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

22:41Dr. Gabrielle Lyon:Okay, the worst is going to buy sheets and they look pretty. You get home, unpack them, wash them, and they are terrible and scratchy and ultimately just need to be thrown out. And that is why I chose Cozy Earth as one of the sponsors of the show. I've been using Cozy Earth products for years. They have the softest, coziest, most comfortable home products ever beyond sheets. They have towels and they have comforters. And their comforters are breathable, temperature regulating, incredibly soft without feeling heavy and scratchy. and it makes winding down at night effortless and beautiful. They also have essential socks that are thoughtfully cushioned and supportive and even are better with a foot rub.

23:23Dr. Gabrielle Lyon:So whether you are traveling, training, or just at home, I love these products and they are built with intention and they are beautiful. And Cozy Earth stands behind their products with a 100-night sleep trial and a 10-year warranty. Huge fan, have been using them for years. head to CozyEarth.com and use code Dr. Lion for 20 % off. You can experience it at home. Foot rubs don't come with it. Talk to me about GLP-1 use and also there's various delivery systems for GLP-1s. You know, it's fascinating with GLP-1s because in my years of training, I had very little exposure. So these medications, oddly enough, have actually been around, some of them, for about two decades.

24:11A lot of people just remember the Ozempic jingle that came out a few years ago. What is that? Oh yeah, oh yeah, oh yeah, there's a jingle. I have a terrible voice, so I'm not going to sing it, but it was on all the commercials all over TV. But some of these medications have actually been out for about two decades, so they are not brand new. And they've been doing research on them for a long time. It's just the initial medications didn't pan out in clinical trials. But none of my training really talked about GLP-1s because they didn't kind of reach the press and the media and they weren't more accessible until around 2018 when Ozempic or semaglutide came out for diabetics.

24:48So my first exposure actually to these medications, so I was a GI fellow at the time, and I actually got exposure to this medication outside of my own training program. So I was already very fascinated with weight management and cardiometabolic health. So I asked someone who ran the weight management program at UT Southwestern. He's an endocrinologist. And I said, I'm a gastroenterology fellow, but I would love to rotate through your endocrine. Who was that? Dr. Jamie Almendez. He is phenomenal. He is the man who changed the trajectory of my career, not even within my own training specialty. So I rotated through his clinic, and that was my first exposure to watching a dietician talk to a patient.

25:31It was my first exposure to see a doctor talk to a patient about what does their family unit look like? What does their budget look like? What are their health and wellness goals? What is their nutrition intake? What is their movement? And then give them a realistic plan on all the foundations of health and wellness, nutrition, movement, but then also introduce medications when they were appropriate. And to the point that he inspired me, I kind of created my own little weight management clinic as a trainee, and I was actually teaching my attendings at the time. Unbelievable. Which was fascinating.

26:02Dr. Gabrielle Lyon:You bring up a really good point. The misconception about GLP-1s is that they are new medications, but they have been around and have been FDA approved for type 2 diabetes. Then, 2018, they are then available to be used for weight management. And I think that that's probably the biggest shift. Would you agree? because the medications were around. Yeah, so the initial medications, Victoza was initially FDA approved for type two diabetics. They started seeing that people were losing weight. They did additional clinical trials and that's when Sixsenda came out. So these are daily injections and that's loraglutide is kind of the generic name.

26:41Now loraglutide or Sixsenda for weight loss only gave you about five to 6 % weight loss. So it's something, but for overall cardiometabolic health, we typically want to hit around 7 % to 10 % of weight loss. It's not 100 or 200 pounds, it's 7 % to 10%. So it was helping. The good thing also about it is a lot of the other diabetic drugs on the market, like insulin, which we used to use a lot, were weight promoting. So it wouldn't be fair to the patients if we said, hey, Sally, you gotta lose a bunch of weight. We have to start insulin for you because of your diabetes. My goodness, we just made it a lot harder for Sally to lose weight because we're giving her insulin, which is a fat storage hormone.

27:23So at least we had medications that were targeting both the diabetes management, but also help them lose weight. And then Ozempic came out in 2018. So that is a once per week injection. So the other name for that is semaglutide, but actually Wagovi, which is the same medication, but different dosing came out in 2021. So it actually wasn't until 2021 that we had medication FDA approved for weight management in people with a BMI of 27 or above with a comorbid condition weight-related or 30 and above and they didn't need a comorbid condition. And then more recently is terzepatide. So terzepatide, we have Zeppound for non-diabetics and we have Monjoro for diabetics.

28:03So a lot of people think Ozempic is the only medication out in the world and that's not true. There's really the two kind of main ones which is semaglutide enters epitide. It's just there's a lot of other names because of FDA approvals and indications, but it goes way beyond weight loss and diabetes control. I actually went to a recent longevity conference locally in Miami, and one of the cardiometabolic specialists, he's a lipidologist, he was speaking on GLP-1s and longevity. So GLP-1s are now actually entering the whole longevity space, which I think is amazing. He made a very interesting phrase.

28:39He said, we need to stop saying these are weight loss drugs and diabetes drugs. These are metabolic reprogrammers. And I love that.

28:49Dr. Gabrielle Lyon:The Sixenda would give an individual daily injection 5 % or so. Arguably could be good for liver, but not necessarily effective for cardio metabolic health. In terms of reasons why someone wouldn't try these medications, what are those reasons? I think there's a lot of fear mongering out there. So with social media and the digital age, obviously it's an incredible resource for information. But when it comes to GLP-1 medications, it is very stigmatizing. You have people who are pro and you have people who are anti. And there's not many people in the middle ground, which is kind of fascinating to me.

29:35It's also a big stigma for patients themselves. I have many patients who will not tell anyone, even their husbands or their wives, that they're on the medication because oftentimes they think it's a failure on their part because they couldn't lose the weight, quote unquote, on their own, which I think is really awful. These medications act in probably 50 different mechanisms, most of which we don't quite yet understand. I think a lot of people have this thought that they just shut down your appetite, which is not the only mechanism. Yes, they delay gastric emptying. So they slow down the rate at which your stomach empties.

30:10It takes a normal stomach, about four hours to empty a standard meal like an egg sandwich. These medications slow down that process so that maybe the meal stays in your stomach for five hours or six hours. So it helps in particular for people who eat a meal and they don't feel satisfied. Or they feel satisfied and then they have hunger one or two hours later. that's where it can be very helpful it also you know our body naturally makes this hormone glp1 right people talk oh i want to go on a peptide i go listen you're already on one glucagon like one peptide right um so this hormone when food goes down into our intestine our body releases this glp1 hormone it sends signals back to our brain and it says brain i'm full but our body also has an enzyme that breaks that down pretty quickly so for people who say oh just take berberan or take all these other supplements that enhance your natural GLP-1?

30:59Well, they may, but they're not preventing the quick breakdown of it. So these medications, like semaglutide or terzepatide, they are synthetic versions of that hormone. So they stay in the body longer. They help get you fuller sooner. They keep you fuller longer. We also have GLP-1 receptors in the brain. So it works on the cravings and the pleasure pathway. Now, what I tell people all the time, my goal is not to shut down your hunger. It's not to create food aversions. I want you to feel hungry because when you work out, if I were to shut down your hunger and you don't eat after your workout, is that a good thing for muscle growth?

31:36Dr. Gabrielle Lyon:I mean, I feel like I'm going to throw up. But I imagine you probably eat something to fuel within a certain period of time. Within the day. Yeah. Within the day, not necessarily post-training, but definitely within the day. Yeah, but fuel is very important for muscle protein synthesis. So what I tell people all the time is my goal is not to shut down your hunger. I want you to get that hunger cue so that you eat something, but you eat your protein, you eat your fiber, and then you feel satisfied and you kind of get rid of that, the food noise in between meals. What about the nausea? There's a lot of discussion around nausea, vomiting, reflux.

