Latest / Come Together with Ephraim Herschmann / Health Series 5: Dr Evan Nadler / Pediatric Obesity Surgeon

Transcript

Health Series 5: Dr Evan Nadler / Pediatric Obesity Surgeon · Come Together with Ephraim Herschmann

• 0:01
  Welcome to another episode of Come Together,
• 0:14
  Just here. 2nd Doctor Nadler, Welcome.
• 0:17
  Welcome back to another episode. I really appreciate you coming.
• 0:19
  Thank you so much. My pleasure, thanks for having
• 0:21
  me. We just, it's so funny.
• 0:23
  You were just telling me that the audio, you had to correct
• 0:25
  it. I recorded a full hour and a
• 0:27
  half phenomenal conversation with a gentleman from Australia
• 0:32
  that was actually doing a little bit of research with LSD and
• 0:37
  micro dosing to cure depression, suicidal ideation.
• 0:41
  And we recorded a phenomenal episode.
• 0:44
  And I thought I heard like Echo, you know, at the beginning and
• 0:50
  it's happened once before and then it was totally fine.
• 0:51
  So I just think, oh, I'm sure it's fine.
• 0:53
  And after a full hour and a half, I listened back and I'm
• 0:56
  like, you cannot, I can't use this.
• 0:57
  And it was such a shame I have to record Part 2 with him.
• 1:00
  And Riverside can't. It doesn't.
• 1:03
  Like clean that up. No, I tried running it through
• 1:05
  AI have a couple of buddies that pay for, you know, I guess more
• 1:08
  potential or you know, yeah, higher capabilities and they ran
• 1:11
  it through and it was because apparently it was a separate the
• 1:15
  Riverside was recording my input and then re recording the output
• 1:19
  on his end. So everything was was her twice.
• 1:24
  But I welcome to the show, so I'm going to have you here.
• 1:28
  Everybody needs a show on how to podcast.
• 1:30
  You know what? I.
• 1:31
  Mean that's right, by the way, by the way, I'm not I've been
• 1:33
  learning that, as you know, throughout throughout the last
• 1:36
  year and change is, you know, I mean, it's a lot of learning
• 1:39
  lessons, but the truth is not to overthink it.
• 1:42
  That's what I found, you know, don't overthink it.
• 1:44
  Pick it up when you can and if it's a bad episode, you know, or
• 1:47
  not as good as you could make it, it's not as good as you can
• 1:49
  make it. Move on to the next one.
• 1:51
  You know, so you, you specialized in obesity,
• 1:56
  pediatric obesity particularly. Correct.
• 1:59
  I'm a pediatric surgeon by training, actually, and when I
• 2:07
  well, even before my formal pediatric surgery training, I
• 2:11
  had this sort of epiphany moment where I decided someone needed
• 2:15
  to do something about the obesity epidemic in the United
• 2:19
  States especially. What year was this or around
• 2:23
  what year? If you're going to date me and
• 2:25
  you're also going to test my memory.
• 2:27
  But I think, well, I've told the story a few times and so to be
• 2:30
  consistent with the story I tell each time, say in the year 2000.
• 2:35
  OK, Was obesity an epidemic at that point already?
• 2:39
  So depending on who you ask, it's been around for 50 years,
• 2:43
  but we as a society didn't really recognize it.
• 2:47
  And my epiphany moment was actually at the Dolphin and Swan
• 2:50
  Hotel in in Orlando and Disney. I think I was at the Swan, but
• 2:56
  the pool was shared between the two hotels.
• 2:59
  And I was sitting in the pool at a pediatric surgery meeting,
• 3:02
  actually, where I was going to present my data on something
• 3:05
  completely unrelated to obesity. And I'm there with my wife.
• 3:08
  And although I guess at that time, we got married in 2001, so
• 3:12
  at that time, she was not my wife yet.
• 3:15
  And we're sitting at the pool and across the pool, I see.
• 3:19
  And by the way, this is like May or maybe even Memorial Day
• 3:22
  weekend. And it's like hot, hot.
• 3:24
  Hot. Yeah.
• 3:26
  Orlando's miserable. This time of year or that time
• 3:28
  of year, Yeah. And or all times a year, but
• 3:32
  the, but that's a different story.
• 3:34
  The, so I'm at the pool and across the pool.
• 3:40
  First of all, everybody at the pool is, is struggling with
• 3:42
  weight issues. And the, but the, the, the
• 3:47
  epiphany or the kid that caught my eye.
• 3:49
  And I certainly don't want to stigmatize this kid, although
• 3:52
  this was in 2000. So he probably will have no
• 3:54
  recollection of, of even if he knew I was talking about him, he
• 3:57
  wouldn't have no recollection. But he's probably about 12,
• 4:01
  clearly struggling with his weight.
• 4:03
  He had a big old greasy hamburger, giant hamburger, a 2
• 4:09
  liter bottle of Coke, sugar Coke, and a 1 LB bag of Lays of
• 4:13
  potato chips. And I can still see the grease
• 4:16
  dripping down his arm. Yeah.
• 4:19
  And I was like, this is crazy. Like, how can we this like, so,
• 4:24
  you know, like what's going on here?
• 4:26
  And, you know, so that led to my pediatric surgery training where
• 4:31
  in 2004 I actually did my first pediatric bariatric surgery
• 4:37
  operation as part of a group of pediatric surgeons who were
• 4:39
  starting to explore it at the time.
• 4:42
  And, you know, I just thought surgery was never going to be
• 4:50
  the cure at a population level, but certain people benefit from
• 4:54
  it. But I thought that maybe the
• 4:57
  lessons learned from surgery, like if we could figure out how
• 5:00
  surgery works, maybe we could come up with medications, maybe
• 5:03
  we could come up with other interventions that could mimic
• 5:06
  surgery, which frankly, 20 years later, we actually haven't
• 5:10
  really. Or 20?
• 5:11
  Yeah, 20 years later, we haven't really gotten there yet.
• 5:14
  I was going to ask what was the, what were the methods at the
• 5:16
  time? If someone, if you, if you were
• 5:17
  at at 20 in the year 20, I guess the year 2000, someone's like,
• 5:21
  OK, you need to lose some weight.
• 5:23
  What do you do? You know, I mean, what would you
• 5:25
  tell someone at the point at that point?
• 5:27
  It's the same sort of basic stuff that's being talked about
• 5:31
  today. And frankly, it's the same basic
• 5:33
  stuff that the fitness guru gurus of the 50s and 60s, Jack
• 5:39
  Lalanne, I like to bring him up, but no one has any idea who Jack
• 5:42
  Lalanne is anymore. But he was the original.
• 5:44
  He was America's original fitness guru in the 1950s, and
• 5:47
  it was diet and exercise. And 75 years later, RFK is
• 5:53
  talking about diet and exercise. I mean, it's like, it's
• 5:56
  incredible to me that we haven't moved past that conversation.
• 5:59
  I mean, I get it because I, you know, so I do videos for like,
• 6:04
  TikTok and other things where I'm in a grocery store and I'm
• 6:09
  showing people what they should and shouldn't eat.
• 6:10
  So yeah, everybody should eat better and everybody should
• 6:13
  exercise if they have the time, no doubt.
• 6:16
  I'm totally in favor of all that stuff, but to think that that's
• 6:19
  going to cure the 140 million Americans who suffer from
• 6:23
  obesity and the 15,000,000 children who have obesity.
• 6:26
  If you think that diet and exercise is going to fix them,
• 6:30
  then you just don't haven't been paying attention.
• 6:33
  Because there are, you know, boatloads of data, hundreds of
• 6:37
  studies in the medical literature showing that the diet
• 6:42
  and exercise programs, even at their best, even if it's like
• 6:46
  super intense, even if it's like The Biggest Loser, which by the
• 6:49
  way, there's a Netflix documentary that's exposing all
• 6:53
  of the bad things that were going on behind the scenes.
• 6:56
  I don't see me. At that point in television, in
• 6:59
  entertainment history, there was bad things going on behind the
• 7:01
  scenes everywhere you looked. I mean, you could not catch a
• 7:04
  break from that point in time. And they're.
• 7:06
  Actually now a bunch of great documentaries being made because
• 7:09
  of that. But anyway, the but like the
• 7:12
  people from The Biggest Loser all regained their weight after
• 7:14
  they left their show. Most of them, but in the
• 7:17
  scientific. Community, do we do we know why
• 7:19
  that was? Was it because they did not
• 7:23
  maintain it or was it because there was other factors that
• 7:25
  were required or so you know, I feel yeah, go ahead.
• 7:28
  Oh. No.
• 7:29
  Well, so we know. So all this has been studied and
• 7:32
  studied actually really well now and there are hundreds of
• 7:35
  studies and medical leaders are showing this.
• 7:37
  So 95% of people who used lifestyle intervention to lose
• 7:45
  weight will regain their weight once they stop the intervention.
• 7:49
  So you basically have to behave like you're on The Biggest
• 7:52
  Loser. For the rest of your life, the
• 7:54
  rest of your life, it's not going to work.
• 7:57
  And that's, and so with medications, the GLP 1
• 8:02
  medications, and I'm sure we'll get to that at some point
• 8:04
  because it's a hot topic that everyone wants to talk about.
• 8:09
  80% of people regain their weight after stopping.
• 8:13
  So better than better than lifestyle, but neither of them
• 8:17
  come even close to surgery where the numbers completely flips,
• 8:21
  flips flipped where only 20% of people after bariatric surgery
• 8:27
  regain the significant amount of their weight.
• 8:30
  So. Surgery.
• 8:33
  Always been surgery has always been the most sustained weight
• 8:37
  loss and it's usually you asked why and in the early days people
• 8:42
  just blame the patient. Oh, you know, a firm must be
• 8:47
  cheating. He's he's you know, he, he, he
• 8:50
  got his surgery or he's on. He took his medication.
• 8:53
  He stopped his medication and now he's having a smoothie.
• 8:55
  It's Smoothie King every day and pounding sugar packets in his in
• 8:59
  his free time. Well, that you know that that
• 9:02
  didn't happen. People didn't do that.
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  Like nobody sabotages themselves.
• 9:06
  Maybe not nobody. Few people sabotage themselves
• 9:09
  to that degree. Like why would why would you do
• 9:12
  that? Why would you purposefully do
• 9:13
  that to yourself? But that was what we thought for
• 9:15
  ages. We just blame the patient.
• 9:17
  It's the easiest thing to do. But then we realized it's
• 9:19
  actually just the biology of of obesity, which we didn't really
• 9:26
  understand. We still don't understand big
• 9:29
  chunks of it. But there have actually been
• 9:31
  recent studies that are really interesting, which talk about
• 9:36
  epigenetics. And for your listeners who don't
• 9:39
  know what epigenetics is all about, that's the study of how
• 9:45
  the environment changes your genes.
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  And then what that means is that your genes don't work the same.
• 9:53
  They may not work as well. They might make different
• 9:55
  proteins, they may not make any protein sort of different
• 9:58
  depending on the gene, but. Wait, yeah, I'm sorry, before we
• 10:01
  get there, which I'm I want, I want to get there.
• 10:03
  I just have a couple of quick follow-ups just and a couple of
• 10:06
  things you said at first just to break it down in case anyone has
• 10:09
  any questions or that anyway because I just.
• 10:12
  Yeah, yeah, yeah. I'm trying my hardest to keep it
• 10:15
  simple, but it's complex. You're doing a great job.
• 10:17
  No, there's so far, so far this is perfect, but there's just a
• 10:20
  couple of like what I like to do is introduce a concept and then
• 10:24
  if I have any questions like that, I myself don't know, you
• 10:30
  know, would like to know more about to elaborate them real
• 10:32
  quickly and then kind of keep keep track along the way.
• 10:35
  Can you just explain real quickly how the surgery works?
• 10:40
  Sure. And what and what the process is
• 10:42
  for that, please? Sure.
• 10:44
  Yeah, thanks. So there, there are two major
• 10:45
  types of bariatric surgery in the United States make up the
• 10:50
  vast majority of procedures, although there are other
• 10:52
  procedures as well that are performed by some.
• 10:55
  But the two major ones are the gastric bypass, which is the one
• 11:01
  that most people know about and most people equate with
• 11:04
  bariatric surgery because that was the one that got really
• 11:07
  popular sort of in the late 90s, early 2000s.
• 11:10
  It's the one where people had some really bad complications.
