing, right?
• 48:05
  Rebecca Berens MD: You're just getting constant negative feedback.
• 48:08
  Rebecca Berens MD: And point of this being this is a well-established issue, and are we now making it fat-free mass stigma, and visceral fat pers- score f- stigma, and body score stigma?
• 48:25
  Rebecca Berens MD: Again that's my concern.
• 48:26
  Rebecca Berens MD: We've kinda been talking about this, but we're just creating more data points to become stigmatizing.
• 48:32
  Sonia Singh MD: I think one issue is with weight stigma specifically, it's so visual, and these are things that somebody can't look at you and know, your body composition.
• 48:43
  Sonia Singh MD: But, I do understand what you're saying, is you're just creating more and more ideals to live up to- Yeah that are going to make people feel that they're failing- Yeah at something, and-
• 48:54
  Rebecca Berens MD: And I actually think it might imp- how valuable- it might worsen self-stigma.
• 48:57
  Rebecca Berens MD: Because the perceived stigma is what it is.
• 48:59
  Rebecca Berens MD: But if you now have a body score that's not an A+ now- Yeah now you're, madder at yourself, right?
• 49:07
  Rebecca Berens MD: Yeah.
• 49:07
  Rebecca Berens MD: And especially if you"Okay, I'm gonna do all these things.
• 49:10
  Rebecca Berens MD: I'm gonna get...
• 49:11
  Rebecca Berens MD: I wanna be healthier.
• 49:12
  Rebecca Berens MD: This is what I'm gonna do," and then you go back and get another body comp and it didn't change.
• 49:16
  Rebecca Berens MD: That makes you feel bad, right?
• 49:17
  Rebecca Berens MD: It feels- what was the point?
• 49:19
  Rebecca Berens MD: Maybe I'm not doing this right.
• 49:20
  Rebecca Berens MD: Maybe I don't know what I'm doing.
• 49:22
  Rebecca Berens MD: Maybe I should just give up.
• 49:23
  Rebecca Berens MD: And I think it could go one of two ways.
• 49:25
  Rebecca Berens MD: I think it could be so discouraging that the person just gives up, and they're like,"What's the point?
• 49:29
  Rebecca Berens MD: Nothing I do works." Or it could go"I have to be stricter.
• 49:32
  Rebecca Berens MD: I have to be more rigid.
• 49:33
  Rebecca Berens MD: I ha- and then they go down a really disordered eating pathway, right?
• 49:36
  Rebecca Berens MD: And so I'm like, neither one of those is good.
• 49:39
  Sonia Singh MD: Yeah.
• 49:40
  Rebecca Berens MD: Is it actually worth it?
• 49:41
  Rebecca Berens MD: And again, I didn't find any data about it, so it hasn't been studied.
• 49:45
  Rebecca Berens MD: Maybe I'm totally making this up, but this is my concern.
• 49:50
  Rebecca Berens MD: And I think maybe before we say, this is a vital sign that should be done screening on everyone, we should maybe investigate that a little bit.
• 49:58
  Sonia Singh MD: Yeah.
• 49:59
  Sonia Singh MD: I think the idea that oh, yes, we should all be doing it and it should be a vital sign, that to me feels premature.
• 50:04
  Sonia Singh MD: That's jumping the gun.
• 50:05
  Sonia Singh MD: We clearly have not proven that with any real significant data yet.
• 50:10
  Sonia Singh MD: It does sound like to me that it is a better predictor or a better proxy for certain, health outcomes or metabolic health than a scale or- just a BMI calculation.
• 50:22
  Sonia Singh MD: I think that's the strongest argument to say we're currently using very flawed metrics- Yeah to guide us, so why not use this thing that appears to be a better predictor?" Yeah.
• 50:32
  Sonia Singh MD: But with the caveats that that is not really an evidence-based practice yet, and there are potential harms which we also have not studied,
• 50:40
  Rebecca Berens MD: and the other thing I'll say is this is not covered by insurance.
• 50:42
  Rebecca Berens MD: Insurance does not cover this- even if it's in your doctor's office.
• 50:46
  Rebecca Berens MD: They don't cover it at the gym.