32:11Dr. Gabrielle Lyon:People are afraid. I also, before we get to what happens, side effects I really appreciate what you said about there's a lot of stigma. I would argue we've only seen that with one other group of medications. Hormones. That's it. And I do both. And so it's very interesting. Although I have people who they're much more likely to open up about hormones. So I have a lot of patients who are on both HRT or menopausal hormone replacement therapy with GLP-1s. and they will tell their friends they're on hormones and they change their lives and they won't necessarily disclose if they're on a GLP-1. They don't need to disclose it, but oftentimes I will find that people are more likely to disclose they're on hormones rather than the GLP-1s.

32:57I think it's still, you know, there's this thought that it's a failure on their part. And I see that in both men and women. It's, you know, it can be hard for them to talk about.

33:08Dr. Gabrielle Lyon:Yeah. Nowhere else in medicine. You know what? I shouldn't say that because SSRIs, lithium some of the other psychiatric drugs there's been a long time stigma with that but no one cares about cough medicine or something like that or even a sleep medication these medications that seem to really affect arguably body composition end up really being so polarizing and i think because people put it in like this aesthetic category where they're like oh, you just want to lose weight to look better. And I would argue, I'm sorry, what's wrong with that? What is wrong with looking good and feeling well? Because confidence is so incredibly important.

33:52If you wake up in the morning and you hate what you see in the mirror, that will set the tone for the day. Right? And so there's absolutely nothing wrong with wanting to feel confident and liking what you see in the mirror. Now, these medications are not developed to lose, you know, five pounds.

34:07Dr. Gabrielle Lyon:um so people need to understand that the percentage of weight loss that someone should expect yeah so depends on the medication right so if it's something like loraglutide which is six enda that's about five to six percent if we're talking about no one people don't use that anymore do they some depending on insurance coverage some will if that's the only one they can get covered then they will still use that one we found that um and again everyone practices medicine different ways when we started prescribing six center which we don't really prescribe anymore it was patients didn't like giving themselves a shot every day and we didn't find it incredibly effective yeah again i'm sure that this is nothing against extender or whatever the company is you know i feel like it's almost obsolete yeah and now that we have a lot more medication the cash pay rates are going down i think it's definitely less common it just it really depends on the person though i would say one niche population would be if someone is really worried about side effects and they're worried if they do something like semaglutide and the side effects are going to last a little bit longer because the half-life is longer then that may arguably be a reason to kind of do a test dose with something like loraglutide because it's you know quicker out of the body type of thing and what is the mechanism of action of sixenda the same thing yeah that's also a glp1 yep okay yep five percent with six end up yes so somatatide you're going to get around 12 to 14 and these are looking at max doses typically at the 72 week mark so 12 to 14 percent and then terzepatide is roughly 16 to 22 percent and then retitrutide we're looking at 22 percent so as these medications become more and more effective for weight management what does that mean?

35:54Well that means the risk of malnutrition can definitely go up because now we're looking at percentages that are equating to bariatric surgery. What's interesting about bariatric surgery is there is a barrier to entry, right? You have to call someone, you have to schedule an appointment, you see the bariatric surgeon and then often for you to actually go through the process a couple things have to happen. Typically you have to be cleared by a psychologist, you have to see a dietician typically like on a monthly basis for a six-month period and then you get the surgery and then you have post-op care you may not see the bariatric surgeon post-op but you're going to have some sort of care where they're making sure you're getting your supplements post-bariatric you know you're still making progress there is a barrier to entry because you have to call someone pick up the phone make the appointment and have the follow-up versus now weight management has become weight loss commerce.

36:46You have on weight loss commerce. Maybe I'll trademark that. So when it comes to weight loss commerce, everyone's selling weight loss. So you have all these virtual platforms that are popping up, which are basically script mills. I'll tell you the easiest part of my job is writing a script. What is the hard part? It's counseling people on what matters, on how to not only get them to lose weight in the short term. I don't care about six months from now. I care about six decades from now. And that's where you can never replace the foundation. These drugs are becoming extremely powerful. The hard part is not losing the weight.

37:24It's keeping the weight off long-term. Because as you and I know, neither of us are getting any younger. I am, I understand. We have metabolic adaptation. We have anabolic resistance. We have hormonal changes. We have higher risk of frailty and fracture as we get older. We have to take all these things into consideration. And so these virtual platforms, they don't care. They're just writing the script and saying, I'll follow up with you in six months. And so that's what we need to be careful about.

37:54Dr. Gabrielle Lyon:Basically, what you're saying is people are, they used to be overfed and undernourished. and now they are underfed, arguably, if they're on these medications, and undernourished. Yeah, and they're not getting guidance. So that's where kind of the press and the media is really pushing this out, is people are sharing their stories when they've had bad experiences. And there are bad experiences out there. I mean, the poison control hotlines have gone up like a million percent because people aren't being guided. They're getting either compounded formulations or they're using, let's say, ozempic pens and they're titrating the dose based on the number of clicks but if they're not being guided on how to do the dosing and with compounded formulations it's kind of all over the map with some of these drugs and each batch could be vastly different which is why if someone uses a compound pharmacy they should go to a compound pharmacy with a really good reputation exactly so there's just so many unknowns even though these drugs aren't new there are a lot of unknowns and there's not enough supervision there's two things that i definitely want to touch on number one is the effect on muscle.

38:59Dr. Gabrielle Lyon:And then number two, we were talking about delaying gastric emptying and symptoms. If someone is on these medications, are there ways to mitigate things like reflux, nausea, vomiting? You also hear about pancreatitis. I haven't seen that clinically. Also, I would love for you to touch on, I don't know if it still carries a black box warning for thyroid cancer. So yes, so the black box warning that's easiest to tackle first it was actually only seen in rat models. So that it's not all thyroid cancer, it's medullary thyroid cancer, which is actually a rare type of cancer. So I have a patient who had a history of papillary thyroid cancer, and his thyroid oncologist said, no worries, he can still go on the medication because it's not medullary.

39:45So medullary thyroid cancer is a contraindication. And then the only other contraindication is a family or personal history of multiple endocrine neoplasia type two. Most of my patients have never heard that term before. So those are the two reasons why we shouldn't prescribe the medication, mainly because it's on the black box. But again, it was only seen in rat studies, but those, you know, otherwise it's fair game, okay? Now, one would also say, well, what if I already have a lot of gastrointestinal symptoms, right? I'm a gastro, so a lot of people with gastro issues come and see me. A lot of people are worried, right?

40:18Dr. Gabrielle Lyon:Yeah, that'd be weird if they came to see you for knee pain. Yes. Oh, I have plenty of patients that see me for knee pain. A lot of times it's weight related, so I help them target that. But a lot of people, like we mentioned, GI issues like acid reflux and dyspepsia are related to obesity. So they're concerned that if over 60 % of people on a GLP-1 will have a GI side effect, am I only making their problems worse? Potentially, yes, in the beginning. As people are trying to understand how their body is going to react to the medication, acid reflux oftentimes gets worse before it will get better.

40:52but if we're getting rid of the ultimate trigger which is the visceral fat then as they lose weight and they lose inches around their midsection their reflux will often get better do you have

41:02Dr. Gabrielle Lyon:tips or tricks to deal with reflux if someone is on the medication yeah is it baking soda do you say for a short period of time taking an acid take mastic gum or any number of natural type supplements yeah so if they're already on let's say an antacid let's say they're not they're not they go on yeah one of these medications and their first symptom is reflux or they're burping something up or you name it but it's kind of that refluxy symptom yeah so very common and i tell people this is not out of the the norm where it's when we start a medication typically if we increase the dose they're going to feel it or within the first one to two days post injection those would be the three most common your body will often adjust to the medication and as you lose weight and you lose visceral fat, those symptoms will get better.

41:53Okay. But some people will still have reflux. So we got to say, okay, one thing we want to treat it. Okay. What we know from the data is if you have, let's say a lot of reflux or nausea and you're not eating as much, that doesn't mean you're going to be more successful with weight loss. So we, we want to treat you. My goal is, what do you mean? Oh, so like I would, let's say start you on an antacid. I wouldn't say, okay, suffer through it. You're not going to eat as much. And then I think you're going to lose more weight. So we don't want people to suffer through it. We know those people, if they're having more symptoms, are not necessarily more successful with losing weight.