• 11:13
  So it made a lot of news. What was that?
• 11:17
  What? How does that surgery work?
• 11:18
  How does the gastric bypass work?
• 11:20
  Right. So in that surgery, what we do
• 11:21
  is we well, so first of all, back in the old days, we used to
• 11:27
  do those surgeries via a cut on the abdomen.
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  Now we use laparoscopic instruments, which means five
• 11:33
  small holes, biggest one's about a inch.
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  And we can do everything with a camera and instruments that look
• 11:39
  like, well, they almost look like chopsticks with little
• 11:43
  something on the end of it to, to, to do what you need to do.
• 11:49
  And so there's been a lot of advances in bariatric surgery
• 11:51
  since 1991, when the NIH, the National Institutes of Health
• 11:56
  first sort of approved bariatric surgery as a treatment of
• 11:58
  obesity until now, which is what, 35 years later.
• 12:04
  But with that operation, we make a, we take a stapling device, we
• 12:08
  make a small pouch out of the stomach, and then we actually
• 12:14
  divide the intestines and bring a piece of intestine up to that
• 12:20
  small pouch. So that food goes in, it goes
• 12:24
  into this little pouch. So you don't eat very much
• 12:26
  before you feel full. It goes.
• 12:28
  Out into your intestines, but it bypasses A, hence the main
• 12:33
  bypass. But it bypasses the stomach and
• 12:36
  then a fair amount depending on how it's done.
• 12:39
  It bypasses a significant amount of your small intestine, so some
• 12:43
  of the foods you eat doesn't even really get absorbed that
• 12:45
  well. Right.
• 12:47
  So what happens to that food, hypothetically?
• 12:50
  Oh, it just runs through you for lack.
• 12:54
  Of OK, gotcha yeah, OK we're. Going to keep it PG.
• 12:57
  But it but it limits but it but so but it would so it
• 13:00
  essentially limits the amount that you can consume.
• 13:04
  It limits how much you eat and then OK also limits to some
• 13:08
  degree what you can absorb of what you eat.
• 13:12
  So for kids that wasn't really a great option in my mind.
• 13:17
  And now about actually, I would say almost 20 years ago for
• 13:24
  adults as well, everybody, most people move to something called
• 13:28
  the sleeve gastrectomy, which is a much simpler surgery, easier
• 13:33
  to perform, easier left, lower complication rate.
• 13:38
  And with that operation, we basically just remove about 80
• 13:41
  to 90% of your stomach, take it out.
• 13:45
  Yeah. So it also obviously limits how
• 13:47
  much you can eat, but it doesn't impact your absorption at all
• 13:51
  because your intestines are still in the normal anatomy.
• 13:55
  And it it in kids has been shown to be pretty much just as good
• 14:00
  as bypass. In the adults.
• 14:03
  It's still a little there's still controversy.
• 14:07
  Which is better? What would be the controversy?
• 14:10
  Which is more effective? Well, they both have similar
• 14:14
  weight loss and similar resolution of the obesity
• 14:18
  related diseases. Upfront bypass is a little bit
• 14:23
  more weight loss, but there's some question about recurrence
• 14:28
  or weight regain and whether sleeve gastrectomy has higher
• 14:31
  weight regain, which I think is going to become irrelevant
• 14:35
  because I think what's maybe is going to happen is that when
• 14:37
  people start to regain their weight, they'll just that's when
• 14:40
  they'll get on their GLP one medication.
• 14:43
  And because it is depending on whose numbers you look at, the
• 14:47
  sleeve is about 10 times as safe as the gastric bypass or 10
• 14:51
  times safer. I guess is the is is English. 10
• 14:56
  times safer. Yeah.
• 14:57
  So if you if, if a gastric bypass complication rate might
• 15:03
  be 1%, OK, sleeve gastric? Ah, I see, is 1/10 of that. .1%
• 15:10
  yeah. I see, I see, I see.
• 15:13
  So for kids that became like that was easy.
• 15:15
  But you know, when I started doing kids in 20 and and 2000
• 15:19
  and I guess nine, well, I guess my first bariatric surgery
• 15:22
  operation on the kid was in 2004.
• 15:24
  But then when I started my own program in 2010, I only wanted
• 15:31
  to do, I only wanted to do sleep gastrectomy because I didn't
• 15:36
  want, I was worried about the gastric bypass in terms of
• 15:42
  nutrition and because of the, of the amount of food you don't
• 15:46
  absorb for kids. And then I was also worried
• 15:49
  about the complication rate and I should, I should go back one
• 15:53
  step and say so from 2005 to 2009, I was doing laparoscopic
• 15:59
  adjustable gastric banding in kids, which that procedure is
• 16:03
  pretty much almost extinct now, although you can still find it.
• 16:06
  What was it? We put a little device around
• 16:10
  the top of the stomach and it had it's basically like a belt
• 16:14
  with a balloon on the inside. And the balloon was attached to
• 16:17
  actually a port that sat outside of your abdomen underneath your
• 16:20
  skin. And you would come into the
• 16:22
  office, let's say once. What was it?
• 16:26
  It was early. It was becoming frequently and
• 16:30
  then it would spade maybe once a month and then he spaced out and
• 16:32
  you would just put a little bit of fluid into that balloon and
• 16:35
  eventually it would tighten up and it would basically make you
• 16:38
  feel full all the time. But it had lots of complications
• 16:43
  and it was a pain for patients to have to come in and get the
• 16:47
  adjustments and it just didn't really work that well.
• 16:50
  It's still FDA approved and I still think one company makes
• 16:53
  them, I think, but it doesn't make up.
• 16:57
  It's not generally practiced right, right, right.
• 17:00
  And real quick, I'm sorry if when someone's walking into
• 17:03
  these cases, say either with surgery, you know, either of the
• 17:09
  surgeries say, right, what's the process look like in terms of
• 17:13
  weight loss? Does that happen immediately?
• 17:15
  Does that what do they walk out and they're £40 less or how does
• 17:19
  that work exactly? Can you explain that please?
• 17:21
  Yeah. So I should say first of all,
• 17:25
  almost every patient goes through a three to six month
• 17:27
  preoperative preparation period where you sort of learn how to
• 17:31
  eat, you sort of make some of the behavior changes that are
• 17:34
  going to be necessary. So it's not like you walk into
• 17:38
  surgery and then after surgery. The so one of the really
• 17:45
  interesting scientific findings that has spurred a lot of
• 17:49
  scientific discovery, including some of the GLP one type
• 17:55
  hormones is that for gastric bypass patients, they, if they
• 18:01
  had diabetes and they were on insulin, many of them, if not
• 18:06
  most of them would no longer require their insulin even
• 18:11
  before they left the hospital, even before they lost any.
• 18:14
  Because you don't really lose weight.
• 18:16
  You lose weight in the first three months more or less.
• 18:19
  And you can lose 100 lbs in three months, but, but you don't
• 18:23
  lose it on the day of surgery. And so that was a really
• 18:28
  interesting finding that a lot of people have spent a lot of
• 18:30
  years trying to figure out why that happens.
• 18:32
  And I, I don't really think anyone has quite figured it out
• 18:35
  yet, but the. Yeah.
• 18:41
  So you, you get surgery usually go home one or two days post
• 18:45
  procedure. You really are almost doing
• 18:49
  nothing but drinking for the first two weeks.
• 18:50
  And then you get advanced on. Everybody has their own sort of
• 18:54
  special little diet, but most patients after either surgery
• 18:57
  can only eat about a handful of bites before they get full.
• 19:00
  So we need to teach people before that, you know, if you're
• 19:04
  only going to eat this little bit, this is what you need to
• 19:07
  eat. You need, you need to take a
• 19:09
  multivitamin and you need to stay hydrated.
• 19:12
  And most recently there was a, a publication where I think it was
• 19:19
  the, whatever the lifestyle medicine association doctors are
• 19:24
  got together with the obesity society, I think, and then the
• 19:29
  obesity medicine association to talk about how to tell how to
• 19:34
  teach people how to eat after while taking AGLP one medication
• 19:38
  because it, it makes it so you don't eat very little and, and,
• 19:42
  or you don't eat very much. And as soon as it came out, I
• 19:44
  actually emailed like the lead guy because he's randomly some
• 19:50
  guy that I went to college with. And I said dude did, did no one
• 19:56
  bother to talk to the surgeons? We've been teaching people how
• 19:59
  to eat 5 bites of food three times a day for 30 years.
• 20:04
  Like you guys, you guys didn't think that we could be of use.
• 20:08
  And he actually was honest with me.
• 20:11
  He was like, Oh yeah, I didn't think to.
• 20:13
  I didn't. I have nothing against the
• 20:14
  surgeons, but it didn't occur to me to include them in these
• 20:16
  guidelines. And I'm like, yeah, that's the
• 20:19
  problem. And that's the problem with
• 20:20
  like. Everything is too
• 20:22
  componentalized. Yeah, it's a problem with
• 20:24
  medicine in the in in America anyway, but it's certainly a
• 20:26
  problem with obesity. And it's getting better.
• 20:29
  We're we're starting to learn to play in the same sandbox more
• 20:31
  and more. And that's a great people
• 20:33
  understand that Like Medicaid, kind of like with cancer, where
• 20:38
  chemotherapy and surgery work together to best cure the
• 20:41
  cancer, treat the cancer. It's the same thing with
• 20:45
  obesity. It's like it's not, you know, do
• 20:48
  you need meds or do you need surgery?
• 20:50
  There's a good and lifestyle goes for every, everybody gets
• 20:53
  lifestyle. But then what else?
• 20:55
  Is it medicine? Is it surgery?
• 20:57
  And the answer is, you know, you figure out which one's right for
• 21:00
  you to start, but you might need both and you might need, you
• 21:03
  know, medication, surgery, then medication.
• 21:05
  Or no one at the individual level can predict what your
• 21:10
  outcome is going to be like. I can't, you know, even with the
• 21:13
  best genetic testing out there, I can't say you're going to.
• 21:17
  Benefit, there's too many, there's too many variables,
• 21:19
  right? I mean, there's too many
• 21:20
  variables that you can't that that I couldn't even begin to
• 21:23
  tell you as a patient and you couldn't even begin to think to
• 21:26
  figure out as my doctor, right? Yeah.
• 21:29
  Well, that's why I think like, you know, they're, they're the,
• 21:31
  the medication advocates and, and I have nothing against them
• 21:35
  and I will, I'm starting a practice where I'll be
• 21:38
  prescribing these medications as well.
• 21:41
  But there are a lot of folks who are really excited that someday
• 21:46
  there'll be a medication combination that can be as good
• 21:48
  as surgery. But I think that that probably
• 21:52
  is never going to happen because when you do surgery there are
• 21:55
  internal connections between the gut and the brain that get for a
• 22:01
  better. Word, I was actually about to
• 22:02
  start asking you about that, right, right then.
• 22:05
  And that's that that communication is through the gut
• 22:08
  microbiome, right, the communication.
• 22:12
  Between the gut. Potentially.
• 22:15
  I'm not sure either way. OK, please.
• 22:20
  There's something called a gut brain axis and basically you
• 22:24
  know, there's the vagus nerve which goes from your stomach to
• 22:27
  your brain. And then there are all sorts of
• 22:29
  like mediators like GLP, one that your gut releases that go
• 22:35
  through your circulation to your brain and they mostly.
• 22:38
  Tell your brain you're hungry or not right?
• 22:39
  Which is. The part of your brain, that's
• 22:42
  what the hypothalamus does, it's sort of the hunger center it,
• 22:45
  but it turns out it's not only the hunger center, it's actually
• 22:47
  also the fullness center, the satiety center.
• 22:50
  And it's also where your weight set point gets for better, for
• 22:57
  lack of a better word. It gets determined probably in
• 23:00
  utero by your hypothalamus. And the hypothalamic set point
• 23:10
  may have to do with the mom's gut microbiome, the fetus, it
• 23:15
  doesn't have a gut microbiome when they're born, but it can
• 23:19
  certainly it's a possible mechanism by which the
• 23:25
  environment can impact your weight.
• 23:28
  And and the reason I'm a little bit of a skeptic about the
• 23:31
  microbiome, although I'm open minded about almost everything
• 23:35
  so I don't want. To.
• 23:38
  Close off that opportunity that the microbiome is important, but
• 23:42
  I'm a skeptic because I've done, I published one study in my own
• 23:46
  patients where we looked at their microbiome both before
• 23:51
  surgery and then after they'd lost, you know, 50 lbs.