• 50:47
  Rebecca Berens MD: Although the gym gives it away'cause they wanna sell you stuff.
• 50:50
  Sonia Singh MD: And- Well, once you buy the machine, like you as the owner of the machine, once you buy the machine, is there a per use cost that you're still paying?
• 50:56
  Sonia Singh MD: Do you replace anything in it, or is it's just a one-time investment?
• 51:00
  Rebecca Berens MD: So you have the one-time upfront cost, which I'll be very transparent, was$7,000.
• 51:04
  Rebecca Berens MD: So- Ooh, okay it's not a, it's not an inexpensive item.
• 51:08
  Rebecca Berens MD: And then there is a$600 a year like software fee that you have to pay.
• 51:13
  Rebecca Berens MD: The ongoing cost is not super high, but like you wanna recoup the$7,000.
• 51:19
  Sonia Singh MD: Yeah.
• 51:19
  Sonia Singh MD: Now- So the incentive is to do as many scans- To do it more, and charge as many people for the scan.
• 51:23
  Sonia Singh MD: Yeah.
• 51:23
  Sonia Singh MD: Not
• 51:23
  Rebecca Berens MD: in your practice.
• 51:24
  Rebecca Berens MD: And, I'm not a, I'm not a great business person, so I don't charge anything for it.
• 51:27
  Rebecca Berens MD: But but-
• 51:28
  Sonia Singh MD: Great.
• 51:28
  Sonia Singh MD: I'll, I will be there tomorrow.
• 51:30
  Rebecca Berens MD: Yeah, perfect.
• 51:31
  Rebecca Berens MD: I I think that certainly in these- other direct to consumer places.
• 51:38
  Rebecca Berens MD: There's a lot of incentive to keep people coming back- for more and more of these scans.
• 51:44
  Rebecca Berens MD: And it's cash pay, and this may sound great to a patient and they're like,"Oh yeah, let me go get this done every three months or whatever," but could those resources have been used elsewhere?
• 51:54
  Rebecca Berens MD: For a more evidence-based use.
• 51:56
  Rebecca Berens MD: Not to mention I'm driving to this place, I'm sitting there for however long, I'm missing some other thing in my life.
• 52:03
  Rebecca Berens MD: These are just...
• 52:03
  Rebecca Berens MD: There's costs we have to weigh.
• 52:05
  Rebecca Berens MD: And the cost benefit ratio, especially for the general population, I'm not convinced- that is useful.
• 52:12
  Sonia Singh MD: It's interesting'cause that calculation would be, different for your practice or my practice versus a traditional practice because our practice is a very low volume, so- Yeah it's gonna take us a while.
• 52:22
  Sonia Singh MD: And we don't...
• 52:23
  Sonia Singh MD: if I got one, I would include it as part of the membership fee.
• 52:26
  Sonia Singh MD: Yeah.
• 52:26
  Sonia Singh MD: I wouldn't charge anything- Yeah per patient, and I don't think I would acquire new patients because I have this machine.
• 52:31
  Sonia Singh MD: So honestly, it's a very dumb business decision.
• 52:34
  Rebecca Berens MD: It is.
• 52:34
  Rebecca Berens MD: It was a very dumb business decision.
• 52:35
  Rebecca Berens MD: But,
• 52:36
  Sonia Singh MD: But it would make...
• 52:36
  Sonia Singh MD: It would add value for my patients that's really the reason I'm thinking about it.
• 52:40
  Sonia Singh MD: It would make my current panel happy, I think, to have the option of having body composition.
• 52:44
  Sonia Singh MD: But, so anyway, for us we wouldn't...
• 52:47
  Sonia Singh MD: The ROI on it would not be very big.
• 52:49
  Sonia Singh MD: But if you think about, in a traditional practice if you say you're seeing 20 to 25 patients, one provider is seeing that many patients, or one clinician is seeing that many patients and, you're saying,"Oh, it's 10, 50,$25 extra to, get your body comp," the, again, that the business part of that changes- Yeah very quickly,
• 53:08
  Rebecca Berens MD: and that's why I'm also concerned.
• 53:10
  Rebecca Berens MD: What is the incentive behind- Recommending this?