42:24So I always want to treat it.

42:26Dr. Gabrielle Lyon:I see. So the symptom severity doesn't correlate with more weight loss. So if someone has significant nausea, that doesn't necessarily mean they're going to lose more weight. So we don't want people to be miserable. But again, my other goal is not to give someone one medication and have to give them five others to treat all the side effects I'm causing. So we always want to go back to the drawing board and say, OK, are there triggers that have caused this? We have to go back to normal physiology, right? If someone is eating too late and we know that this medication delays the rate at which the stomach empties, if they're eating at 8 o 'clock at night and it's a fatty meal and we know out of all the macronutrients, fat has the biggest influence on delayed gastric emptying.

43:09So if they're eating a 16-ounce steak at 8 o 'clock at at night, then they're lying down at 10 to watch Netflix, on or off the medication, they're probably gonna have reflux. So if they have reflux with that off the medication, I tell them it's only gonna get worse on the medication, right? So we gotta figure out how can we change that. I tend to tell people to front load their calories earlier in the day, right? When you're more active, you're upright, you're moving around, your stomach is gonna empty faster than eating a heavier meal at night. So that can be very important. Is that when you also recommend they take the injection?

43:42So the time of the injection actually doesn't matter so much because the half-life is a week. So you still have some of the medication in your body. The day of the injection should be fairly consistent. The time of the day doesn't matter so much because it is a long-acting medication. But eating habits are very important. So we want to eat earlier in the day. If we're going to have a fattier, heavier meal, we want to have that also earlier in the day, which is very important. We also need to chew our food. So I don't know about you, but I am really guilty of inhaling my food. And so if we're not chewing properly, we're not going to digest properly, we're not going to absorb properly, and we're more likely to swallow a lot of air and cause more reflux and bloating symptoms.

44:23So those are really two powerful tips to mitigate a lot of those side effects that we see.

44:28Dr. Gabrielle Lyon:But no, are there any natural supplements that you use? And the reason I ask is because I swear when I was pregnant, I had the world's worst reflux. I I also had hyperemesis gravenil. Oh. It was awful. It was just awful. Because then you also can't take a lot of medications for that. It was terrible. Yes. But one of the things that really helped me was DGL. It's, you know, this licorice type extract. I don't know if there's things, and also I don't know if there's evidence behind that. Yeah. Are there any kind of natural type supplements or say aloe, something like that? Some people will take aloe supplements.

44:59I'm a big fan of like decaf tea. Ginger tea is like a smooth muscle relaxer, so I'm all for ginger tea. As far as supplements, I'll use like peppermint capsules. There's things like Ibogard or FDGard that have like menthol and peppermint in them, but they're delayed release. So if someone's having intestinal spasms, that can help with a smooth muscle relaxant effect in the gut. But if you have a bunch of mint, like mint and gum, that actually can worsen reflux. Mint can relax the lower esophageal sphincter. So it depends on what the symptom is. there are natural remedies, but a big part of it is if you're eating pizza at 10 o 'clock at night, you're probably not going to feel well on this medication.

45:40So the lifestyle, again, the foundation we cannot skip. If you want to lose weight, maintain your weight loss, and more importantly, feel well doing so, the nutritional changes are absolutely essential.

45:52Dr. Gabrielle Lyon:What about constipation? very common more so with semaglutide i see it less with trisepatide so if you were to ask me how do i pick one medication from another obviously it depends on the person it also depends on what their budget is some of the medications are more expensive than others you know nowadays at least the cash pay rates are going down insurance i honestly have lost a lot of faith in insurance coverage. A lot of my patients meet all the FDA criteria available and still get denied because it's not under their benefit plan. So it's a problem when it comes to coverage. And that's very frustrating for people because they say, doc, like I have diabetes or I've been struggling with weight my whole life.

46:36Why is my insurance company covering bariatric surgery and won't cover Wagovi? I mean, it's so backwards. Why we'd go to a more aggressive method when we can try medication first, but that's, you know, the healthcare system for you these days. Hopefully it's changing.

46:50Dr. Gabrielle Lyon:Hopefully. Hopefully it's changing soon. Thank you to Timeline for sponsoring this episode. Time isn't just about how long you live. It is about the quality of those years. It's having the energy you need to move through your day without fatigue. The strength to pick up your kids, your grandkids, who knows, someone else's kids. And the clarity to show up as your best self. Now, that kind of strength does go deeper than muscle. It starts with your mitochondria. the energy-producing engines inside your cells. We've learned about mitochondria, I don't know, in our fifth grade science class. And here's the reality.

47:25Dr. Gabrielle Lyon:As we age, those mitochondria decline. In fact, it's one of the key hallmarks of aging, and it directly impacts strength, recovery, and overall how we feel. One of the ways your body protects itself is through mitophagy, which helps clear out damaged mitochondria and replace them with healthier ones. And you're thinking, okay, so why is she talking about this? Well, I use Timeline powered by Mitopure because it contains urolithin A, which is a molecule backed by over 18 years of research and multiple human trials. It works at the cellular level to support mitochondrial renewal. It's not a quick fix or a stimulant.

48:04Dr. Gabrielle Lyon:It does support your body from the inside out over time. And if you've been considering trying it, it's a great time. Timeline has just lowered their price and you can get an additional 20 % off your first month when you go to timeline.com slash lion and use the code lion lower price same science bigger biceps. Hey living longer doesn't mean living less vital. Are you concerned about, so for constipation, for example, in our clinic, we might give people a regimen of Senecott and Marilax if we start them on a GLP-1. Do you have protocols like that to help with constipation? Yes, absolutely. So part of the way these medications work is they also have a diuretic effect.

48:52So sometimes dehydration can contribute to the constipation. If I'm lowering your appetite and I'm telling people to focus on protein, oftentimes they're not getting enough fiber. So that's really important is targeting 25 to 35 grams of dietary fiber a day. And that also just helps with the gut microbiome and the health of the colonic cells. And then obviously using things like supplements or medications, big fan of Miralax. All that does is it's an osmotic laxative. It just helps pull water into the colon. Then you can also use like stimulant laxatives like Senna or Dolcolax, and those will stimulate the bowel to move.

49:27some people just they have bulky stool and it gets trapped in the rectum and so that's where suppositories or enemas can be helpful so not all bowel regimens are created equal it really just depends on what the person's going through what I also see so much of is pelvic floor dysfunction in both men and women so you could be on the latest and greatest bowel regimen in the world if you have pelvic floor dysfunction where you're trying to push and you're not able to generate enough pressure to get it out of your rectum no amount of colonic stimulation is going to help you with that. So I send a lot of patients to pelvic floor physical therapy.

50:00Dr. Gabrielle Lyon:For specifically for constipation. Yes, absolutely. We had Dr. Sue McDonald on the podcast, which she was on Dr. Amy Perlman. You might know her. Her name sounds familiar. And Larry Lipschultz. They did an episode, I believe both Larry and Dr. Amy did an episode. Dr. Sue McDonald. If you guys did not hear that episode yet, please listen she covers pelvic floor dysfunction yeah in women of course but in men yeah yeah which we often like i was told in gastro that it's typically women who have had four-step vaginal deliveries that get pelvic floor dysfunction those are not the only people that struggle with that a lot of people do so anyone with constipation or this feeling of incomplete evacuation that can definitely be a problem um and and starting a glp1 medication can oftentimes just exacerbate the problem.

50:54So we want to make sure we are tackling it from all different points of view. But yes, amalgatide is definitely more likely to cause constipation than newer medications like terzepatide. So there are many medications on the market. There are many different pen delivery systems and there are injections and there are pills. So I want to kind of simplify it for the viewers because even in someone who practices in this space, it can be quite confusing. And I'll tell you this, it's only getting more confusing.