• 23:55
  And it actually wasn't that different between before surgery
• 23:57
  and after surgery. Then we're back.
• 24:00
  Sorry about that. So sorry.
• 24:02
  So my question before we cut out was what factors determine or do
• 24:07
  we know if factors determine the gut microbiome health?
• 24:10
  Because I mean, I'm sure weight has something to do with it, but
• 24:13
  if someone's like, especially post surgery, if someone's not
• 24:17
  getting a lot of nutrition, if someone's not eating a lot of
• 24:19
  food, I could imagine that it wouldn't necessarily be
• 24:22
  strengthened right away until they got back to a regular diet,
• 24:26
  no? Well, I think, I mean, I think
• 24:29
  it's a complicated question because I don't Well, first of
• 24:31
  all, the it's certainly possible that the reason for instance, in
• 24:38
  my study there weren't great microbiome changes is that we
• 24:41
  don't actually have a good way of measuring the microbiome,
• 24:44
  right. The microbiome mostly people
• 24:46
  measure in stool samples, but what's actually in your small
• 24:52
  intestine might be completely different than what is coming
• 24:55
  out in your stool. So part of the issue is that we
• 24:59
  don't have a great way of measuring it for most people.
• 25:04
  But the the issue, so you know, I think, I think we're sort of
• 25:12
  staying away from ultra processed foods and eating foods
• 25:15
  that come right out of the ground and eating healthier.
• 25:18
  I think those things can contribute to a healthier
• 25:21
  microbiome. Again, I'm not 100% sure whether
• 25:27
  a healthy microbiome helps you lose weight or contributes to
• 25:32
  the the development of obesity or if it's just an innocent
• 25:37
  bystander where like if you lose weight and get healthier, your
• 25:41
  micro changes. Like what direction is the
• 25:44
  interruption? I don't know.
• 25:46
  And there are companies who are trying to market like even,
• 25:50
  well, not just companies like there's now like you can buy a
• 25:53
  soda that has probiotics in it because.
• 25:56
  That's all over the place now. Right.
• 25:58
  People are playing on the idea that the microbiome can be
• 26:04
  manipulated for better health, but unfortunately the reality is
• 26:08
  that just like everything that seems to be a viral trend before
• 26:14
  before too long, the science just isn't there yet.
• 26:17
  Like people are like making companies based on the
• 26:20
  microbiome well before the microbiome has been shown to
• 26:24
  actually have an important place in human health.
• 26:28
  Yeah, we're jumping the gun. And then what happens is people
• 26:31
  need to make money from that company.
• 26:32
  So they become they, you know, they get online influencers or
• 26:35
  they become online influencers. I like to, I'm positioning
• 26:40
  myself as AD influencer. So I'm going online or videos or
• 26:45
  podcasts like this one where I just basically talk about facts.
• 26:49
  I don't talk about like if I have a topic where I don't
• 26:53
  actually know the facts, I can present the facts that are on
• 26:56
  both sides if they're if they're they're not in in congruence
• 27:01
  with each other, if they don't jibe with each other.
• 27:04
  But I'm not going to go tell you, you know, go buy a
• 27:08
  supplement because I'm not selling any supplements and also
• 27:11
  because most supplements don't do anything for your health.
• 27:13
  But where we're at as a society is where, you know, our HHS
• 27:18
  secretary and then the woman he's appointed to be the surgeon
• 27:25
  general. Yeah, Doctor means.
• 27:27
  Yeah. I.
• 27:28
  Mean yeah, they're basically peddling in the misinformation
• 27:35
  sort of business like they. You feel that way?
• 27:39
  Oh, for 100% if you like and I'll tell you why.
• 27:42
  Sure. So certain things that RFK says
• 27:46
  or wants to do are for sure great.
• 27:49
  Like they don't need our. The dyes, yeah.
• 27:51
  It needs those, yeah. And yes, everything should have
• 27:54
  has have less sugar totally support all that.
• 27:57
  And I've actually been on TVA fair number of times talking
• 27:59
  about those things. But then in the next breath he
• 28:01
  talks about vaccine conspiracy theories or he talks about beef
• 28:05
  tower. And and these are things that
• 28:08
  are that completely have been vetted by the scientific
• 28:12
  community and there's no question about them anymore.
• 28:15
  But his base doesn't want to believe that.
• 28:20
  So they peddle in these sort of. Yeah, I understand.
• 28:25
  I think right now is actually we're living in a beyond
• 28:29
  fascinating time because there's been a collapse of.
• 28:33
  And I've talked about there's a bunch on the show, just, you
• 28:35
  know, both in a professional setting, you know, with
• 28:38
  professionals and shooting the shit with my friends.
• 28:40
  But the sense that no one really kind of knows who to trust
• 28:44
  anymore, that there's just been such a breakdown of trust and,
• 28:47
  and processes. And, you know, and, and, and,
• 28:50
  and like what you just said, on one hand, someone could say
• 28:52
  something that makes a lot of sense, like food dyes are bad,
• 28:55
  you know, and, and you know, and you probably don't want to be
• 28:57
  consuming as much ultra, ultra processed food as we do, you
• 29:00
  know, and, and that, and that resonates with people.
• 29:02
  And So what follows is that any, you know, beef tallow, whatever
• 29:05
  follows next is, is held in the same light or associated with
• 29:09
  the same kind of positivity and vice versa on people that feel,
• 29:13
  you know, that if they feel disenchanted with the whole, you
• 29:15
  know, with everything that has to do with COVID, then all of a
• 29:18
  sudden anyone that makes any kind of recommendations for
• 29:20
  health, they say, what do you know, you did, you messed up
• 29:21
  with COVID. You know what, just because
• 29:23
  you're right about one thing doesn't mean you're wrong about
• 29:24
  everything else. And vice versa.
• 29:26
  But even the COVID example and and getting back to to KC means
• 29:29
  like she never finished her medical training but she ended
• 29:34
  up starting like a sort. Of yeah levels medicine.
• 29:38
  You know, arthritis medicine practice and became a wrote a
• 29:41
  book and became a social media influencer.
• 29:44
  And now that's, that's who our surgeon general nomination is,
• 29:48
  not some, you know, academic guru who actually only talks
• 29:52
  about science and facts, but a woman who, you know, is on the
• 29:57
  fringe of accepted medical practice.
• 30:00
  But even with COVID, so like, or the COVID vaccines.
• 30:05
  So yes, some of the mRNA vaccines had side effects for
• 30:11
  sure. Like lots of people have had
• 30:13
  side effects from those vaccines and some of them were severe and
• 30:16
  some of them were not so severe. But it's been made into, it's
• 30:21
  been demonized actually to the point where now RFK has
• 30:27
  basically stopped running for all mRNA vaccines, which is like
• 30:32
  basically paralyzing us for the next COVID that comes along, the
• 30:38
  next virus that comes along. If we can't use mRNA technology,
• 30:42
  we are hosed. And so even if you didn't like
• 30:47
  the COVID mRNA vaccine, the answer is to study it more.
• 30:52
  It's not. The answer is to stop all
• 30:54
  funding for that particular type of vaccine or even that vaccine
• 30:59
  in itself. Like there are still people who
• 31:01
  are getting, especially kids who get long COVID, and it's
• 31:04
  devastating for them. And they don't have the vaccine.
• 31:08
  It's not available this fall because RFK basically disbanded
• 31:13
  the committee that makes the decisions and then repopulated
• 31:17
  it with his sycophants, not medical like giants, but people
• 31:22
  who we knew were going to make his base happy.
• 31:27
  And that's sort of where we are in politics and in the world.
• 31:29
  And and as you said, it's just like it's really, I mean, I saw
• 31:33
  something in, I can't remember which news agency, whether it
• 31:38
  was, I don't know, anyway, some, some CNN or New York Times or
• 31:43
  Washington Post or something, U.S.
• 31:45
  News Award report, can't remember.
• 31:46
  But somebody did a survey of sort of trust and leadership.
• 31:51
  Yeah. Across the different domains and
• 31:55
  it was crap. In life, it's been, it's been
• 31:58
  going down. It's been going down for 6070
• 32:01
  straight years and the last five, the last five or six years
• 32:05
  have the last five or six years have really plummeted.
• 32:08
  I was actually curious to ask because, and I don't want to
• 32:14
  stick on it too long because I feel like it's a topic that's
• 32:16
  kind of been beat over the head so many times, but I think it's
• 32:19
  relevant just just as a finishing point.
• 32:22
  I think it's interesting because, you know, there at the
• 32:25
  beginning of COVID, everyone kind of was like freaked out.
• 32:28
  And then at one point, I remember at one point there was
• 32:31
  a shift and maybe it was after a month or three months or five.
• 32:34
  I don't remember exactly what it was, but at some point I got the
• 32:38
  IT dawned on me like, Oh my God, this has turned into a political
• 32:41
  conversation. It's not a health conversation.
• 32:43
  Like this isn't a question of like is, you know, how do I, how
• 32:47
  do I make sure that I'm healthy and not sick?
• 32:49
  And how do we stop this? What feels like a rampant virus
• 32:52
  been going through now it feels like it's a question of like,
• 32:55
  are you, are you Republican? Are you Democrat?
• 32:57
  Are you moderate? What do you think?
• 32:59
  And I'm like, what the heck does one thing have to do with the
• 33:01
  next? And why, why is this even?
• 33:02
  Why is this even that? And so I was, you know, and I
• 33:06
  think that health, especially now with the, with the obesity
• 33:11
  conversation and the general, you know, the fact that and you
• 33:14
  know, again, I mean, I don't, there was a great point I heard
• 33:19
  recently, I forgot who was saying it, but I haven't heard
• 33:21
  anyone public figure in my at least in my life.
• 33:24
  And I'm only, you know, I'm 30, but you know, ever, ever
• 33:29
  campaign politically on health, on Children's Health, on adults
• 33:34
  health, on the, you know, on fitness, on, on any of that.
• 33:37
  And I thought that was really, really fascinating.
• 33:39
  Yeah, I think RFK tried that because he didn't really have
• 33:42
  much to offer in anything else. But as you saw, it didn't get
• 33:46
  him anywhere close to enough of a support to be a major party
• 33:50
  candidate. But the Yeah, and like, again,
• 33:55
  if Anthony Fauci, he's not a perfect human being.
• 34:00
  I I know people who have worked with him said he was kind of
• 34:03
  like a know it all jerk in many ways, but he was trying to do
• 34:10
  what he thought was right for the country.
• 34:12
  It wasn't because he had one political agenda or another.
• 34:16
  He was just trying to save as many lives as he thought as he
• 34:20
  could. And he thought he was doing
• 34:23
  what, you know, he was trying to accomplish that aim.
• 34:26
  So again, even if you disagree with him, and I think that again
• 34:30
  getting getting back to you, it goes back to like everything in
• 34:32
  our world today, rather than having a like an intellectual
• 34:36
  discourse with him or with other public health figures, it just
• 34:40
  became. You know, a shouting match,
• 34:42
  Everything's a shouting match, everything's a shouting match.
• 34:44
  The same thing happens today. Like, you know, again, I go back
• 34:48
  to the, you know, the example of the mRNA vaccine.
• 34:51
  Like there's nothing wrong with that technology necessarily
• 34:57
  until they prove that there is. But like, it's such a political
• 35:01
  hot button that, you know, it was like, oh, we're just.
• 35:04
  Going to yeah, it's going to be very even even if there is even
• 35:07
  if anything's done, it's going to be hard for it to be
• 35:09
  objective because it's become so politicized.
• 35:11
  So. And now, yeah, that's.
• 35:13
  On the flip side, like anything that comes from the vaccine
• 35:20
  committee that RFK has now reappointed, everybody, no one's
• 35:24
  going to believe that either. Like no one's everybody's like.
• 35:26
  That right and either way, we either way, we end up worse off,
• 35:30
  which is a shame, you know, and that's kind of yeah.
• 35:32
  And I mean that was that was actually, you know, you know,
• 35:34
  full circle back to even my podcast.
• 35:36
  It was, you know, there was that things have strayed so far from
• 35:40
  just being able to have a regular conversation that it's
• 35:45
  obscene, you know, and it's really, it's really a shame.