• 53:13
  Rebecca Berens MD: But is it because you wanna have the machine for certain situations, but you're like,"Hey, I need to recoup this, so I'm just gonna charge people," and then it's a- their profit line?
• 53:21
  Sonia Singh MD: Right
• 53:22
  Rebecca Berens MD: that shouldn't be how we do things,
• 53:23
  Sonia Singh MD: This is
• 53:24
  Rebecca Berens MD: the- And that is how we often do things.
• 53:25
  Sonia Singh MD: Yes.
• 53:26
  Rebecca Berens MD: Not me hopefully, but that is how many people often do things, but that doesn't mean it's okay.
• 53:30
  Sonia Singh MD: That is a theme in the, the wellness world generally, and I think about this all the time as a practice owner because I constantly get these emails that the first line is like,"Looking for another revenue stream?" Yeah.
• 53:42
  Sonia Singh MD: And then it's followed by selling me a laser, selling me m- sell...
• 53:45
  Sonia Singh MD: I shouldn't name names.
• 53:46
  Sonia Singh MD: Selling me a laser, selling me some bizarre seat that you use for urinary incontinence, selling me- m- my own customized supplement line, selling me a cut of the supplements I sell on a website.
• 53:58
  Sonia Singh MD: Yeah.
• 53:59
  Sonia Singh MD: Yeah.
• 53:59
  Sonia Singh MD: It's, it's- so many of the things that are happening in these wellness practices, IV vitamins, 12 shots, a, a lot of these things, all they are is just a side stream of revenue.
• 54:10
  Sonia Singh MD: Yeah.
• 54:10
  Sonia Singh MD: They are not...
• 54:11
  Sonia Singh MD: There's no evidence basis.
• 54:13
  Sonia Singh MD: They are not making anyone healthier.
• 54:15
  Sonia Singh MD: They are just revenue for the practice.
• 54:17
  Sonia Singh MD: And practices gotta stay open.
• 54:19
  Sonia Singh MD: I understand a lot of those people are also doing good things, yeah.
• 54:22
  Sonia Singh MD: But y- I think patients just do not perceive it that way.
• 54:25
  Sonia Singh MD: They perceive all these things as added value.
• 54:27
  Sonia Singh MD: Yeah.
• 54:27
  Sonia Singh MD: And they do not see that's really just a few, that's a few more bucks that they're trying to
• 54:33
  Rebecca Berens MD: Yeah
• 54:33
  Sonia Singh MD: extract out of you.
• 54:34
  Rebecca Berens MD: Yeah, and again I'm gonna get into this.
• 54:36
  Rebecca Berens MD: Why did I get one?
• 54:37
  Rebecca Berens MD: Okay, we'll talk about that.
• 54:39
  Rebecca Berens MD: But I think if this was a intervention that was determined to have very little risk of harm and would be motivating to some patients And people wanna know I think that would be very different than we actually don't know how this affects people psychologically, if it triggers more disordered eating, if it triggers more weight stigma resulting in people avoiding healthcare.
• 55:10
  Rebecca Berens MD: We don't know if it does that.
• 55:11
  Rebecca Berens MD: So we should probably figure that out before we start routinely recommending it, and certainly before we decide that's gonna be, another vertical for our practice, right?
• 55:21
  Rebecca Berens MD: It just, I think it's just- Worth thinking about,
• 55:25
  Sonia Singh MD: yeah.
• 55:25
  Sonia Singh MD: Especially in, you, you have a disproportionate number of patients with eating disorders or recovering from eating disorders.
• 55:31
  Sonia Singh MD: I have a disproportionate number of people with health anxiety, and there, there are plenty of reasons that both of those populations- Yeah may not necessarily benefit from having this additional data.
• 55:42
  Sonia Singh MD: Yeah.
• 55:43
  Sonia Singh MD: I guess my biggest motivator, I know that a lot of my patients will be excited because they are a lot of A-type patients that really like data.
• 55:50
  Sonia Singh MD: I like data too, so I'm not anti-data.
• 55:53
  Sonia Singh MD: But I, I guess I feel nervous about a lot of my patients who are successfully losing weight with a GLP-1, and I feel nervous that they are losing m- and I know they are losing muscle mass.