51:21Dr. Gabrielle Lyon:Because we're going to have different generations. Yeah, because there's more medications coming out on the market. So patients need to understand what are the different options out there and why is their provider choosing one or the other? That's really important. So the first medication I have here is Ozempic. Ozempic comes in a multi-dose delivery pen. So this is FDA approved for diabetes, but I will actually use it off-label in non-diabetics because they can kind of multi-dose it and it kind of saves them money. And when you say multi-dose, what do you mean? So what I mean by that, so you can use the clicks here and kind of adjust the dose.

51:57Okay. Now this is not necessarily what the manufacturer is telling you to do, but a lot of providers are doing it because it will save cost. So you'll still deliver a standard dose, but it's just a highly concentrated pen, if that makes sense. This is different compared to - And what is the starting dose? So the starting dose is always 0.25 milligrams per week of somagotide. Now this is the same medication as Wagovi. Why would I choose this one instead of this one?

52:24Dr. Gabrielle Lyon:And if you guys are just listening, in one hand she has the Ozempic pen, and in the other hand she has the Wagovi pen. Yes, so these are the exact same medication. They are both binovo, they're both semaglutide. This one is just a different pen delivery system. This one you can adjust the dose. This one is a single dose auto-injector. Is the first one, is the azepic pen an auto-injector? So it's not necessarily. You attach a needle here. This one, the needle is built in, and you adjust the dose here, and then you would click it and then inject the medication. This auto-injector, I'm literally not doing anything.

53:07I pull off the cap. When I'm ready to inject, I push this little plunger in here. The needle pops out, And so it's a one and done thing. And then they throw it out. Exactly. It's one pen per week. On this, you can adjust the dose on the pen, okay? But again, it's the same exact medication, but technically, if you want to go kind of by the guidelines, Zempic is FDA approved for diabetics. Wagovi is FDA approved for non-diabetics for weight loss, okay? So this came out in 2018, Wagovi 2021.

53:39Dr. Gabrielle Lyon:And these medications can be also used off-label. Yes. Written for off-label. So a lot of people would say, oh, I'm only using the FDA indication. But the reality is when they do drug studies, they're not trying to get every indication covered because those studies would take literally a million years. What we're seeing nowadays is - And we'd be really old by that. We would be really old. So initially developed for diabetes, then weight management. Now, next kid on the block is Zeppel, which is terzepatide. And then you have the same delivery system, Monjoro. So those, there's no delivery system changes.

54:12It's just this single dose pen here. So this is ZepBound. So now ZepBound is actually FDA approved for moderate to severe sleep apnea. So that's the added indication here. And Wagovi is now approved for F2, F3 fatty liver. So F2, F3 means the degree of fibrosis. So more indications are expanding. They are doing active clinical trials in Alzheimer's, alcohol, PCOS. Yes, near and dear to my heart is inflammatory bowel disease. So as a gastroenterologist, it used to be when these medications first came out, I wouldn't touch a patient with Crohn's or ulcerative colitis with a 10-foot pole with these medications.

54:51Now we're actually doing clinical trials in IBD patients because of the anti-inflammatory effects. So that's where you have this pleiotropic effect with these medications, way beyond weight management and insulin control. Now we're looking at the anti-inflammatory effects. and there's clinical trials in autoimmune conditions.

55:10Dr. Gabrielle Lyon:What is the dose? Is the dosing different? So the dosing for Zepound and Monjoro are the exact same. The dosing for anti-inflammatory. Oh, different. Yeah, it's different. So I'm hearing that it's more like the micro dosing versus these other doses, which are different. Yeah, so it depends on what the target is. But at least for sleep apnea and for fatty liver, those doses are the same that we would see in diabetes and weight management. because the mechanism is in part weight loss exactly yeah and the insulin pathway versus the anti-inflammatory pathway it's so fascinating do you think it's too good to be true i think there's a lot of things that are too good to be true i would say this has completely revolutionized health care where even if you as a prescriber or a doctor are not prescribing these medications i will tell you your patients are on them whether or not they're telling you these medications are going to infiltrate every single field in medicine.

56:10We need to stop telling people to just do it on their own. They're going to be doing on their own, but why not use tools in the toolbox to do two things, make it a little bit easier and a little bit less painful. Why not?

56:25Dr. Gabrielle Lyon:It's fascinating that we are, I mean, you realize that we are at the precipice of an entirely new landscape of medicine it's you know i used to run a weight management clinic in my fellowship we didn't have access and these were morbid people struggled with morbid obesity and we were not using these medications Because it wasn't indicated. And it was heartbreaking to watch two years later. They come to the program, they fall off. So many comorbid conditions. It's amazing. Well, we're also using it in post-bariatric patients because these tools, these medications, bariatric surgery, they're not cures for obesity, they are treatments.

57:12And what we even see in the bariatric population is weight regain, let's say, five years later. So a lot of those patients are actually going back to their bariatric surgeons and they may get a revision surgery, but many of them are actually going on GLP-1s to help combat some of the weight regain that we see.

57:29Dr. Gabrielle Lyon:You also had the pill form. Oh, yes. So show me the pill form. Oh, here we go. Okay. So Novo just came out with the pill form. So the pill form has actually been out for a couple years now. That was named Ribelsis, but that was FDA approved for diabetes. And they were at lower doses. They are daily pills. The past couple of months - Once a day? Once a day, yeah. The past couple of months ago, Novo came out with Logovi, which is the pill version. Now, the pill version of ribelsis, the highest dose of that, didn't get you anywhere close when it came to the weight loss that the injections of Ozempic did.

58:07And so you didn't get the degree of weight loss that you got with the injection. So if people needed to lose more weight, we would typically put them on injections instead of the pill. But they've actually changed the delivery device or the vehicle so that our body doesn't break down this medication. So now we're seeing that the Wagovi pills are equally as effective as the injections available. Now, you may say, or a lot of people would think that, oh, why would someone want to, you know, jab, right? Do the jab. I don't know if you've heard that phrase. People are using it all the time now for these medications.

58:38Why would you do the jab if you could take a daily pill? Now, I'll tell you from experience, and I've talked to a lot of my patients, I've asked them, do you want to change to the pill or do you want to stay with the injection? And oddly enough, I don't have a single patient that said they wanted to change to a pill because they're used to the injection. It's once a week, or I now have some patients who are in their maintenance phase who are injecting every two weeks. And they're like, honestly, it's a one and done thing. I'd rather not have to take a daily pill. People also need to realize that they're not really that easy to take.

59:06This medication in particular, it has to be on an empty stomach. You can't take it with other pills. You can only take it with four ounces of water. Then you have to eat 30 minutes later. If you're kind of someone who's traveling kind of on the go and things like that, it can realistically be a little bit of a challenge to take.

59:23Dr. Gabrielle Lyon:What about drug-drug interactions with these medications? So we don't really know. You know, it's interesting, when I used to do a lot of endoscopies, I would see undigested pills still in the stomach. You got to wonder, like, are we telling people, oh, you're not taking your medication or the medication is not effective? What if that person just doesn't have the ability to even break down the capsule? They're not absorbing the medication. I mean, it's really crazy. We haven't done clinical trials to say, okay, you're on Wagovi, how is that going to affect your blood pressure medication? Because technically, that medication is going to sit in your stomach longer than it otherwise would have.

59:57But I would argue, you know, in let's say poorly controlled diabetics, if they have a higher propensity for gastroparesis, which is delayed gastric emptying, are we doing drug trials in them to say, okay, if you're a diabetic, you need to take this blood pressure medication instead of this one because you're going to digest it differently? We're not. We assume everyone digests it the same, but that's not true. So gastric and intestinal motility do play a role in drug absorption. We don't have the studies to actually show what happens.