• 35:47
  And I think that and, and yeah, I mean, I don't want to, I don't
• 35:51
  want to get, I don't, I don't think much more into it than
• 35:54
  this. Because I think that it's a
• 35:56
  different episode it. Is and and you know what at the
• 35:59
  end of the day, I also think that this particular topic also
• 36:02
  has been being on being over the, you know, everyone's head
• 36:04
  until like a dead horse. And I think that I think that,
• 36:08
  you know, it's, you know, what I think for a lot of people, their
• 36:11
  opinions are their opinions at this point about it.
• 36:13
  And there's not much else that that we're really going to do
• 36:16
  because echo chambers and yelling and podcasts and
• 36:19
  everything like that, you know? And so, you know, I welcome, I
• 36:22
  welcome everyone's perspective. And you know, I think it's
• 36:24
  really great. But that's why I'm sort of
• 36:27
  positioning myself as a quote UN quote D influencer.
• 36:30
  Yeah, that's a great. It's it's really cool.
• 36:32
  Because like, I don't really have an agenda other than
• 36:36
  getting people healthier. Like I don't really care.
• 36:38
  I like to. I often describe myself as
• 36:40
  intervention agnostic. Like I don't care if you want to
• 36:43
  use diet and exercise. I don't care if you want to use
• 36:45
  medications. I don't care if you want to use
• 36:46
  surgery. I just want you to to to get
• 36:49
  healthier. And I can tell you the, the, the
• 36:51
  data, I can tell you the facts, the data.
• 36:53
  And then you as the patient should do what you want with
• 36:57
  them. Because that's the great thing
• 36:59
  about being, you know, being a human is that you get to decide,
• 37:03
  well, at least in this country, you get to.
• 37:04
  Decide what you want to do. And so, like, again, it's like,
• 37:09
  why are there people out there who are saying things like, oh,
• 37:13
  if we just change food policy, that's all we need to do.
• 37:16
  Everything's going to get, you know, everything.
• 37:18
  Everybody's going to get healthier or you know.
• 37:20
  There's no magic button. There's no magic button.
• 37:22
  But I think it's just in general, I think it's like, I
• 37:24
  think at least from what I I try to be charitable, my, my, I
• 37:29
  think that these are all positive steps that if we did
• 37:32
  would only have, I feel essentially net positive.
• 37:36
  It's only net positive to get rid of the dyes from the food.
• 37:38
  I mean, unless you can make a case otherwise.
• 37:42
  Yeah. And actually, you know, so I
• 37:44
  think that people in general were held.
• 37:47
  Go ahead, please. Oh, I.
• 37:48
  Was just going to say even if, even if those things don't cause
• 37:55
  problems, like no one needs them, no one needs their ice
• 37:59
  cream to be bright blue or bright green, right?
• 38:02
  Like I said, like it's not a big deal when you do some of those
• 38:08
  things and you're right those are probably net positives.
• 38:10
  They're either neutral or positive.
• 38:12
  There's no downside, but there are some downsides to some of
• 38:15
  the other things. So that's when you really have
• 38:17
  to be a little bit more careful about what you're saying.
• 38:19
  And you know, again, I think the, the the obesity world is
• 38:27
  starting to learn to play together much better.
• 38:31
  And I think that's the key step in the right direction.
• 38:36
  And I think docs in general have started to realize that the old
• 38:41
  fashioned paternalistic, do as I say type of model is not really
• 38:46
  well received. Yeah, not much anymore, yeah.
• 38:49
  So it's like it's called shared decision making or something
• 38:53
  like that. And so I think we're starting to
• 38:57
  move in the right direction in terms of that kind of stuff.
• 39:01
  But you know, yeah, the rest of the.
• 39:03
  I mean, can I ask you about alcohol and and obesity?
• 39:06
  Do do, do, do, do, do, is there a correlation between people
• 39:10
  that, that drink a lot frequently and people that are
• 39:13
  overweight or vice versa? Or what do you what have you
• 39:16
  seen? So actually, so alcoholism is a,
• 39:21
  an example analogy that I used to talk about obesity quite
• 39:25
  often because, you know, 30-40 years ago people thought
• 39:29
  alcoholism was a disease of the weak minded and the weak willed.
• 39:34
  And you know, you just couldn't keep away from the bottle.
• 39:37
  The temptations were too great and you just indulge.
• 39:40
  But then people realized that it's actually a heritable, it's
• 39:44
  a genetic disease that you can inherit from your parents.
• 39:47
  And it changed a lot of the stigma around alcoholism and it
• 39:51
  changed how we treat it and how we view it.
• 39:54
  And obesity is the same way. Like people just think obesity
• 39:57
  is because people don't work out enough or eat well and that
• 40:00
  they're lazy or whatever, which is insane.
• 40:04
  And we actually now know that there are a lot of it is
• 40:06
  genetically inherited, but it's still so stigmatized that folks
• 40:12
  don't want to, they don't want to appreciate that.
• 40:15
  They don't want to consider that.
• 40:16
  So take some time I think. Yeah, so it's actually the
• 40:20
  opposite. People with alcoholism tend not
• 40:23
  to, they actually, they're usually skinny because they
• 40:25
  don't eat enough anything else. So most people with alcoholism
• 40:30
  are actually on the thinner side.
• 40:31
  But if you drink a lot of sugar sweetened beverages, certainly,
• 40:35
  certainly alcohol has a lot of calories too.
• 40:37
  And obviously everybody knows, everybody knows somebody with a
• 40:40
  big beer belly. So it it, it's not black and
• 40:44
  white, but yeah. So calories consumed by drinking
• 40:50
  are probably the number one modifiable behavior for people
• 40:56
  if they really want to start to think about their weight or
• 41:00
  address their weight and get healthier is, you know, like
• 41:05
  every, there's sugar in almost every drink that's out there
• 41:09
  unless you specifically look for things without it.
• 41:13
  And obviously, like I had a, I was in New York.
• 41:19
  I used to live in New York City. I haven't lived there in a
• 41:21
  while, but I was in New York, let's say, I don't know, 15
• 41:25
  years ago. Which part of the city are we
• 41:26
  living in? I lived in Murray Hill, which is
• 41:29
  so I worked at NYU, so I. Lived in Murray Hill, gotcha
• 41:32
  even. Before that I was in the Upper
• 41:34
  East Side, so I did my general surgery training at.
• 41:38
  I love the East Side, by the way.
• 41:40
  I love it. It's a great, it's a great, it's
• 41:42
  my favorite part of Manhattan. It's it's, it's quiet, it's
• 41:45
  residential, and it's affordable or more affordable, relatively
• 41:48
  speaking. Yeah, everybody has their own.
• 41:50
  Everybody has their own favorites.
• 41:53
  But I remember I was downtown, probably in Soho because that's
• 41:57
  one of my favourites. And I went to, I can't remember,
• 42:00
  I was meeting, I mean meeting my wife.
• 42:02
  I don't know who I was meeting, but I was at bar and I, they
• 42:07
  were sort of famous for their mojitos and I had them make me a
• 42:10
  mojito and that one of their things is they make them right
• 42:12
  in front of you. And the dude or dudette woman, I
• 42:17
  don't know who was started making one and he or she opened
• 42:25
  four of those little sugar packets.
• 42:28
  Oh man. To put it in the bottle of the
• 42:31
  mojito with the, I guess the mint to, to muddle it and then
• 42:35
  put it in the rum and whatever. And I've never had a mojito
• 42:37
  since I was like, Oh my God, if I knew that a mojito had each
• 42:44
  one of those sugar packets is usually about 5 grams of sugar
• 42:46
  or 4 grams of sugar. So if I knew a mojito, I had 20
• 42:49
  grams of sugar in it, I never would have had them.
• 42:52
  So that's where alcohol can really, mixers especially can
• 42:58
  really increase your calorie intake.
• 43:01
  I had the same thing, by the way, with beer, right, because I
• 43:03
  love craft beer. And so Ipas apparently part of
• 43:06
  the way or sours, the way that they get these Ipas or sours up
• 43:10
  to 8910 percent ABV is by dumping more sugar in or more
• 43:15
  fruit, you know, more, more fruits, you know, and, and it
• 43:18
  might. I think it's, I don't actually
• 43:22
  know the caloric difference between an IPA and or a sour and
• 43:26
  let's say a lager. Well, I mean, a Bud Light, a
• 43:29
  buddy has less than 100 calories, right?
• 43:32
  Or Guinness, I think has famously, you know, they say
• 43:36
  whatever that whatever that means.
• 43:37
  I don't know what the equivalent of whatever it says on the
• 43:39
  bottle, you know, 100 calories. But I, there was a brewery I
• 43:43
  went to where they had the calories next to the beers and
• 43:47
  they had a stout which was like a heavy barrel aged, you know,
• 43:51
  you know, sweet beer. And I think I had like 450
• 43:55
  calories for an 8 oz pour or something crazy like that.
• 43:58
  Well, right. And you know, I'm no brew, no
• 44:01
  brew Meister, but I do know that, you know, the sugar is the
• 44:04
  fuel for the yeast to make the alcohol.
• 44:06
  So I think, you know, they have to add more sugar in it to to
• 44:10
  get the higher alcohol contents. But yeah, like it's a, it's a,
• 44:14
  it is AI think that's sort of helped start the whole like the
• 44:20
  White Claw craze or whatever the, the the seltzer.
• 44:22
  Craze. Because they can make them with
• 44:24
  relatively little few calories. You know, it's basically like.
• 44:28
  Alcohol consumption in general feels like it's going down, I.
• 44:31
  Mean, yeah, I just saw that actually in a I'm always
• 44:37
  scouring the news because I'm always looking for things to
• 44:39
  sort of pitch to TV, cable TV networks because I, I've been,
• 44:44
  was doing a bunch of them, although it's dried up over the
• 44:47
  last month or so. But anyway, the I think mostly
• 44:50
  because there's so much other news other than health that
• 44:54
  people talk about. But I did see another survey
• 44:58
  that did and it was actually interesting because it said that
• 45:04
  that so in general, alcohol consumption is down for sure.
• 45:07
  But they, for whatever reason, they they compared it by
• 45:12
  political party, which I have no idea why that anybody.
• 45:16
  But supposedly the there's a bigger decrease in alcohol
• 45:21
  consumption among Republicans than Democrats.
• 45:25
  I have no idea what that means. I don't.
• 45:29
  Even if I were to take a wild, a wild stab, really I would.
• 45:35
  I would just probably say that younger crowds tend to be
• 45:42
  left-leaning. Younger crowds are a little bit
• 45:44
  more leaning towards weed and cannabis today than they are
• 45:47
  towards alcohol in general. And I think that, but it's I
• 45:51
  think that. It's Republicans who've dropped
• 45:53
  less, dropped more than Democrats.
• 45:57
  Oh, yeah. Well, because I don't think, but
• 45:58
  I don't think Democrats were drinking very much recently
• 46:00
  anyway. So a lot of, you know, these,
• 46:02
  you know, Logan Bros Bros or whatever, you know, I've been
• 46:05
  hearing about this last five years.
• 46:07
  I think a lot of those kind of people have been, you know, have
• 46:10
  been dropping that. But either way, it's
• 46:13
  fascinating. I bet you're going to say, I
• 46:15
  thought you're going to say it's due to the, you know, Trump one
• 46:18
  and Trump 2 that the Democrats are still drinking their
• 46:20
  sorrows. No, that's funny.
• 46:24
  I didn't think about that. So can we get back to
• 46:28
  epigenetics a little bit now? I'm sorry that, you know, that's
• 46:31
  right, that's right because I, because I think it is the
• 46:33
  perfect spot back-to-back. Well, we're back to it, right?
• 46:36
  Because now we're talking about people.
• 46:37
  Don't you know, think that it's not just a stigma anymore, just
• 46:41
  like alcoholism. And so, So what, what, what are
• 46:44
  epigenetics and what are the, what's the context for alcohol,
• 46:46
  for, for sorry for, for obesity? Yeah.
• 46:50
  So epigenetics is the field of how genetic material gets
• 46:57
  altered by the environment, by the extreme environment.
• 47:01
  And it's a burgeoning field. It wasn't even really a field
• 47:04
  until maybe like 1520 years ago. And it's not really well
• 47:10
  understood. But what is understood is that
• 47:13
  your DNA can be altered by. Experience.
• 47:18
  Yeah, let's say ultra processed foods or let's say environmental
• 47:21
  toxins, you know, that's that's how radiation meets the cancer,
• 47:25
  for instance, potentially. And what what is known now is
• 47:35
  that the epigenetic, the epigenetically modified DNA
• 47:41
  genes passed down can be passed on from parent to right.