• 56:04
  Rebecca Berens MD: Yeah.
• 56:04
  Sonia Singh MD: And so I feel it would be doing my due diligence to have...
• 56:09
  Sonia Singh MD: to be monitoring that- Yeah and making sure that they're trying to mitigate it, yeah.
• 56:14
  Sonia Singh MD: Or hopefully that data would, that information would help them feel motivated to try to mitigate it with resistance training and adequate protein and all of the things.
• 56:21
  Rebecca Berens MD: And that is exactly why I got one.
• 56:23
  Sonia Singh MD: Oh, okay.
• 56:24
  Rebecca Berens MD: That was the reason.
• 56:24
  Rebecca Berens MD: Oh,
• 56:24
  Sonia Singh MD: on the same
• 56:25
  Rebecca Berens MD: page.
• 56:25
  Rebecca Berens MD: That was the reason I got one, because I, I'm very intentional with my patients about we don't wanna be losing weight too quickly.
• 56:32
  Rebecca Berens MD: Which, I don't know, I can't remember where it was in one of these things, but there was evidence that faster weight loss has a higher risk of more lean mass loss, which makes sense.
• 56:41
  Rebecca Berens MD: I don't remember which article it was in.
• 56:42
  Rebecca Berens MD: I'll post them and hopefully people can find it.
• 56:44
  Rebecca Berens MD: But but we know that's true, and I'm very intentional about keeping the weight loss very slow.
• 56:51
  Rebecca Berens MD: If someone's gonna be a GLP-1, I'm generally- targeting the metabolic outcomes- and ensuring the person is eating, a balanced diet, enough protein, incorporating resistance training.
• 57:02
  Rebecca Berens MD: I'm not targeting a certain amount of weight loss, which is really frustrating'cause sometimes the insurance company's"They must lose five, lose 5% of their body- Yes
• 57:09
  Sonia Singh MD: in six months-" I know"or we're
• 57:10
  Rebecca Berens MD: not gonna cover it." I'm
• 57:10
  Sonia Singh MD: like,"What's the rush?"
• 57:12
  Rebecca Berens MD: And I...
• 57:12
  Rebecca Berens MD: Exactly.
• 57:13
  Rebecca Berens MD: There's no evidence that's helpful.
• 57:15
  Rebecca Berens MD: Their...
• 57:16
  Rebecca Berens MD: look at their labs.
• 57:17
  Rebecca Berens MD: Yeah.
• 57:17
  Rebecca Berens MD: They've completely reversed all of the conditions- Yeah that they had.
• 57:19
  Rebecca Berens MD: Like, why are we focusing on the scale?
• 57:22
  Rebecca Berens MD: But anyway, but that was my thing.
• 57:23
  Rebecca Berens MD: I was like, I would like to make sure that we are not seeing a disproportionate amount of lean mass loss in these patients.
• 57:32
  Rebecca Berens MD: Yeah.
• 57:32
  Rebecca Berens MD: And I also have patients who sometimes wanna keep pushing the dose'cause they wanna lose more weight, and I'm like,"Is that something we should do?" If all your labs are looking great and your blood pressure's looking great and like everything's looking great- what's the reason to push the dose?
• 57:48
  Rebecca Berens MD: Is it for more weight loss?
• 57:49
  Rebecca Berens MD: In which case, let's look at where your lean mass is, because if you're already on the low side, that's gonna get lower, and is that- really beneficial for you?
• 57:56
  Rebecca Berens MD: So- that is why I got one.
• 57:58
  Rebecca Berens MD: Yeah just to go to maybe the next section.
• 58:02
  Sonia Singh MD: Yeah.
• 58:03
  Sonia Singh MD: What can we learn about this as humans and doctors?
• 58:05
  Rebecca Berens MD: Yeah, so I think my, my takeaway was there is probably a role for using body composition tools, but I think they need to be approached thoughtfully, and I think they need to be studied to better understand the potential harms associated with them.
• 58:23
  Rebecca Berens MD: There is actually no evidence that they improve anyone's outcome.
• 58:27
  Rebecca Berens MD: They...