1:00:24Dr. Gabrielle Lyon:And we don't know, for example, if someone was on oral birth control, how would these medications make it less effective? Do we? Yeah, so birth control is one that we have to be careful with because it can definitely affect the efficacy where I don't know if you've heard of like ozempic babies, right? Where because I have, but I actually thought it was because of increased fertility. Yeah, there's a couple things, right? So if people are more likely to have infertility because of, let's say, PCOS and they're losing weight and we're improving their insulin resistance, they are more likely to get fertile.

1:00:58And so some of them may or may not be practicing safe sex, but now that they're more fertile, they can't get away with that anymore. So that's one reason the other thing is it can it can affect the efficacy of birth control so typically what we tell people is when you're starting the medication or you go up on the dose you should be on two forms of birth control but i don't think we honestly know enough about it but better safe

1:01:20Dr. Gabrielle Lyon:than sorry after even though these medications have been around for 20 years yeah but as you know research in women we're we're just too complicated i mean my husband says that but I don't know. So it makes sense that we should do clinical trials. But I think, you know, it's really hard to do clinical trials in, you know, well, in women. It's just, it's not that it's hard. It's just not done that often. But, yeah, we just don't have the data. We don't know, unfortunately. From a personal perspective, not evidence-based, but just evidence-informed, are you seeing that perhaps it affects antibiotic use?

1:01:57Dr. Gabrielle Lyon:are there other things that an individual would want to think about as they're on these medications? I do see hair loss, and that is a big concern in my patients. Now, I think it's multifactorial. One is a lot of these patients are mid-age. So are they also perimenopausal? Absolutely, I think that's contributing. The second thing is they're eating less, and they tend to be eating less protein. And as we know, protein is really important for hair. So I want to obviously optimize protein intake. How do you end up recommending people do that? I actually aim on the higher end of protein recommendations.

1:02:33So I really tell people, well, my ultimate goal is like one gram of protein per pound of ideal body weight. But if I'm starting someone on a GLP-1, that's not going to be happening. It's not realistic. So I'll tell people in general to try to hit at least 100 to 120 grams of protein per day to start. And I know you tell people at least 100 grams a day. So I have to be realistic. If I tell someone 200 grams, they're gonna say, you are crazy, that's never gonna happen. I have to meet the patient where they're at, and it also depends on how much protein they're getting at baseline. If they're used to getting 30 and I start them on a GLP-1, I cannot realistically recommend, oh, hit 150 by tomorrow, that's ridiculous.

1:03:16So if someone's hitting 40, I say, please track your protein, let's try to get you to 80, and then next month, let's try to get you to 100. It has to be a step-rise approach.

1:03:25Dr. Gabrielle Lyon:Thank you to one of the new sponsors of the show. If you are someone who is intentional about what you put in your body and how you use it, this is something I've been experimenting with in a very specific and particular way. It's called Lucy, and I use the two milligram nicotine gum. For me, it's not something I use passively like I'm chewing bubble gum. I use it as a tool at specific times when I want to stay focused and locked in. The science here is actually quite compelling. Nicotine mimics acetylcholine, and that's a primary neurotransmitter involved in learning and focus. There's data that can support that it improves visual attention, working memory, motor processing speed, all of these things that I need when I have long writing sessions, travel days, high stakes projects.

1:04:15Dr. Gabrielle Lyon:I need sustained attention. What I love is that Lucy is a tobacco-free product. It's clear in its dosing. You're isolating the compounds to leverage its potentially neuroprotective effects and neurotropic potential without all the junk. I recognize that this may have caught some of you by surprise. Why is she using nicotine? Was she a smoker? No, but I will say that for me, I wanted to look for something other than caffeine to help my memory, to help my focus, there is really good data about nicotine and brain function. They also have a nicotine pouch called Breakers, which have a small tiny capsule that you pop for an extra release of flavor.

1:05:01Dr. Gabrielle Lyon:But for me, I keep coming back to the gum. You might see me chewing gum all the time. It's simple, predictable. I love it. And if you are going to use nicotine, the key to using it is with intention. If you want to try it for yourself, go to Lucy.co and use the promo code Dr. Lyon for 20 % off your first order. Also, Lucy has a 30-day return policy. That's Lucy.co and the code for 20 % off is Dr. Lyon. Lucy products are only for adults of legal age and every order is age verified. Now, the warning is this product contains nicotine, and nicotine is an addictive chemical. For hair loss, in our clinic we typically look at ferritin stores, iron stores, we look at copper.

1:05:56Dr. Gabrielle Lyon:Are there certain markers that you look at in the blood when just as it relates to hair loss? So I do a whole gamut of labs to get their nutritional status, and what a lot of people don't realize is just because someone is overweight, a lot of overweight or obese individuals are malnourished. So we should be checking baseline labs. Baseline labs, I would check not having to do with hair, but it's an advanced lipid panel. It's their insulin level, their complete metabolic panel, their blood count. But I also check their B12, their vitamin D, and then depending, their iron labs. I have a lot of people who have normal hemoglobins, but are very iron deficient.

1:06:34And a lot of people are missing that so i want to check yes their baseline nutritional status do you find

1:06:39Dr. Gabrielle Lyon:obviously you say for hair loss one of the recommendations that you have is protein another thing that we use in the clinic are essential amino acids which especially if someone is starting on a glp1 that can be so helpful because it just is providing amino acids with none of the bulk. Yeah. We've just found that that's really easy to tolerate. Do you see any labs get worse? Meaning, do you see, obviously, HSCRP improves, but do you see things like ferritin getting worse? Or do you see various markers? I haven't, but I'm just curious. Yeah, I haven't either. And I do trend these things. I wouldn't do it every month.

1:07:26It really depends on the person. I'm all for supplements. I'm all for food is first, but supplements can be very helpful, especially when it comes to B12, iron, vitamin D, those key players. I'm a big proponent of creatine. People are plus or minus on collagen. I've had a lot of patients that report better skin, hair, nails on collagen. So I'm all for it. There's very little harm. But I think we also have to be careful with a lot of the other supplements out there. I've had liver enzyme abnormalities with things like Nutrafol. So it does depend on the quality of the supplement. I'm not one for giving someone a supplement that has everything in the kitchen sink, right?

1:08:04I'm all for, okay, your B12 is low. Let's optimize your B12. Your iron's low. Let's optimize your B12. Because a lot of these all-in-one type supplements, they are containing so many things in there that actually interfere with the absorption of another. Like multivitamins. If we know that calcium interferes with iron, why would I give you a supplement that has calcium and iron? because you want to cause constipation obviously the metformin craze there was a whole metformin

1:08:31Dr. Gabrielle Lyon:craze we actually had um dr eisenberg on the show he's a urologist and he was talking about how metformin can potentially affect birth defects the reason i bring this up is because metformin again, used ubiquitously affected B vitamin metabolism, B12. Makes sense. Do you think that there is something like that with GLP-1s? Well, a lot of my patients are already starting with low B12. And so I obviously want to optimize that. So I can't obviously blame the GLP-1 on that. A lot of my patients, because we're delaying gastric emptying and affecting digestion, red meat is just less appetizing. or it tends to really just stay in their stomach like a brick.

1:09:18So they tend to be getting less B12 through their nutrition on the GLP-1 medications. So oftentimes I will supplement those folks as well if they're having trouble taking in dietary vitamin B12 sources.

1:09:30Dr. Gabrielle Lyon:That makes sense. And basically what I'm trying to get to the underbelly is, is there something potentially we're missing? Because again, these medications, are they too good to be true? I mean, I don't know. Look at hormones. one could also argue that hormones estrogen progesterone testosterone are too good to be true but our body makes them and our body does make glp1 yeah the overdose situation with the new medications the half-life is long do we have a solution if someone by accident takes the wrong dose they take a much higher dose are they going to be stuck with nausea vomiting i mean i can only imagine that would be terrible.

1:10:15Yeah, there's no antidote for these medications. So if someone takes too much of a dose or they're just having a side effect, if we up titrated or they're initiating the medication, there's no medication I can give you something like a benzo or a morphine where I can reverse the effect. So a big part of it, you know, it's all about supportive care. It's making sure... Have you ever had a patient do that? I have actually. Me too. Yeah, they got mixed up. They were doing it in the car. They weren't paying attention. They called me a day after and they said, I am just so miserable. And I said, walk me through what happened.