• 47:47
  So it, you know, the people who are in the food camp, like the
• 47:53
  food is medicine people, which I don't necessarily support
• 47:56
  because food is food and medicine is medicine.
• 47:58
  But they argue that the obesity epidemic can't be about anything
• 48:03
  other than food because food is the only thing that's changed in
• 48:05
  the last 50 years. And as we talked about earlier
• 48:08
  50 years about when the obesity prevalence really started to
• 48:11
  rise. But what they don't consider is
• 48:14
  that, yes, it's the food, but it's the food and how it
• 48:16
  interacts with your genes. And that's how it gets passed on
• 48:19
  from parent to child. That's why you know, me as a
• 48:22
  pediatric surgeon and a pediatric obesity expert, I see
• 48:25
  kids who are 8 or 9 who haven't been on earth long enough to to
• 48:28
  eat enough to eat themselves into obesity.
• 48:32
  Even if I believe that anybody did that, which I don't like,
• 48:35
  nobody eats themselves into obesity.
• 48:38
  People eat and then their bodies react with obesity because, you
• 48:45
  know, we all know. We all either have a sibling or
• 48:49
  a family member or a cousin or a friend who eats the same as we
• 48:53
  do but is either, you know, 20 lbs heavy.
• 48:56
  Yeah, of course, 20. Pounds lighter.
• 48:57
  Like, sure, or you can be a freak athlete and you can work
• 49:00
  out every day and eat garbage, sorry and eat garbage and you're
• 49:04
  fine and then they're sorry. Vice versa, you know you're
• 49:07
  healthy all day and the people that you know genetically, they
• 49:09
  just walk out of the bag of candy all day and they're
• 49:10
  totally fine and they're good to go.
• 49:13
  Right. So, so it's clearly more
• 49:15
  complicated than diet, but the study that came out recently,
• 49:21
  which I think really is going to help shed light on, on the whole
• 49:28
  weight regain thing that we were talking about with both
• 49:33
  medicines and surgery and lifestyle, is that there's now
• 49:41
  evidence that fat cells have what's, what people are calling
• 49:45
  memory. So like the the genes and the
• 49:49
  proteins that are being made in fat cells, even if you lose
• 49:54
  weight, they still, they may not change.
• 49:57
  So when you stop your intervention, they may still
• 50:03
  basically drive you back to the unhealthy.
• 50:06
  Fascinating that you. Had originally and it actually
• 50:10
  makes a lot of sense if you think about it because.
• 50:13
  Would that be coming to form of a craving?
• 50:15
  Is that like is is this? Or is this just that it reacts
• 50:19
  to food in a similar way? Well, so again with the gut
• 50:23
  brain axis, we don't really know how fat cells interact with the
• 50:27
  brain directly or even indirectly.
• 50:29
  But let's say they have let's say fat cells have a memory and
• 50:34
  fat cell when you have obesity is has changed your brain to,
• 50:41
  you know, prefer salty foods or or or processed foods or.
• 50:45
  Or. Sugar, sugar, foods, whatever
• 50:47
  and then you have surgery and if you have surgery, let's say and
• 50:54
  you respond well. So we didn't haven't talked
• 50:56
  about statistics, which bores everybody, but I'd like to.
• 50:58
  Talk about No, I'd love to. I'd love to talk about it.
• 51:00
  Yeah, please. Well, mostly because
• 51:02
  everything's a bell curve. So like when you hear average
• 51:05
  patient, what does that actually mean and what does that mean for
• 51:08
  you as an individual? It almost means nothing for you
• 51:11
  as an individual. You might be average or you
• 51:13
  might be a super responder or non responder.
• 51:16
  And the data are that like with any bell curve, 2/3 of the
• 51:21
  people are within one standard deviation above the average or
• 51:26
  below the average 2/3, but then 1/3 live on.
• 51:30
  The either end live. Further out.
• 51:32
  So if you're in the one for 1/3 that is a super responder, good
• 51:35
  for you. Like you're going to respond to
• 51:38
  surgery like gangbusters. You might probably not going to
• 51:40
  need anything else ever, like medication or anything else.
• 51:42
  But you also might be in the lowest 5% where surgery doesn't
• 51:47
  really do much for you. And some of that might be due to
• 51:51
  your epigenetics and whether your fat cells are still,
• 51:57
  whether the epigenetic modifications are so entrenched
• 51:59
  that you can't fix them or are they still modifiable.
• 52:03
  And that may explain why, you know, 20% of people gain weight
• 52:08
  from surgery, but 80%, I mean, to regain their weight, you
• 52:13
  know, two years after surgery. And 80% of people don't.
• 52:16
  It also there are data from pediatric bariatric surgery that
• 52:22
  show that the effects of surgery are actually longer lasting than
• 52:25
  they are in adults. And it could be the same thing,
• 52:28
  like maybe we're getting the kids before these epigenetic
• 52:32
  changes are so entrenched in there fascinating fat.
• 52:36
  It could be other cells around the body, like it's such a new
• 52:39
  field that we really don't even we don't even have enough
• 52:42
  information to to hang our hat there.
• 52:45
  Although I, I've always believed in the what what's called the
• 52:50
  intergenerational transmission of obesity, meaning from parents
• 52:53
  to kids, because I've seen so many young kids with obesity.
• 53:00
  And again, there's just no way, even if I believe that poor
• 53:05
  behavior, not poor behavior, lack of exercise and not eating
• 53:09
  right could lead to obesity, which again, I don't believe
• 53:11
  that. But even if I did, you can't
• 53:14
  tell me that, you know, 8 year olds can do that in eight years
• 53:18
  on earth. Like it's just.
• 53:20
  Well, I mean, we know, I know, for example, and I don't know
• 53:23
  whether what like what this has, I'm sure this has to do with
• 53:26
  genetics for sure. But my, you know, my wife just a
• 53:29
  couple months ago was just, you know, she gave birth thing, you
• 53:32
  know, and thank God everything was smooth and OK, thank you
• 53:34
  very much. She's really exciting little
• 53:36
  girl. And, and, you know, and we're
• 53:41
  talking to the nurse and she was telling and the baby was born I
• 53:43
  think at 7/1 or 7/3. And the nurse said that she was
• 53:48
  just coming. And she's like this past, you
• 53:50
  know, the last couple of days I've seen, you know, 1012 LB
• 53:54
  babies being born on a regular basis.
• 53:57
  And, you know, I mean, I grew up and I'm one of six and none of
• 54:01
  us were anywhere ever really anywhere near that.
• 54:03
  You know, it was considered, it was considered crazy at that
• 54:06
  point. But apparently it's becoming
• 54:07
  pretty common. I'm sure that has to do with
• 54:08
  what we're talking about, right? Right.
• 54:10
  So we know that moms who gain excess weight during their
• 54:16
  pregnancy or get gestational diabetes or actually have
• 54:19
  diabetes from their weight going into pregnancy, their babies all
• 54:24
  have a much higher incidence of obesity.
• 54:28
  And actually interestingly, another interesting study that
• 54:31
  is relatively recent, it turns out that those same babies have
• 54:35
  a higher incidence of autism spectrum disorder.
• 54:39
  So like in when all this again, the vaccines causing autism
• 54:45
  furor came up, there were a lot of publications that showed that
• 54:49
  actually, you know, there are a lot of other factors outside of
• 54:53
  even before people are born that can impact your autism risk.
• 54:59
  So, yeah, no. So for sure the obesity epidemic
• 55:02
  has has impacted fetuses, for lack of a better word, and they
• 55:10
  are being born bigger and they are born with often with again,
• 55:15
  higher hypothalamic weight set points.
• 55:19
  And there was even a study at CNN that I saw that showed that
• 55:22
  sugar exposure, what was it in the first 100 days?
• 55:27
  No, 100 days. Wait, what was it first?
• 55:30
  Thousand days first. Hundreds are lost.
• 55:34
  Thousand days is 3 years, right? Yes.
• 55:37
  So the first thousand days from conception from from nine months
• 55:44
  pre. Right to two years old.
• 55:47
  Post birth sugar exposure in that period of time was and
• 55:54
  sugar obviously on the fetus is coming from mom.
• 55:58
  Sugar exposure in that period of time was critical to your risk
• 56:03
  of developing type 2 diabetes as a child.
• 56:07
  And again, it's like no one thinks about people that young,
• 56:12
  right? They just think, you know, kids
• 56:14
  will be kids if they're chubby, they'll grow out of it or it
• 56:18
  doesn't really matter how much what they eat because they're
• 56:21
  going to be exercising, running around all day so they can eat
• 56:22
  whatever they want. And for lots of people that's
• 56:25
  true. And that may be true even for
• 56:27
  the majority of people. But I think where the like the
• 56:30
  genetic scores that are being developed and some of the other
• 56:35
  predictive models that are coming out, this is where this
• 56:38
  is where they can be useful. Because like, well, first of
• 56:40
  all, I encourage any woman, any person actually, man or woman
• 56:46
  who's thinking of conceiving to think about their own health
• 56:49
  before they conceive. Because if you optimize your own
• 56:52
  health before you conceive, you're going to optimize the
• 56:54
  health of your child that you're going to conceive, probably also
• 56:58
  optimize your chance of conceiving.
• 57:03
  And you know, so, but not only, you know, not only do you do
• 57:09
  moms have to pay attention to their not only mom could not
• 57:13
  only would it help if moms pay attention to their or potential
• 57:16
  moms pay attention to their weight before they conceive, but
• 57:18
  during pregnancy and then in the first 2-3 years of life and on.
• 57:23
  Because obviously it's not only sort of the direct impact of
• 57:29
  what you're feeding or of what the kids eating or whatever, but
• 57:33
  also just think about the behavior that you're modeling,
• 57:35
  right? So if you're a a young parent,
• 57:38
  mom or dad and you're eating chips in front of your 4 year
• 57:42
  old, your 4 year old's going to automatically be like, Oh yeah,
• 57:47
  chips are like that's normal. Yeah, chips.
• 57:49
  Yeah. So like.
• 57:51
  We grew up thinking of wanting a tree, and you have a strawberry.
• 57:54
  We thought like, you know, we thought, we thought that, you
• 57:56
  know, blueberries, like my mom would be like, OK, if you're
• 57:58
  good, we'll give you a strawberry, you know, but you
• 58:01
  grew up. In a stricter household than I
• 58:03
  did. I grew up and I'm also 25 years
• 58:05
  older than you, so things were, you know.
• 58:08
  Yeah, I think it was. Heavily easier, but.
• 58:11
  It was, it was, it was I think my mom was heavily influenced by
• 58:14
  her Eastern European parents, you know, which there's a whole
• 58:17
  generation in them of themselves, you know, But yeah,
• 58:20
  tough cookies. And they're very, very, you
• 58:23
  know, very sensitive, I guess, towards this kind of stuff.
• 58:25
  So I just, you know, I like my, my youngest brother is 13, you
• 58:29
  know, he'll make himself a snack.
• 58:31
  Like he doesn't go to the, he doesn't go to the supermarket
• 58:33
  to, or it's the gas station. He grabs an apple, you know, or
• 58:36
  a couple of, a couple of oranges.
• 58:38
  And that's how he just, that's all he knows.
• 58:40
  That's all he's used to. Yeah, but even in communities
• 58:45
  where that sort of dietary behaviour is common and like I
• 58:53
  used to work at in, in New York City, at NYU and there were, you
• 58:57
  know, Hasidic communities, you know, in the in, in Brooklyn and
• 59:03
  elsewhere. And they have the same Eastern
• 59:09
  European roots as you do. But there were families with
• 59:14
  severe obesity problems in it. I believe it most, it's mostly
• 59:17
  genetic. It just got passed down from
• 59:20
  generation to generation and you know, I, I've taken care.
• 59:25
  Of, well, they, they, a lot of these guys don't eat like Saints
• 59:28
  either. I'll, I'll tell you that.
• 59:29
  Well, and not anymore, right? They may have, it may have
• 59:32
  started that way, but but maybe not anymore.
• 59:34
  But but but but it definitely, I mean it runs in families.