• 58:27
  Rebecca Berens MD: we know that it is a risk predictor, and we know that it can help us better understand someone's nutritious stat- str- nutrition status.
• 58:34
  Rebecca Berens MD: I didn't really get into this, but when I was doing some research on this, there was some evidence of in patients who are malnourished with cancer or whatever, it predicting their risk of rehospitalization and all that.
• 58:43
  Rebecca Berens MD: But again what do you do with that information?
• 58:45
  Rebecca Berens MD: So you know, it's maybe affecting your interpretation of their overall risk, but is it actually changing their outcome?
• 58:53
  Rebecca Berens MD: Unclear.
• 58:54
  Rebecca Berens MD: And then I think the biggest thing that I would say for a, on the patient side is it matters where you do this.
• 59:02
  Rebecca Berens MD: There are methods that are more accurate than others.
• 59:04
  Rebecca Berens MD: The more inaccurate the machine is, the more likely it is to give you some unnecessary anxiety,'cause it's likely gonna be going up and down and confusing you.
• 59:12
  Rebecca Berens MD: And if you are gonna monitor it over time, it should ideally be the same machine- Longitudinally,'cause that minimizes the risk of unusable data.
• 59:20
  Sonia Singh MD: Yeah.
• 59:20
  Rebecca Berens MD: But like I said, I did mine every day for two weeks, and it did change every time.
• 59:23
  Rebecca Berens MD: So take that for what it's worth.
• 59:26
  Rebecca Berens MD: And we also need to be really mindful of how we are using this data.
• 59:30
  Rebecca Berens MD: So as a patient, if you get some data in a body comp and you feel some kinda way about it,, how are you responding, and is it...
• 59:40
  Rebecca Berens MD: Are you targeting a number unnecessarily, and is it making you use really rigid behaviors?
• 59:46
  Rebecca Berens MD: Or is it making you feel like none of my efforts are worth it, so I give up?
• 59:50
  Rebecca Berens MD: So that, that was the main takeaways I had.
• 59:52
  Rebecca Berens MD: What about you?
• 59:54
  Sonia Singh MD: The same.
• 59:55
  Sonia Singh MD: I am actually surprised by the lack of data there is on clinical utility.
• 1:00:00
  Sonia Singh MD: I would've expected there to be something more because it's not a new technology.
• 1:00:04
  Sonia Singh MD: It's been around.
• 1:00:06
  Sonia Singh MD: Yeah, I think just thinking about how we're using it and seeing if it actually in practice seems to motivate people or discourage Yeah Motivate or discourage is, I think, is gonna be a really interesting thing to see.
• 1:00:22
  Sonia Singh MD: Yeah.
• 1:00:22
  Sonia Singh MD: For you now that you already have one.
• 1:00:24
  Rebecca Berens MD: Yeah.
• 1:00:24
  Rebecca Berens MD: And I have not re-scanned anyone.
• 1:00:26
  Rebecca Berens MD: I've had this for a couple months, so- I've done some initial scans for several people, but I haven't done any re-scans, which I think is the most useful time- To see, did it actually change, right?
• 1:00:36
  Rebecca Berens MD: And yeah, it looks like a lot of the data was in comparison of, how accurate is this version versus the gold standard, and then there is a lot of mechanistic understanding like potentially this has a benefit, right?
• 1:00:47
  Rebecca Berens MD: It's just study to prove it that we're missing, and so I would love for someone to do that study.
• 1:00:51
  Rebecca Berens MD: Yeah and I of course will do my internal, evaluation.
• 1:00:54
  Rebecca Berens MD: But what I will say, and just to go into how we talk to our patients about this so like I said, I got the best one I could find that was the closest to DEXA and I am currently using it to monitor patients who are on GLP-1s, or for patients who have, some sort of metabolic health condition that's developing to talk to them about this is the picture I'm seeing and these are the interventions that I think would help with these things.
• 1:01:21
  Rebecca Berens MD: And it's, again, it's not anything different than I would normally say.
• 1:01:25
  Rebecca Berens MD: But again I wanna see, does it actually help motivate people?
• 1:01:27
  Rebecca Berens MD: But what I do differently than I think a lot of these people do, I'm not giving people a printout.