1:10:43And I'm like, okay. All right. Now, luckily they did not go to the hospital. They were fine. They were just pretty miserable for about a week. Right. Cause the half life is a week.

1:10:52Dr. Gabrielle Lyon:Oh, absolutely. Yeah. So it's all about supportive care. Hydration is key, right? So like they don't, people can survive without food for a week. We can't survive without fluid. So my go-to is it's actually not slamming down a bunch of water. It's making sure we have oral rehydration solution. So simple things like Pedilite or I have recipes of homemade solutions if people don't like Gatorade. Gatorade is fine, but it's not technically a hydration solution. There's not enough salt in there. So you have to actually add salt to maintain hydration. So it's maintaining hydration is the key. And then using medications as supportive care to help prevent the vomiting, the diarrhea.

1:11:30So it can happen. I would say, are we missing something? Are these too good to be true? as access improves, which is great, you still are gonna have these weight loss companies that are just writing scripts for people. So we wanna make sure we have an appropriate candidate. We wanna make sure - How do we define appropriate candidate? Well, someone who is ready to invest in their health and make the other foundational changes along with the medication. I want people to have realistic expectations that the goal is not just to lose 50 pounds, stop the medication, because what do we see in the data?

1:12:05We see the weight regain. And people may gain, with the weight gain, gain a little bit of muscle, but the majority is regaining a lot of that fat and then ends up causing this vicious cycle. So we have to really look at how do we optimize long-term health outcomes, improve cardiometabolic health. So yes, improving access is important, but making sure the patient understands how do these medications work and how can I be successful long-term is really important. Now, the typical indications though were all weight related. I have plenty of people that come to me who have a normal BMI, who I think are candidates for GLP-1 medications.

1:12:42Maybe they're struggling with alcohol. I live in Miami, that's a big problem. Maybe they're perimenopausal and they have a normal BMI, but they've gained a bunch of fat around their midsection and they're struggling and now they're insulin resistant. I use those medications off label in those individuals. So that's where there's really the art to the medicine piece.

1:13:01Dr. Gabrielle Lyon:compounding pharmacies we didn't mention that as you're showing the pills and the injectables we do use compounding pharmacies i think that they're great as long as they're reputable yeah the other thing that i wanted to ask you about was you talked about the foundational plan fiber i know that you have some show more show and tell which i appreciate them being empty fiber in the microbiome yes fiber is so important but what's interesting about kind of social media is you have people again yeah that or you know you have people who are pro and who are against like people who are all about keto and and plants are trying to kill us type of thing there is overwhelming evidence to support the optimal effects of fiber on the gut microbiome so we use a lot of different terms like prebiotic and probiotic and it can get a little bit complicated for people so let me break it down prebiotic is dietary fiber so nuts seeds whole grains all of those things when we eat dietary fiber those molecules are broken down by the bacteria in our gut and then produce other molecules that have more downstream effects things like short chain fatty acids that then hit our colon and help optimize the health of our colonic cells so that's one of the reasons why dietary fiber is really important.

1:14:22But also, our bacteria in our gut really like the dietary fiber. So it helps promote a healthy gut microbiome. When we eat whole food, when we eat dietary fiber, our bacteria like it, and then we grow the good bacteria. When we have good bacteria, those bacteria take care of us. So when we eat ultra processed food, and you and I may define that a little bit differently, but I would define ultra processed. I mean, technically, Let me grab my little show and tell here. Technically, all these things are processed, right? They're in a bag. This did not come in.

1:14:55Dr. Gabrielle Lyon:So she has for you that are not watching this, which you should be because her outfit is fabulous. We've got, what do we have here? I have my plain Greek yogurt. I have my good culture cottage cheese, roasted chickpeas, peanut butter powder, roasted lentils, a chia seed bar, and almonds. Wait, peanut butter powder? Yeah. Let me see that. So it's literally just pulverized peanuts. That is super easy that you can kind of mix in with like a Greek yogurt or cottage cheese, and it adds typically about eight grams of protein, or you could add it to a shake. But that's fake news, fake protein. Because it's plant protein, so if it says eight grams, it's probably closer to four, maybe.

1:15:40So that's my little peanut butter powder here. um so yeah so fiber is very important um protein is very important these are all things that are travel friendly except for at the airport these are a little bit too big unfortunately to get through no wonder i had to get here tsa so yes these are technically all processed because they're not coming from that naturally but they are healthier alternatives to most of the stuff you're going to find at the nearest 7-Eleven gas station or at the airport. And many of these also contain fiber. Now, these are not high protein sources. You're not going to get your protein requirement for the day, but they will give you at least some protein towards your daily goal.

1:16:25Dr. Gabrielle Lyon:The fiber component, insoluble versus soluble fiber, you said 25 to 30 grams. Do you believe, is that enough? Should it be higher? Depends on where someone is starting from. I think we we could probably benefit from more. But to put things into perspective, like one cup of broccoli gets you about four grams of fiber. So that's a lot of broccoli to eat in a day. A lot of people are eating like 10 grams of fiber. And fiber is one of those things where, as a gastroenterologist, I see people either too little or too much. If you overdo fiber like anything else, too much of a good thing can be a bad thing.

1:17:02There's a lot of diet food products like these keto tortillas or breads that in one serving will get you like 25 grams of sodium. I know.

1:17:10Dr. Gabrielle Lyon:I thought I was doing so great. I used to eat. Do you remember? They still have them. They're just these fiber wafers. This was in college. And I just thought, this is such a great idea. I can eat this, have some peanut butter. Yeah. But it really, I just felt terrible. Oh, yeah. So bloated after. Yeah. The bloating is a real thing because fiber, a lot of it is indigestible by the human body. Do we care the percentage of soluble versus insoluble? It depends on the person. Soluble fiber is going to help kind of bulk up the stool. So if someone overdoes that, you can bulk up the stool so much that it can actually worsen the constipation.

1:17:48In general, any high fiber food is going to have a good mixture of both.

1:17:54Dr. Gabrielle Lyon:Whole food. Yes. Whole food. again now we're talking about the food matrix yeah would have an appropriate proportion of soluble versus insoluble yes broccoli is insoluble fiber mostly lentils nuts is there should someone say if they have small intestinal bacteria overgrowth are there certain fibers that people with gut dysbiosis should use versus other fibers honestly in my perspective it depends on what the person likes right so if someone tells me they have a food aversion to lentils i'm not going to tell them to eat lentils a big part of it is what are they currently eating what are they willing to eat just to really reintroduce fiber into their diet and i start there i mean we can either make it simple or overly complicated in general people just need to eat more whole food and more fiber we start there and kind of go over the nuances as we go would you consider short chain fatty acids to be a postbiotic then?

1:18:54We don't have much data taking short chain fatty acid supplements as far as having like better outcomes. We want to make the short chain fatty acids by the food that we're eating. So taking things like butyric acid, people used to use it for certain conditions like butyric acid kind of enemas that may be helpful in things like proctitis for some individuals, but taking a short chain fatty acids supplement, you're not gonna see the same results that you do from actually getting dietary fiber through food.

1:19:25Dr. Gabrielle Lyon:And the way someone would get short chain fatty acids would be through just the consumption of fiber. Exactly, dietary fiber. And our microbiome takes care of it for us. That's the beautiful thing about the human body. How do we define microbiome? It's trillions of bacteria and fungi that live in our gut. And really the microbiome, it's in our vaginal canal, it's on our skin, it's in every organ. When we talk about the microbiome, most of us are really talking specifically for the gut microbiome. I know you're big into muscle. We were gonna do pushups. And you guys already trained the gut muscle access.