• 59:38
  And then I'd see families where, let's say you said you had
• 59:44
  you're one of six, I'd see families where everybody in the
• 59:47
  family eats as you described, but one of the six kids has a
• 59:52
  weight problem. And the parents would come in
• 59:54
  and they'd be like super upset because I don't understand why
• 59:58
  is my one child having weight issues when nobody else in the
• 1:00:01
  family has? And they eat the same stuff and
• 1:00:03
  they exercise the same amount, you know, And then I'll start
• 1:00:06
  asking like, well, does, does, does mom or dad do either of you
• 1:00:09
  guys have any obesity that runs in your families?
• 1:00:12
  Oh, yeah. You know, somebody's brother or
• 1:00:16
  somebody's uncle or cousin or whatever.
• 1:00:18
  Somebody. And then you can usually chase
• 1:00:20
  it back to where. It might have had some genetic
• 1:00:23
  origins, but again, that's sort of it's like the natural
• 1:00:26
  experiment that I've lived throughout, taking care of all
• 1:00:29
  these. Patients.
• 1:00:30
  Where I mean, I know, I know for a fact that diet and exercise do
• 1:00:35
  not impact obesity in everyone because again, because I've seen
• 1:00:43
  families where it. Yeah, it's, it's it if, if it
• 1:00:49
  the we're, we're so used to trying to come up with 111 word
• 1:00:53
  answers for all these things. You know, I mean, think about
• 1:00:56
  how long we it took. So how many years it did it
• 1:00:59
  take. And I'm not comparing, you know,
• 1:01:01
  at all by any means, of course, but you know, the homeless issue
• 1:01:04
  that we've had in the last, you know, 30-40 years or maybe less,
• 1:01:08
  but you know, how many, how long people spent saying it's a money
• 1:01:10
  problem, You know, where as, and now we're having the
• 1:01:13
  conversation, a lot of it's a mental health problem as well.
• 1:01:15
  A lot of this is a sickness. A lot of this is, you know,
• 1:01:17
  other factors that, and I'm, and I'm, I'm not saying this to
• 1:01:21
  compare, God forbid, I'm not trying to do that.
• 1:01:23
  I'm just trying to say that anyone that says it's, it's one
• 1:01:26
  thing, it's just diet. It's just if you, if you were,
• 1:01:29
  if you just got off the couch, a random marathon, then you
• 1:01:31
  wouldn't be obese anymore. You know, like, I'm sure that's
• 1:01:34
  not the case either. Well, so, you know, it's human
• 1:01:37
  nature. Humans don't like ambiguity and
• 1:01:39
  they don't like not knowing the answers.
• 1:01:42
  It's much more satisfying to be able to say yes or no, black or
• 1:01:47
  white, you know, like people don't like grey.
• 1:01:50
  And so like, people don't like, even in medicine, people don't
• 1:01:54
  like the, you know, doc, what should I, what should I have
• 1:01:58
  surgery or should I take a medication?
• 1:02:01
  Right. You know.
• 1:02:02
  It's that that there's there are no answers to those types of
• 1:02:05
  questions. And the reality is, again, I go
• 1:02:08
  back to statistics and it's because of bell curves and how
• 1:02:12
  statistics work. And it's just, it's never going
• 1:02:14
  to be most questions are never binary.
• 1:02:18
  These questions are, you know, what's the solution to
• 1:02:22
  immigration? It's not just throwing people
• 1:02:25
  out of the country. It's something far more complex.
• 1:02:29
  That's the, you know, any, any major issue you brought up
• 1:02:33
  homelessness, poverty, you know, whatever.
• 1:02:38
  Whatever divorce rates that's a it's a big deal in the in the
• 1:02:41
  country for the last 20. Years or like, I mean, just
• 1:02:44
  freaking look at what's going on internationally.
• 1:02:46
  What's the what's the solution in the Ukraine?
• 1:02:48
  What's the solution? In Gaza, it's yeah, yeah, like.
• 1:02:52
  There, there's no. I mean, I don't want to be too.
• 1:02:57
  I don't know what the right word is, pessimistic or nihilistic,
• 1:02:59
  but there are no solutions to those.
• 1:03:04
  There are. There are like, there are
• 1:03:06
  compromises that everybody hates.
• 1:03:09
  Yeah, there's no solution like. Yeah, I don't, I don't, Yeah,
• 1:03:12
  especially because all because, you know, because issues that
• 1:03:15
  are complicated to get to require complicated and nuanced
• 1:03:19
  answers too. You know, I think that's also
• 1:03:21
  the thing, right. Not to like again, if we can't
• 1:03:23
  even tell you what the factor, what factors epigenetics have or
• 1:03:26
  not, then how in the world you're going to tell me whether
• 1:03:29
  or not it's going to be something that's going to be
• 1:03:30
  part of the part of the answer. Like I, I, I, I, I hear you.
• 1:03:34
  I right. It's a great.
• 1:03:34
  Point, but I do think you know, again going back to that the
• 1:03:37
  positives with RFK and the positives with the food is
• 1:03:39
  medicine movement. Like there are, there are
• 1:03:43
  modifiable food factors and dyes and ultra processing and things
• 1:03:50
  that we can definitely improve upon to make food in the United
• 1:03:55
  States healthier, but it's not going to.
• 1:03:59
  Cure. It's not going to cure obesity.
• 1:04:02
  It's not going to cure obesity. It might help prevent obesity in
• 1:04:05
  future generations. But the only like, real
• 1:04:08
  solution, if you're talking about solutions, and I'm not
• 1:04:10
  even sure this would be a solution, but it's the best I
• 1:04:13
  can come up with, is you basically have to do everything
• 1:04:15
  all at once. You have to treat everybody who
• 1:04:16
  has obesity now before they have the next generation of kids,
• 1:04:20
  while improving the food and improving exercise opportunities
• 1:04:23
  and getting rid of the stigma and dealing with mental health
• 1:04:26
  and adverse childhood experiences and all the other
• 1:04:30
  things that have been shown to. It's a societal problem.
• 1:04:35
  So if you could do all that at once, yeah, if you could do all
• 1:04:37
  that at once, that's like the same as saying, well, you know,
• 1:04:40
  if you can, you know, you know, again, all these complicated
• 1:04:44
  problems have, as I said, complicated solutions.
• 1:04:48
  And maybe even like I like I was sort of alluding to with the
• 1:04:52
  international affairs type of stuff.
• 1:04:56
  Maybe it's not, maybe solutions aren't even really what we
• 1:04:58
  should be looking for. Maybe we should just be looking
• 1:05:00
  like to make things better to a degree, like or, or just, you
• 1:05:04
  know, making things like if we can make, let's say we can even
• 1:05:09
  get obesity rates. The basically rate in America
• 1:05:11
  right now is about 40%, which is crazy.
• 1:05:13
  And it keeps going up. It's, it hasn't like plateaued,
• 1:05:18
  but maybe we could just get it to plateau.
• 1:05:20
  Like maybe that's what we should be like.
• 1:05:22
  That's the first step. Let's just try to get things to
• 1:05:24
  stop getting worse. And now we can start to think
• 1:05:27
  about how do we make things better And how do we, you know,
• 1:05:30
  how do we stop things from getting worse by letting people
• 1:05:32
  get treatment and encouraging people to get treatment.
• 1:05:35
  And you know, like the healthcare costs related to
• 1:05:39
  obesity and the cancers, Oh my gosh, obesity.
• 1:05:42
  It's like, it's just like all this, there's all this data and
• 1:05:46
  information that frankly is mind blowing that it hasn't spurred
• 1:05:50
  some sort of massive, as you said, like not even maybe not a
• 1:05:55
  political movement, but like a movement.
• 1:05:57
  Awakening. Yeah.
• 1:05:58
  Awareness. Yeah, if we wanted to, if we
• 1:06:00
  wanted to deal with the with our 30, whatever it is, 3 trillion
• 1:06:04
  or $30 trillion debt or whatever our national.
• 1:06:06
  Yeah, yeah, yeah. 30 trillion. Treating obesity actually might
• 1:06:10
  be the best way to do it because if we could figure out, and of
• 1:06:13
  course treating obesity right now is expensive, but the long
• 1:06:16
  term savings, if we could figure out, you know, like how to
• 1:06:19
  maintain the health benefits, long term savings would be
• 1:06:24
  immeasurable. And again, that's never that's
• 1:06:26
  never going to happen. Like that's pipe dream that.
• 1:06:30
  I you know, so you think, do you think that it's one of those
• 1:06:32
  like shoot for the moon and if not, you land along along the
• 1:06:35
  stars kind of, you know, cutesy things where like you try to,
• 1:06:38
  you say, let's try to cure it. And then the people, if people
• 1:06:40
  are a little better and don't even if they don't make it to
• 1:06:42
  the finish line, at least they're better than they were
• 1:06:44
  before. So like you're kind of hoping
• 1:06:46
  for that. I mean, like, I guess like
• 1:06:48
  that's just my immediate thought when I think of that.
• 1:06:51
  Well, on the individual level, people can definitely get better
• 1:06:55
  and get healthier and live happier and healthier and longer
• 1:06:58
  lives 100% on a societal level and a population level.
• 1:07:04
  I mean, I think that's actually why sort of food is medicine has
• 1:07:07
  so much traction is because it's, it's somewhat achievable.
• 1:07:11
  It's just not likely to have a huge impact.
• 1:07:13
  So how do you like what, what's the right strategy?
• 1:07:16
  Shoot for the moon and hope that you get somewhere along the way.
• 1:07:21
  Or, you know, bite off something that's relatively easier to
• 1:07:26
  achieve and hope that it accomplishes something.
• 1:07:30
  But. Even I don't know like.
• 1:07:31
  I think. I mean, when it comes to it, I
• 1:07:33
  think, I think, I think when it comes to, I think when it comes
• 1:07:36
  to health, it's hard. I, I don't because I think that
• 1:07:38
  it's also something that's not even rational for something for
• 1:07:40
  most people, you know, this kind of thing is, has nothing to do
• 1:07:44
  with rationality or whether, you know, it's good or not, You
• 1:07:47
  know, I mean, when I, I beg my dad, I, my dad and I are very
• 1:07:50
  close. We work together and, you know,
• 1:07:52
  very close and I beg him to exercise because he's in his
• 1:07:56
  late 50s and he doesn't work out a ton.
• 1:07:58
  And I'm like, it could only make your life better.
• 1:08:01
  It could only be good for you. You know, I'm, you know, please.
• 1:08:04
  And he's like, I know, I know, I know, I know, I, I, I know it's
• 1:08:07
  good for me. I know I have to.
• 1:08:07
  You just can't. But like, it's not about
• 1:08:09
  rationality. It's not about whether you know
• 1:08:11
  something, you know there's something.
• 1:08:13
  Else and there's been yeah, right, there's been lots of
• 1:08:16
  advocates who feel like education campaigns are what we
• 1:08:20
  need to to health America's health.
• 1:08:23
  But I would argue no one drinks a Coke thinking it's good for
• 1:08:26
  them. No one eats a bag of chips
• 1:08:28
  thinking it's good for them. Everybody knows what's.
• 1:08:30
  Good for you. Yeah, but you deny it's that bad
• 1:08:32
  for you. A lot of people deny.
• 1:08:34
  Oh, it's not so bad, you know, I'm drinking a Diet Coke.
• 1:08:36
  It's better than a Coke, you know, Like by the way, which I
• 1:08:38
  do want to ask though. Sorry, I think it's like like
• 1:08:43
  your dad like most people know that they should eat better and
• 1:08:46
  exercise more. It's not rocket science.
• 1:08:49
  And, and people have heard that message for years.
• 1:08:52
  It's how do we make that easier for folks?
• 1:08:55
  And you know, and then again, part of it is that like your dad
• 1:09:01
  will go through a period where if he ever starts to exercise,
• 1:09:04
  where it sucks because starting to exercise sucks.
• 1:09:07
  And he's going to be, but if he can fight through that period,
• 1:09:12
  he'll then get to a period where he feels great.
• 1:09:14
  And they're like, Oh my God, I wish I'd done this 10 years ago
• 1:09:16
  or whatever. But it's getting to that first
• 1:09:18
  initial suckatude or or yeah, pick a word that's.
• 1:09:22
  You. Yeah, I like soccer tea.
• 1:09:24
  Soccer tea is good. Is good.
• 1:09:27
  Can we, can we talk a little bit about?
• 1:09:29
  Can we talk a little bit about? That sodas are terrible.
• 1:09:32
  That's. Probably work that sodas are
• 1:09:34
  probably terrible. Are terrible.