• 1:01:33
  Sonia Singh MD: Okay.
• 1:01:33
  Rebecca Berens MD: We're talking about it in generalities.
• 1:01:35
  Sonia Singh MD: Okay.
• 1:01:36
  Rebecca Berens MD: And I'm keeping it in my record.
• 1:01:38
  Rebecca Berens MD: Now, if someone demanded the printout, I would...
• 1:01:40
  Rebecca Berens MD: I would give it to them, right?
• 1:01:41
  Rebecca Berens MD: It's their medical record.
• 1:01:41
  Rebecca Berens MD: Oh,
• 1:01:41
  Sonia Singh MD: Rebecca, but people love the printout.
• 1:01:43
  Rebecca Berens MD: But that's where I perceive the harm could be- Is in the printout.
• 1:01:47
  Rebecca Berens MD: And so I'm-
• 1:01:49
  Sonia Singh MD: I'm gonna demand the printout, just saying.
• 1:01:51
  Rebecca Berens MD: Whatever.
• 1:01:52
  Sonia Singh MD: You can have it.
• 1:01:52
  Sonia Singh MD: Actually, I don't even qualify'cause I'm not on a GLP-1, so I don't know why I even asked.
• 1:01:55
  Sonia Singh MD: If you wanna just come and do it,
• 1:01:57
  Rebecca Berens MD: that's up to you.
• 1:01:58
  Rebecca Berens MD: You have autonomy.
• 1:01:59
  Rebecca Berens MD: And I trust that you understand the data properly.
• 1:02:02
  Rebecca Berens MD: But anyway I think I don't give people the printout unless they specifically ask for it.
• 1:02:06
  Rebecca Berens MD: And I think that's my way of trying to mitigate any potential harms is, So something really interesting I've noticed actually that I wanna mention is the people who have sedentary jobs typically have a significantly decreased muscle mass in their legs and torso compared to their upper body, which makes sense.
• 1:02:23
  Rebecca Berens MD: So what that's really helped me with is, kinda telling them you have decent body co- muscle mass up in your arms.
• 1:02:31
  Rebecca Berens MD: These are areas a little weaker.
• 1:02:32
  Rebecca Berens MD: Obviously you have this sedentary job.
• 1:02:34
  Rebecca Berens MD: You're not moving those muscles as much.
• 1:02:35
  Rebecca Berens MD: What are some ways that we could address that?
• 1:02:38
  Rebecca Berens MD: Could you get a standing desk?""Could you go for walks a couple times a day, take a break?" Just coming up with ideas with the patient and saying like- Not"You need to lose all this weight," but- this is the pattern I'm seeing.
• 1:02:49
  Rebecca Berens MD: It makes sense based on your job, like what are some things we could try?
• 1:02:53
  Rebecca Berens MD: But it's not just"You need to lose as much weight as possible, and your numbers are terrible and you're the worst." That's And your body's forced not to be able
• 1:03:01
  Sonia Singh MD: to be- Yeah, but that's the alternative.
• 1:03:02
  Sonia Singh MD: That's not what you would be saying to them- No in the world without the body composition machine.
• 1:03:05
  Sonia Singh MD: But, I can see how, I think a lot of patients are frustrated with the generalized advice that they get,'cause it just feels so generic.
• 1:03:13
  Sonia Singh MD: It doesn't- Yeah feel like it's anything tailored to them.
• 1:03:15
  Sonia Singh MD: So if you were to talk to this person and you were to know they have a sedentary job, i- even without the body composition it would be, very reasonable and realistic that you might talk to them about how they can get more activity and how they can move their body more.
• 1:03:28
  Sonia Singh MD: But I think that comes across differently to somebody versus you saying,"Hey, look, I'm noticing that you have some more weakness in your legs compared to your upper body.
• 1:03:39
  Sonia Singh MD: What can we do?" That feels so much more personal and specific.
• 1:03:43
  Sonia Singh MD: Yeah.
• 1:03:43
  Sonia Singh MD: Where you feel as though,"I went to the doctor, they analyzed some things." Yeah.
• 1:03:47
  Sonia Singh MD: "They told me this is what I need to do." Even though if they just went home and were like,"I'm gonna be more active and I'm gonna do these things," That would've been great.