1:20:04Dr. Gabrielle Lyon:We talked about the GLP-1s, which some of the weight that is lost is also muscle. So the other part of the gut microbiome is what it produces. And like you said, short chain fatty acids. Do you think that there are specific foods that are helpful for the mitochondria, for the myocytes, beyond protein? And I am truly curious because I haven't really, other than urolithin A, I haven't thought so much about the interplay between the postbiotic after we eat and what we make and its effect on muscle. And as someone who's very clearly, by the way, if you guys are not seeing this, she is jacked. Are there foods that you think, okay, this is my muscle plan for muscle sparing on a GLP-1?

1:20:57I don't think we know. You know, it's interesting when we look at the clinical trials, the dietary guidelines are very general in the GLP-1 study. So they're telling people to eat protein, you know, to eat anti-inflammatory foods. But beyond that, they're not given specific dietary plans. So I couldn't tell you whether someone's eating more plant-based versus animal-based on a GLP-1. That's not how they created the clinical trials. A lot of nutrition studies also, they're just really hard to interpret because they're relying on dietary recall.

1:21:32Dr. Gabrielle Lyon:A lot of epidemiology. Exactly. So we don't know when it comes to nutrition. They may get general guidance, but we don't quite know what they're eating on a day-to-day basis. So no supplements that you think, okay, aside from creatine. Yeah. Yeah. Creatine for sure. Yeah. Nothing that is kind of you're interested in right now or on the top of your mind when it when it comes to mitochondrial health. I don't think anything is gonna replace the foundation, which is whole food, fiber, protein. We gotta just keep it simple and focus on those things. Thanks to one of the sponsors of the show, Amp. Because I can walk two doors down and get a great workout.

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1:23:42Dr. Gabrielle Lyon:Check it out. That's amp.ai. Why? Training should be effective and it doesn't have to be complicated. Hormones. How do you think about the interplay, and I suppose not the direct interplay between the GLP-1s, but ultimately people and patients, they want outcomes. They want to physically transform. You have been utilizing, studying, and prescribing hormones for a long time, fair to say? Actually not that long. So you had initially asked me what is my kind of day-to-day look like or what sort of patients are seeing me and the initial Practice was set up for weight management It actually wasn't until about a year and a half in where so my sister and I are in practice together And what were we noticing?

1:24:31We were noticing that our most successful Happiest patient was our middle-aged man who I was working on his nutrition his exercise programming he was on a GLP-1 medication my sister was managing his testosterone this guy was hitting PRs and marathons he had five pounds more muscle now 40 pounds lighter and we sat down and we said if we can do this for women I'm sorry for men why can't we do this for women so we actually tried to find gynecologists and specialists in the Miami area to send our women patients to to optimize their hormones and a couple things we found one is the really good ones were already so busy they weren't accepting new patients or if they were accepting patients my patients were going to have to wait three to six months to see them the third was some of these providers were still not on the bandwagon of hormone replacement therapy to the point that they were telling my patients my 45 year old patient that i see you have osteopenia but hormones have nothing to do with bone health and i said okay it's one thing for a provider not to prescribe hrt it's one thing to gaslight my patient and give them misinformation so my sister and i said okay if we can't find the providers in the area to see our patients soon and optimize their hormones we're going to take care of it ourselves so we took a course with dr rachel rubin she taught us everything we needed to know about hormones.

1:25:59She's absolutely amazing. We love Dr. Rachel. Whenever I have a question about anything, I just use one text away. And then now those are my happiest and healthiest patients because we're not only helping them improve their cardiometabolic health, getting them and maintaining a healthier weight, we're treating their sleep disturbances, we're treating their hot flashes, their night sweats. All of these things are incredibly important for optimal quality of life. But we found it serendipitously with our middle-aged male patient who was killing it. Those guys, from a body composition perspective, there isn't a ton

1:26:35Dr. Gabrielle Lyon:of data with hormones actually changing body composition. What have you seen in your clinic? It's interesting because, you know, as women reach middle age, and that's, you know, mid to late 30s, right, and early 40s, we start to see body composition changes, as you know, where maybe Maybe the BMI or the weight is pretty similar, five pounds up, but people often, my women come in and they say, I have a belly I've never had before. My body has changed. My skin has changed. This is just very different for me, but my lifestyle hasn't changed. Why is this happening to me now if I'm doing everything I did when I was 20 and 30?

1:27:14And I say, the problem is your physiology is vastly different. Even though you didn't change, your body has changed underneath the hood. so that you know is a big thing what do we see with hormone replacement therapy well a lot of people would argue well if i gained weight during perimenopause if you just give me back some of the hormones won't i lose the weight we just don't see it hrt is not a weight loss strategy now if someone's gaining weight because they can't sleep and you fix their sleep then maybe it will help in that regard but in many of my patients i may actually see a little bit of weight gain Why?

1:27:47Because we're helping with bone and muscle, especially if they're on testosterone, they may actually gain a little bit of weight even though their body composition's changing, their BMI or that number on the scale may not be going down. But what we're seeing actually more and more in retrospective studies currently is the secret sauce is the combination of HRT and GLP-1 therapy. And you had asked me earlier, what are we seeing with lean tissue or muscle changes? And I'll tell you, I can tell exactly the point that I start a patient on a GLP-1 on hormone replacement therapy because their lean mass losses start to kind of go straight and then they start to gain muscle when I'm optimizing specifically my women on testosterone.

1:28:28So that's really cool to see when you're actually tracking the data that matters.

1:28:33Dr. Gabrielle Lyon:Do you have a number in mind if someone is coming in? Because again, there is still surprisingly no, aside from hyposexual desire disorder, no other FDA approval, Dr. Amy Perlman is sitting in here, for testosterone. Do you think about, okay, so the patient comes in, they're on a GLP-1, we know that they don't do anything magic for muscle loss. And I've just been reviewing some the data so i'm excited to hear kind of what you are seeing when it comes to muscle health from my perspective it helps with improved muscle health not decrease muscle health because people will say individuals are losing more muscle mass it's perhaps the rate of weight loss is accelerated with the glp ones but the quality of muscle seems to improve yeah absolutely i mean people will blame everything and anything on GLP-1 therapy.

1:29:39But what do we actually see in the data? So when you compare diet and exercise, GLP-1 therapy, and bariatric surgery, the absolute percentage of lean tissue loss is the same across all. 25 to 40 % of losses you're going to see across all three modalities. But people are losing more weight now on GLP-1s than they've ever been able to lose before with diet and exercise. So of course, the absolute number is going to be more than just diet and exercise. But like you mentioned, is muscle mass, is that the holy grail? I would argue it's not because I'm tracking that, right? But if I have a patient that says, okay, I've lost 30 pounds.

1:30:17Yes, I've lost five pounds of muscle, but I feel stronger now than I did when I started. How many clinics do you think are testing hand grip strength, six minute walk tests, a get up and go test? Because ultimately that's what matters is performance is strength not how much muscle mass you have but the actual contractile forces you're able to to to you know have right frailty and fracture what matters that's my issue actually with dexa scans we're looking at bone mineralization we're not looking at how strong are your bones in actuality so i think that's where we're missing the boat when it comes to you know talking about frailty, fracture, muscle mass, metabolic health is not just what are you made of, but how strong is your muscle and how productive can you be to reduce your risk of frailty and fracture?

1:31:08Dr. Gabrielle Lyon:You are highlighting the diagnostic gap that as healthcare providers, this should be standard. Someone goes to their provider and they get blood pressure checked, they get weight checked, but they don't get hand grip strength which we know is a great one of the greatest indications of longevity and it literally takes 30 seconds or less even it might even be i don't want to say that it's more important than blood pressure but the indications when we think about strength and survivability, muscle is underutilized, underdiagnosed, it's not part of the normal conversation. Yeah. And I'm really glad to hear you say that.