• 1:09:36
  They're probably almost worse for you than sugar soda.
• 1:09:39
  OK, right. So forget about soda.
• 1:09:42
  So we could use soda, diet soda in the as like a, as like a base
• 1:09:46
  metaphor, but the fake sugar versus real sugar or the, you
• 1:09:49
  know, stevia, Splenda, you know, artificial sugar world.
• 1:09:54
  Yeah. How does that impact?
• 1:09:56
  Yeah, it's interesting. I wish I knew more about stevia
• 1:09:59
  because I think of the artificial sweeteners that one
• 1:10:02
  might have more because at least it's from a plant, so it's not
• 1:10:08
  as manufactured as some of the other ones.
• 1:10:11
  But usually those sorts of. Well, first of all, there's now
• 1:10:14
  data that there was always data that saccharine caused cancer.
• 1:10:18
  But back in the 70s, long before you were born, there was a soda
• 1:10:21
  called Tab that basically got run off the market because it
• 1:10:24
  had saccharine in it and it. Caused.
• 1:10:26
  Cancer. Turns out that you had to be a
• 1:10:29
  lab rat and you probably had to drink like 2 liters worth of tab
• 1:10:32
  every day to get saccharine that you would need to to get cancer.
• 1:10:37
  But that didn't matter once the word got out that saccharine
• 1:10:40
  caused cancer. Like you still see some
• 1:10:41
  saccharine packets like sweet and low is still saccharine and
• 1:10:45
  they're still in some like delis and and restaurants.
• 1:10:48
  But that saccharine basically was run off the face of the
• 1:10:51
  earth by by, you know, by whomever by lobbyists or or some
• 1:10:57
  other folks that probably isn't probably was never as bad as as
• 1:11:00
  it was made out to be. But all of those different
• 1:11:03
  artificial sweeteners have some negative health consequences.
• 1:11:09
  Some are linked to cancers, some are linked to diabetes.
• 1:11:13
  Some data suggest that they actually just stimulate the same
• 1:11:17
  part of your brain that makes you crave sugar and it just
• 1:11:20
  makes you crave sugar more. So in general I am not a fan of.
• 1:11:25
  Those That's interesting because your brain thinks you're getting
• 1:11:28
  sugar, but you're not actually getting enough.
• 1:11:30
  Right, Yeah, exactly. Like it makes you want more
• 1:11:33
  sugar. It's like having a sweet tooth
• 1:11:37
  that like gets worse, I guess. But I think like, you know, so
• 1:11:42
  the reason that fruits when they're eaten whole are not
• 1:11:47
  nearly as bad for you as when they're turned into a juice and
• 1:11:52
  and obviously good for you because of some of the nutrients
• 1:11:54
  they provide. Is that the fibre that's in a
• 1:11:57
  real plant in a, in a strawberry or blueberry like you mentioned,
• 1:12:02
  that makes it so that some of the sugar that's in the fruit
• 1:12:04
  actually doesn't even get absorbed.
• 1:12:06
  But when you concentrate that fruit into a juice, you
• 1:12:09
  basically remove all the fiber, but you keep all the sugar.
• 1:12:12
  And now you just have like, like, you know, growing up
• 1:12:15
  again, everybody was thought was told that orange juice was like
• 1:12:17
  the best thing for you. Orange juice isn't actually very
• 1:12:20
  good for you at all. And it's like, you know, it's
• 1:12:25
  just like it's part of the issue with this field in general and
• 1:12:29
  potentially why people have so much mistrust in docs is that
• 1:12:33
  it's not intentional, but things change and our understanding of
• 1:12:38
  of these things change. So sometimes we make
• 1:12:40
  recommendations and then ten years later we're like, you know
• 1:12:44
  what, all that low and that stuff we had you eat in the in
• 1:12:48
  the 90s or the 2000s or whatever, whenever low fat was a
• 1:12:51
  thing. Turns out those are all bad for
• 1:12:53
  you. So sorry our mistake are bad
• 1:12:56
  gave you all this dietary recommendations that were
• 1:12:58
  totally off base, but that's. Scary, but that's scary for
• 1:13:02
  people, no? Right, of course.
• 1:13:04
  Well, that's why it's, it's easiest for like, and, and
• 1:13:12
  they're actually data even it's easiest for people to just sort
• 1:13:15
  of stick to the basics like the Mediterranean diet, like eat
• 1:13:20
  fish, eat olive oil, eat nuts, eat things that come out of the
• 1:13:24
  ground. If you forget about everything
• 1:13:27
  else, that's probably still and the data suggested is still the
• 1:13:32
  best diet for you. So rather than try to get too
• 1:13:35
  fancy and do everything else, it's just really, you know, it
• 1:13:40
  probably comes back. It goes back to what your
• 1:13:42
  parents parents taught them and my parents parents taught them.
• 1:13:45
  It's just everything in moderation.
• 1:13:48
  Like that's probably like still the best advice now as food has
• 1:13:53
  gotten lower quality there. And there are certainly some
• 1:13:56
  things that even in moderation are not good for you.
• 1:13:59
  But again, we don't have to get too, I don't think we have to
• 1:14:02
  get too analytical about it. We really just need to, you
• 1:14:05
  know, lean proteins, fish, lean meats, legumes, nuts,
• 1:14:11
  vegetables, fruits, things that come out of the ground.
• 1:14:14
  It's like, and, and if you do that most of the time, you know,
• 1:14:18
  if you want an ice cream sundae on, you know, once every couple
• 1:14:22
  weeks, it's OK. Yeah.
• 1:14:25
  Like because you're generally healthy and again, I don't think
• 1:14:29
  you need to necessarily depends on who you are.
• 1:14:32
  Everybody, it's different and everybody reacts differently.
• 1:14:34
  And and you know, most people probably don't need to go crazy
• 1:14:41
  with that sort of diet as long as they stick to the tenets of
• 1:14:44
  it. But if you have a high genetic
• 1:14:46
  predisposition towards obesity, maybe that's just how you have
• 1:14:49
  to eat your whole life. Like maybe that's just what you
• 1:14:52
  need from preconception, postconception year old, 4 year
• 1:14:58
  old, 5 year old. You just need.
• 1:14:59
  And even if that happens, you probably there's still going to
• 1:15:01
  be people who still get obesity even with doing everything quote
• 1:15:05
  UN quote, right, You know? That's crazy.
• 1:15:08
  Do you, do you, have you, have you seen that a bunch?
• 1:15:10
  Have you seen someone that's diet is good and they kind of
• 1:15:13
  move around and I'm not saying work out every day, but like
• 1:15:15
  really move around. Yeah.
• 1:15:17
  And, and what is it? They can't lose weight or they
• 1:15:19
  keep gaining weight. What is it?
• 1:15:22
  Well, it depends more of it. Well, I would say that some of
• 1:15:28
  them can't lose weight, some of them gain weight.
• 1:15:31
  But like you know, again, and that's it's sort of why I used
• 1:15:35
  to tell. I have lots of great stories of
• 1:15:37
  people calling me a monster for offering surgery for weight loss
• 1:15:40
  in children, which we can come back.
• 1:15:42
  We can talk about that some other episode when you want an
• 1:15:47
  episode on like, Worst Stories of my career.
• 1:15:51
  Please, I would love that. But I used to tell that like the
• 1:15:57
  haters, I'd say, listen, just spend the day in my clinic and
• 1:16:00
  actually talk to these children who come in to see me.
• 1:16:02
  They're like 15 year olds who are on the soccer team and who
• 1:16:06
  don't eat terrible. And they're on their high school
• 1:16:10
  soccer team, but they're like the goalie or the centre back
• 1:16:14
  because they're too big to play some other position where they
• 1:16:17
  can run up and down the field as easily.
• 1:16:19
  And you know, they're not, they're not eating at McDonald's
• 1:16:24
  five times a week and they're not sitting on their butt
• 1:16:27
  playing video games all day every day, which is what
• 1:16:30
  everybody thinks of kids who have obesity.
• 1:16:33
  And yes, there are some people who aren't exercising and there
• 1:16:37
  are some people who aren't eating right.
• 1:16:39
  But I've also seen the people who are totally doing everything
• 1:16:41
  they're supposed to do and they still they still either can't
• 1:16:46
  lose weight or just kept gaining weight so.
• 1:16:49
  So how does so how does so how does so and so and may and maybe
• 1:16:54
  hopefully let's see if you could try to if it's a little bit too
• 1:16:57
  long of an answer detail of a question and you could just tell
• 1:17:00
  me. But if that's the case, then how
• 1:17:04
  do how do drugs like like Ozempic or whatever work and
• 1:17:10
  successfully having a physical impact?
• 1:17:13
  Because if it is genetic or you know, if you know the other, if
• 1:17:17
  other things don't seem to be working that do work for other
• 1:17:21
  people, then what works about the drugs that that the other
• 1:17:24
  other stuff can't, can't, can't touch really.
• 1:17:27
  Right. So the simplistic, so I've had
• 1:17:32
  patients who I've offered a sleep gastrectomy to where I
• 1:17:38
  tell them I'm going to take out 89% of your stomach.
• 1:17:41
  They will say to me, but doc, I already eat like almost nothing.
• 1:17:45
  So I don't understand how this surgery is going to help me and
• 1:17:51
  it's obviously a legitimate question.
• 1:17:53
  But with surgery, there are all these other hormones that
• 1:17:57
  regulate your metabolism that are impacted.
• 1:18:02
  And actually again, we talked about the gut brain access a
• 1:18:04
  little bit. There is probably direct gut
• 1:18:07
  brain access changes in the hypothalamus that change your
• 1:18:12
  weight set point because the body does what's called
• 1:18:15
  something called metabolic adaptation, where if you lose
• 1:18:18
  weight, your body will react by slowing down your metabolism
• 1:18:22
  because it doesn't want you to lose too much weight.
• 1:18:24
  It thinks you're like starving or dying.
• 1:18:26
  So it'll slow down the metabolism to keep you from
• 1:18:29
  losing more weight. The same thing actually happens
• 1:18:30
  in the other direction in a in a in a short term, like a short
• 1:18:35
  term experiment like the guy who did super size me.
• 1:18:39
  If you like, try to gain weight intentionally.
• 1:18:42
  Your body will speed up its metabolism because it wants you
• 1:18:44
  to stay within a fairly narrow range.
• 1:18:46
  Oh, interesting. And it may be that the ultra
• 1:18:49
  processed foods are impacting obesity rates by changing your
• 1:18:55
  hypothalamic set point where people set points are being
• 1:19:00
  artificially elevated. Yeah, that's a whole nother so.
• 1:19:03
  Common my brother-in-law who's in high school is very focused
• 1:19:06
  on on on working out and he his friends call it dirty dirty
• 1:19:10
  weight. A dirty what's it called?
• 1:19:11
  Dirty weight gaining where like in order to bulk up dirty
• 1:19:14
  bulking in order to gain in order to get bigger.
• 1:19:17
  If there's scrawny kids, they eat a lot of garbage food and
• 1:19:20
  they get big on purpose, and then they work out and they work
• 1:19:24
  out like crazy and then they kind of sculpt that into
• 1:19:26
  whatever they want. But I can't imagine that's a
• 1:19:27
  very good for you either, right? No, and it's actually not going
• 1:19:31
  to work long term either. There were actually studies back
• 1:19:34
  in the early 2000s where, and this is talking about things
• 1:19:37
  that could never be done again today.
• 1:19:40
  But there is a study that where they had inmates at some prison
• 1:19:44
  intentionally gained like 20 lbs.
• 1:19:45
  Like they just fed them 24/7 until they gain weight.
• 1:19:49
  And then when they stopped feeding them like that and just
• 1:19:52
  like let them go back to their natural eating habits, they all
• 1:19:55
  came back down to their starting weight.
• 1:19:58
  Because that's what your body wants to do.
• 1:19:59
  Your body wants you to be at whatever weight it thinks you
• 1:20:02
  should be at, for better or worse.
• 1:20:05
  But so the drugs again, like so if you don't, let's say you
• 1:20:10
  exercise and you don't eat a lot yet you're still struggling with
• 1:20:12
  weight. I think the medications sort of
• 1:20:15
  can do some of the same stuff. That the surgery does in terms
• 1:20:20
  of changing your metabolism certainly changes your food
• 1:20:25
  preferences certainly get sort of like food noise.