• 1:03:54
  Sonia Singh MD: That would've been fine, too.
• 1:03:56
  Sonia Singh MD: I don't know how much additional benefit they're gonna get knowing that they specifically have some weakness in their lower body.
• 1:04:02
  Sonia Singh MD: But I d- I do think there's something about that makes it land differently, and maybe would make it more effective.
• 1:04:08
  Sonia Singh MD: So- Yeah.
• 1:04:09
  Sonia Singh MD: But, we don't know.
• 1:04:10
  Rebecca Berens MD: Yeah.
• 1:04:10
  Rebecca Berens MD: And I agree.
• 1:04:11
  Rebecca Berens MD: And that was the other thing is when we talked about getting a fasting insulin, right?
• 1:04:16
  Rebecca Berens MD: Does it change our medical management?
• 1:04:17
  Rebecca Berens MD: Usually no.
• 1:04:19
  Rebecca Berens MD: But does it change the patient's management?
• 1:04:21
  Rebecca Berens MD: It may.
• 1:04:22
  Rebecca Berens MD: And so if it does, that's worth it.
• 1:04:25
  Rebecca Berens MD: But again, it's the harms that I'm concerned about, and that's why I don't routinely give people the printout, because that's where I see the most risk of harm.
• 1:04:34
  Rebecca Berens MD: And just talking about it in generalities and patterns I'm noticing, and saying"Oh, you know what?
• 1:04:38
  Rebecca Berens MD: You have higher than normal level of visceral fat, so you're at more risk of these conditions.
• 1:04:42
  Rebecca Berens MD: What are some things we can do to mitigate that risk?" And again, it's the same stuff we would already be talking about if we didn't have this data, but maybe it is more motivating to the patient.
• 1:04:52
  Rebecca Berens MD: And I think that's fine.
• 1:04:53
  Rebecca Berens MD: That is very reasonable.
• 1:04:55
  Rebecca Berens MD: And I'm not opposed to using that in a wider population if it's helpful, but I think I am very mindful that there's could be a lot of harm with that.
• 1:05:06
  Rebecca Berens MD: And so I think we need to be very thoughtful about that.
• 1:05:11
  Rebecca Berens MD: That makes sense.
• 1:05:12
  Rebecca Berens MD: Yeah.
• 1:05:12
  Sonia Singh MD: Okay.
• 1:05:13
  Rebecca Berens MD: I think the other thing that I thought about when I was getting the body composition was, like, are there any applications in terms of understanding the severity of someone's malnutrition when they have an eating disorder?
• 1:05:24
  Rebecca Berens MD: Yeah.
• 1:05:24
  Rebecca Berens MD: And helping to understand if more intensive level of care is beneficial.
• 1:05:30
  Rebecca Berens MD: 'Cause a lot of times there's people who have restrictive eating disorders whose BMI is technically normal.
• 1:05:36
  Rebecca Berens MD: And it's difficult sometimes for them to tell me specifically how much they're eating and know, how much below your needs are you.
• 1:05:43
  Rebecca Berens MD: And labs are not always super helpful to determine the degree of malnutrition, but could this be a way that we could better understand the malnutrition and maybe have a more informed conversation about levels of care?
• 1:05:54
  Rebecca Berens MD: But I'm not gonna do that until I have evidence that it might be helpful, because I think, again, potential harms.
• 1:06:00
  Rebecca Berens MD: But that's- Yeah something I'm thoughtful about that I think is a potential use case in the future.
• 1:06:06
  Rebecca Berens MD: And and like I said, if you have had excessive weight loss or, malnutrition for some reason we do know that it helps predict risk.
• 1:06:14
  Rebecca Berens MD: And so this is another population in which I think it could potentially be beneficial, but I have no evidence to support that, so that's maybe a future discussion.
• 1:06:22
  Rebecca Berens MD: But anyway.
• 1:06:24
  Sonia Singh MD: Okay.
• 1:06:24
  Sonia Singh MD: Yeah.
• 1:06:25
  Sonia Singh MD: That's interesting.
• 1:06:25
  Sonia Singh MD: That makes sense, too.