• 1:20:28
  So even if you so if you are eating some, if you have some
• 1:20:35
  unhealthy foods mixed in with your healthy eating, because no
• 1:20:37
  one's perfect, it certainly limits that.
• 1:20:42
  But yeah, I mean, that's, it's sort of it's, it's, it's why
• 1:20:45
  obesity is such a complex and interesting disease, because if
• 1:20:48
  it was just purely eat less and exercise more and you'll lose
• 1:20:53
  weight, then that should work for everybody.
• 1:20:56
  And it actually works for almost nobody.
• 1:20:59
  So it's just a, you know, it's just it, it, it's why frankly,
• 1:21:05
  it's why it's super interesting to me because it's a completely
• 1:21:09
  unsolved mystery. And I think it makes it more
• 1:21:12
  interesting to me that because I'm from New Jersey and I, I
• 1:21:16
  like to pick fights with people. I think it makes it more
• 1:21:19
  interesting for me because I think everybody else does it
• 1:21:21
  wrong. Like I think the rest of the
• 1:21:22
  world, not the rest of the world, but most people,
• 1:21:25
  especially the people who are in power these days, they have it
• 1:21:28
  wrong. So it's like super interesting
• 1:21:31
  and then super important because they're sort of gaslighting the
• 1:21:34
  country by telling people this. And, and it's just not, it's not
• 1:21:38
  accurate. And that's just not just RFK and
• 1:21:41
  HHS and case Cali means or whoever Casey means, whichever
• 1:21:45
  means it is. But it's also like all the
• 1:21:50
  online influencers and and like, again, even some medical
• 1:21:54
  professionals who who will tell their patients, if you just, you
• 1:21:59
  know, lifestyle medicine docs or the food is medicine people,
• 1:22:02
  they're also gaslighting patients to a degree because
• 1:22:08
  again, there's because. We don't know what it is.
• 1:22:10
  Well, there's hard science that shows that it doesn't work.
• 1:22:13
  There's hard science that shows that dynamics.
• 1:22:15
  Well, they didn't work for everyone, we said, right?
• 1:22:18
  Right. Well, so in the most intense
• 1:22:23
  behavioral lifestyle treatment programs, you lose about 5 to 7%
• 1:22:28
  of your body weight. So I shouldn't say it doesn't
• 1:22:30
  work, but because it works, you lose 5 to 7%.
• 1:22:34
  But that's not enough for most people with obesity and even the
• 1:22:40
  weight loss medications that you know, the reason there was so
• 1:22:43
  much excitement about them is that you lose closer to 15 to
• 1:22:46
  20%, really 10 to 15%. Let's say surgery is a minimum
• 1:22:52
  of 20 percent, 20% or more. So that's why if you have
• 1:22:55
  obesity, So if you weigh 300 pounds, 5% of your body weight
• 1:22:59
  is 6 lbs. So at the end of your intensive
• 1:23:03
  lifestyle treatment, you'll weigh 294.
• 1:23:07
  And that's not really right. Is that right?
• 1:23:10
  No, that's not right. That's the maths wrong. 300 when
• 1:23:13
  I say 5 percent, 15 lbs. So you weigh 285 but.
• 1:23:18
  If you have £300 right, Well, OK.
• 1:23:21
  And I guess this would be, I should have actually opened with
• 1:23:23
  this question. Well, I guess I guess I'll close
• 1:23:25
  with it. What's, what's the, what's the
• 1:23:27
  definition of obese versus overweight?
• 1:23:29
  So. Well, so the.
• 1:23:32
  I really should have opened with that.
• 1:23:33
  Yeah, exactly. You can put in the front, you
• 1:23:35
  can always put in the front of the podcast, But the and I, I
• 1:23:38
  have to correct you because you shouldn't use obese as an
• 1:23:41
  adjective because it's a we're moving away from it's called
• 1:23:45
  patient first language. So rather than say someone is
• 1:23:48
  obese, you should. So it suffers from obesity.
• 1:23:52
  Yeah, someone who has obesity, right, Because you don't want to
• 1:23:54
  call someone you want to call someone a diabetic anymore.
• 1:23:57
  You want to call them a person with diabetes.
• 1:23:58
  Because it's more you want to define people by their disease.
• 1:24:01
  I see. Yeah, yeah, yeah, definitely.
• 1:24:03
  OK. Yes, absolutely.
• 1:24:05
  So anyway, that's just the preferred language for for all
• 1:24:07
  diseases. The nomenclature, right?
• 1:24:10
  Interestingly, the autism community is the one, sort of.
• 1:24:14
  Yeah, that's right. They don't want that.
• 1:24:16
  They want to be called autistic. They don't want to be called
• 1:24:18
  someone with autism, which is weird, but whatever.
• 1:24:21
  Again, patient advocacy patients should be able to do whatever
• 1:24:24
  they want. So there is a medical definition
• 1:24:29
  of overweight and obesity. And actually the definition of
• 1:24:33
  obesity is still being debated in recent debate over the
• 1:24:38
  diagnosis of obesity and how one should define it.
• 1:24:41
  But right now we use BMI, which is a ratio of your weight to
• 1:24:47
  height and they're cut offs, so 20.
• 1:24:50
  So what is it? 18 to 25 is normal weight.
• 1:24:56
  BMI of 25 to 30 is overweight, 30 and above is obesity, and
• 1:25:00
  then there are different classes of obesity when you get to 35
• 1:25:03
  and 40 and 45 and 50. I see.
• 1:25:06
  But the reality is that BMI is a surrogate.
• 1:25:12
  It doesn't really necessarily tell you.
• 1:25:15
  Like you could be a very muscular person, you could be a
• 1:25:17
  bodybuilder and have almost 0% body fat, but by BMI you'd
• 1:25:21
  probably be classified in the obesity range because.
• 1:25:24
  Oh, fascinating. Because you've got so much
• 1:25:25
  muscle mass. So it's, it's, it's just a proxy
• 1:25:28
  and it's a screening tool. But I mean, that's why there's
• 1:25:32
  so much argument about whether or not, you know, what really
• 1:25:36
  truly defines obesity. And I like to, I like to joke
• 1:25:40
  that similar to autism spectrum disorder, that we should change
• 1:25:44
  the name of obesity to something like weight gain spectrum
• 1:25:46
  disorder because like, it's just not one disease.
• 1:25:50
  Most likely it's probably a lot of different quote UN quote
• 1:25:53
  diseases that just look the same at the end of the day.
• 1:25:56
  Oh, fascinating, right? We call it a phenotype, which is
• 1:25:59
  how something looks, but it comes from different genotypes.
• 1:26:03
  Genotypes are how things like come.
• 1:26:05
  To be. Yeah, yeah.
• 1:26:07
  So. That's so interesting.
• 1:26:09
  Wow, that's so fascinating. We should come up with.
• 1:26:11
  I think that's the point. That's the point of language,
• 1:26:13
  and that's the point of vocabulary is like that.
• 1:26:15
  Specific words encompass specific contexts and.
• 1:26:18
  And so the F word fat now has negative connotations because
• 1:26:25
  you call someone fat. Oh, you're fat, and that's
• 1:26:27
  negative. But fat just started as a way to
• 1:26:30
  describe adipose tissue, like adipose tissue is fat.
• 1:26:34
  There's brown fat and there's white fat.
• 1:26:36
  It didn't always start as a. Negative.
• 1:26:38
  Well, of course some people deal with it, right?
• 1:26:41
  So it's sort of Obcs the. Same.
• 1:26:43
  That's why I think that changing the term doesn't necessarily
• 1:26:45
  help because if people are going to just use a different term to
• 1:26:47
  be just as derogative, then I think they have to just stop
• 1:26:50
  being derogative. That might be definitely help if
• 1:26:52
  it's. Weight gain spectrum disorder.
• 1:26:54
  So WGSD, they'll just change those initials.
• 1:26:57
  They'll say like, they'll just make it into like.
• 1:27:00
  Yeah, they'll just sprout a new word that we'll see you floating
• 1:27:03
  around on the Internet. Like WGSD will be it'll it'll be
• 1:27:08
  stand for white guy with serious I don't know.
• 1:27:12
  D. Diameter there it is.
• 1:27:15
  So that's what they're going to, you know, they'll just change it
• 1:27:17
  into something bad, into something mean or whatever you.
• 1:27:21
  Know. That's just what we do,
• 1:27:23
  unfortunately. Well, not not not in this
• 1:27:27
  podcast, I guess. You know, like I do think
• 1:27:31
  they're, you know, I don't know what the, there's the obviously
• 1:27:36
  the Joe Rogans in the world who sort of made their podcast world
• 1:27:44
  from being controversial and argumentative and, and frankly
• 1:27:47
  sometimes being mean or, or not necessarily positive.
• 1:27:53
  I actually think it's it's, it's kind of like I'm trying to just
• 1:28:00
  do the opposite. I figure like, you know, and
• 1:28:02
  maybe I'll get nowhere because maybe no one will want to listen
• 1:28:04
  to me unless I start to be, you know, calling.
• 1:28:07
  People. I don't think that I don't,
• 1:28:09
  yeah. It's just, I have to hope that
• 1:28:12
  like it's just enough people in medicine and other fields just
• 1:28:18
  get out there and just start speaking truths and stop with
• 1:28:22
  all the opinion and all the hoopla and all the whatever,
• 1:28:26
  that maybe maybe that'll help get the world back to sort of
• 1:28:29
  some sense of normalcy. Like, you know, I don't even
• 1:28:32
  need it to be a perfect world. I just need it to be like a
• 1:28:35
  relatively normal and stable world where you can predict, can
• 1:28:39
  predict what the next day is going to mean or like what the
• 1:28:42
  next political movement's going to mean.
• 1:28:43
  You don't have to like worry about all kinds of, you know,
• 1:28:47
  like, I don't think anybody who grew up post Roe V Wade actually
• 1:28:51
  thought there would be a day where it would get reversed.
• 1:28:54
  Like, I don't think anybody ever even contemplated that that
• 1:28:57
  could happen. But but that's where we are
• 1:28:59
  like, it's just, you know, it's just the world is just whatever.
• 1:29:06
  The world, it's, it's a pendulum.
• 1:29:09
  Everything's a pendulum. It just gets them swinging in
• 1:29:11
  different directions, you know, and, and the only thing you can,
• 1:29:13
  the only thing that I, I'm kind of hoping for is that it doesn't
• 1:29:18
  swing so wildly and that the motions are a little bit more, a
• 1:29:22
  little bit less volatile. You know that if it is going to
• 1:29:25
  be a pendulum, then it shouldn't.
• 1:29:26
  It should be a clock going from, you know, 7 to 5 instead of
• 1:29:30
  1:50. Exactly or like a metronome
• 1:29:33
  where it's, you know, like it goes back and forth, but it goes
• 1:29:35
  back and forth in a more predictable pattern and again
• 1:29:39
  with not such wide variation with each movement back and
• 1:29:43
  forth, but. Yeah, well, anyway, Doctor, I
• 1:29:46
  really appreciate the time. This is really awesome.
• 1:29:49
  Maybe we'll do I I would, I would Love Actually to do a Part
• 1:29:51
  2 of your horror stories. I think that'll be a lot of fun.
• 1:29:53
  But until then, this was really great.
• 1:29:55
  I'm so happy we found it. I'm happy we made this work last
• 1:29:58
  minute. But thank you so much for the
• 1:29:59
  time. This is it's really enlightening
• 1:30:01
  and a lot of fun and I think really, really interesting and
• 1:30:04
  really informative. So it's.
• 1:30:06
  Always fun to chat with, you know?
• 1:30:08
  Again, it's like anyone who's open minded and wants to have a
• 1:30:12
  discussion about almost any topic.
• 1:30:15
  It's it can be super fun and interesting and informative.
• 1:30:18
  Like we, you know, we don't have to agree with everything, we
• 1:30:21
  just need to. Have a good time people, and.
• 1:30:23
  Talk about it and have fun and not get so worked up if people
• 1:30:26
  don't agree or whatever. But yeah, happy to come back and
• 1:30:29
  yeah, let me know. Yes, absolutely.
• 1:30:32
  And I'll make it happen. Doctor, thank you so much.
• 1:30:35
  It's such a pleasure. Have a great day.
• 1:30:36
  My pleasure. Take care.
• 1:30:37
  Thank you. Bye, bye.
• 1:30:38
  Bye. Bye.