• 1:06:27
  Sonia Singh MD: All right, so where can people go for more info?
• 1:06:30
  Rebecca Berens MD: So on our Substack, which is at www.theantisocialdoctors.com, no hyphen you can find the summary of this episode, all of our sources, and you can also subscribe and get emails from every new episode.
• 1:06:44
  Rebecca Berens MD: And we are now approved for CME hours and CE hours- Ooh for multiple people within the interdisciplinary team.
• 1:06:51
  Rebecca Berens MD: So if you're interested in getting continuing education credits for the time you are spending listening to this podcast you can do that on our Substack.
• 1:06:59
  Sonia Singh MD: Can we get credits for our own podcast?
• 1:07:01
  Sonia Singh MD: Can I, can I-
• 1:07:01
  Rebecca Berens MD: That's an interesting question.
• 1:07:02
  Rebecca Berens MD: I think we should, but- I have
• 1:07:04
  Sonia Singh MD: spent more hours on the topic And I listen to all of them,
• 1:07:08
  Rebecca Berens MD: this is very true.
• 1:07:10
  Rebecca Berens MD: Ethic-
• 1:07:10
  Sonia Singh MD: ethic- I don't see why not gray, ethically gray zone, I would say, but- I don't know.
• 1:07:14
  Sonia Singh MD: I- It's fine.
• 1:07:14
  Sonia Singh MD: I already did all, I just renewed, so I'm already done with all my CME for now.
• 1:07:17
  Sonia Singh MD: Okay.
• 1:07:17
  Rebecca Berens MD: Anyway I, I think it's reasonable to do that because you did review a lot of data, and you learned something that probably changed your practice in many cases, and that's the, the baseline requirement for CME, right?
• 1:07:28
  Sonia Singh MD: Yeah.
• 1:07:29
  Rebecca Berens MD: Exactly.
• 1:07:29
  Rebecca Berens MD: Anyway.
• 1:07:29
  Rebecca Berens MD: All right.
• 1:07:30
  Sonia Singh MD: Thanks, Rebecca.
• 1:07:31
  Rebecca Berens MD: Yeah.
• 1:07:31
  Rebecca Berens MD: Thanks, Sonia.
• 1:07:33
  Sonia Singh MD: Hey, guys.
• 1:07:34
  Sonia Singh MD: Last but not least, we have a very important disclaimer.
• 1:07:37
  Sonia Singh MD: This podcast is intended for educational and entertainment purposes only.
• 1:07:41
  Sonia Singh MD: The content shared on this podcast, including but not limited to opinions, research, discussions, case examples, and commentary is not medical advice and should not be considered a substitute for professional medical evaluation, diagnosis, or treatment.
• 1:07:56
  Sonia Singh MD: Listening to this podcast does not establish a physician-patient relationship between you and the hosts.
• 1:08:01
  Sonia Singh MD: We are doctors, but not your doctors.
• 1:08:04
  Sonia Singh MD: Any medical topics discussed are presented for general informational purposes and may not apply to your individual circumstances.
• 1:08:11
  Sonia Singh MD: Always seek the advice of your own qualified healthcare professional regarding any questions you have about your health, medical conditions, or treatment options.
• 1:08:19
  Sonia Singh MD: Never disregard or delay medical advice because of something you've heard on this podcast.
• 1:08:23
  Sonia Singh MD: While the hosts are licensed physicians, the views and opinions expressed are our own and do not represent those of our employers, institutions, organizations, or professional societies with which we are affiliated.
• 1:08:35
  Sonia Singh MD: Although we do our best to stay up to date, please note that this podcast includes discussion of emerging research, evolving medical concepts, and differing professional opinions.
• 1:08:44
  Sonia Singh MD: Medicine is not static, and information may change over time.
• 1:08:48
  Sonia Singh MD: We, the hosts, make no guarantees about the accuracy, completeness, or applicability of this content, and we disclaim any liability for actions taken or not taken based on the information provided in this podcast.
• 1:09:00
  Sonia Singh MD: By listening to the Antisocial Doctors podcast, you have agreed to these terms.
• 1:09:04
  Sonia Singh MD: Thanks again for joining us.