1:31:54We don't even have, well, okay, I will say we have a blood pressure cuff at our clinic only because my sister does procedures, so we need it if someone feels faint. Or if someone says I have a headache, I will check their blood pressure. Other than that, I never check blood pressure in patients. Why? Because I live in Miami and people are driving in Miami traffic. So I would much rather a patient check their blood pressure at home, send me their wearable information, which is more realistic to how they live on their daily basis, not a one data point from when they're here in clinic. But yet, in the typical healthcare scenario, the number of profound medical decisions we make on one data point in clinic is absolutely insane to me.

1:32:37Dr. Gabrielle Lyon:Amen to that. Amen to that. But when you think and start to see a decline in lean tissue, from the perspective of patient care, how do you decide, is it going to be estrogen? Is it going to be progesterone? Is it going to be testosterone? Let's say they are perimenopause. So not totally in menopause. Maybe their estrogen numbers are lower. Maybe all their hormones are low. How, from a clinical decision-making standpoint, do you approach that? Yeah. So one thing is we have to track in order to see someone's progression. So for instance, people who see me in clinic, I see them on a monthly basis, and I use a medical-grade bioimpedance scale called the SECA, and I'm tracking every month.

1:33:22Now, I will have patients who see me, let's say, out of state. They'll send me their data from, let's say, a Withing scale or the Hume scale. So I have the body fat and the muscle. The trends are important. The absolute number is not so much, but the trends are really important. So if someone's, let's say, on a GLP-1 medication, even though I previously mentioned like that mass is not the end all be all, it gives me data to say, okay, you lost two pounds of muscle this month. How much protein are you taking in? And I know you're telling me you're having chicken breast for lunch, but can you please weigh it out?

1:33:53I need to know if it's two ounces or six, because there's a big difference there. So it gives me a platform to better inform myself and the patient to say, okay, are you getting enough protein? Before I even delve into the hormone piece, the exercise piece, as you know, like exercise is so incredibly important for longevity. If we could package that up in a pill, you and I would never have to work another day in our life, right? Exercise is so important, but I have so many patients that let's say see trainers or they're on this Orange Theory bandwagon or Barry's Bootcamp and they're doing endless kind of circuit training, moderate intensity, and they're not making gains.

1:34:28And so I will actually talk to a lot of trainers. I'll have a phone call, I'll have a Zoom meeting. oh no yeah i'm like you know it's like but i need to understand because not all trainers are created equal like not all doctors are created equal what does your exercise programming look like because if i'm not seeing the results that i would anticipate in my patient by what they're telling me i need to truly understand what does their exercise program look like and i have so many patients that will get a trainer for 45 minutes they're rushing from exercise to exercise they're doing like 15 exercises and i'm like how much are you how much time are you resting in between exercise and they're like two minutes and i'm like no no that math doesn't math you're doing 15 exercises four sets of each like in 45 minutes you know you're doing cardio exactly like where do we where do we build muscle not in the gym we build muscle outside of the gym but you know with recovery and fuel but you need to actually make sure you're resting in between sets you're doing progressive overload and my patients kind of just follow whatever the program is if they don't have of the knowledge to start talking to their trainer about it.

1:35:28So I kind of fill that gap and have that conversation. And I've had patients that switch trainers, and all of a sudden, they start gaining muscle. So that's really key. When it comes to the hormones, it depends on what their symptoms are. If they're having hot flashes and night sweats, we're going to start with the estradiol and then progesterone if they still have a uterus. If a lot of my patients don't necessarily realize the importance of testosterone, as you know, we as women have more testosterone than we do estrogen in all phases of our life. So they'll say, oh, I don't wanna look like a bodybuilder.

1:36:01And I say, do you understand how hard that is to look like a bodybuilder, right? My goal is not to give you male doses of testosterone, but if someone is worried about bone health, if they're worried about muscle health, if they wanna improve their cognition, their libido, right? Testosterone can be very, very beneficial in that regard. But we have to start terming, just like GLP-1s are not just weight loss drugs, we have to stop calling hormone replacement therapy or testosterone as just libido enhancers. They are brain hormones. They are heart hormones. They are muscle and bone hormones. So it depends on what the person's ultimate goals are, but I look under the hood.

1:36:40And if they're eating the protein, they're doing the resistance training, but they're struggling with bone and muscle health, I will say, I really think we should give testosterone a try.

1:36:49Dr. Gabrielle Lyon:How do you think about dosing for testosterone? So I do use a compounding pharmacy for testosterone. I aim on the lower side instead of the higher side because I've had patients come in with significant hair loss, with acne, with mood changes, with clitoral enlargement, which can sometimes need surgery to correct. So I usually start them low because a lot of my female patients are already worried about hair loss. The last thing I wanna do is convert more of that into DHT. So I will typically do a daily cream that's compounded, or I will use oral testosterone like Kaisotrex, which is a little bit higher doses.

1:37:25Dr. Gabrielle Lyon:You are the first physician, I think, that we've had on that is maybe a year ago. I think Kaisotrex is a great medication. I'm on it myself. Okay. Yeah. Talk to me about Kaisotrex, the oral testosterone. So, you know, a lot of people are worried about taking oral hormones, and I get it, because same thing like oral estrogen, that can increase, even though it's a small increase, risk of clotting. And the old oral testosterone formulations caused liver issues. Now, the nice thing about Kaisertrex - Because of first-pass metabolism. Exactly, yeah. So the nice thing about Kaisertrex is we absorb it through our small intestine, right?

1:38:01Now we do have to take it with fat in order to optimize absorption, but it's a very easy pill to take. Now, we don't have the doses approved for women, so I will start the lowest dose possible. And it is a little bit higher than what we're going to get with the cream, but it depends on the person and what sort of formulation they want or they're willing to take.

1:38:20Dr. Gabrielle Lyon:I really think revolutionizing the ability to take hormones because a lot of guys, whether they are traveling or they don't like injections, really struggle. Also women, from a perspective with testosterone and just any kind of hormone, people have kids. You know, it might be too much of a risk for transference. Yeah, yeah. The oral Kaizotrex, what is the starting dose that you guys think about for women? So the lowest dose is 100 milligrams. And that's once a day with food? Yeah, yeah. Versus for men, it's typically they'll do like four pills, like 400 milligrams twice per day. So they don't yet have a lower version.

1:39:07It will be nice, I think, once they have maybe lower versions. Most of my patients are on the compounded cream, mainly because I don't want to drive up their levels too much. So it depends because the Kaiser Trex is going to be a higher dose than what you're going to get on typical topicals.

1:39:19Dr. Gabrielle Lyon:And the women do a lot better on that? I only have actually probably two patients on the Kaiser Trex, actually. Most of my patients are on the lotion. More so because— Yeah, yeah, yeah. I think some of them are just worried about higher doses. And so I typically will start most patients on the cream. Yeah. Do you find that the blood levels look different? For example, if someone is on the cream, do they have a higher conversion to DHT versus if someone is using an oral agent? I think it's hard to say because I don't have, most of my patients are on the topical, so I'm not sure if I can answer that question.

1:39:58But I'm mostly looking at, you know, side effects. And I will see that more so in my patients who were on pellets or injections. So I get those patients that come in and they weren't given any other options. They were literally said, you know, you should be started on hormones, here are pellets. They didn't realize there were other modes of administration. So I see more virilizing effects in those patients. And so I will definitely start them on the topicals just because it's quick, it's lower doses, and they're already worried about side effects. I aim more on the lower end, yeah.

1:40:32Dr. Gabrielle Lyon:Do you have an expectation of how much muscle you want them to gain? We're talking about just the perimenopausal woman where you're like, okay, we're on a GLP-1, you've changed your body composition, you're going through recomp, you've lost 10 pounds of fat, I want to see you put on, or do you have an expectation of the amount of muscle mass that you want them to gain? I would say my goal for each and every one of my patients is when they hit their weight loss goal and they're in maintenance mode, that's when the, actually, that's when the hard part begins. is gaining muscle because the easier part is losing the weight.

1:41:13The hard part is regaining some of the lean tissue that was lost. I want each and every one of my patients to have more muscle than when they started. And that's doable, but it requires obviously that daily consistent effort. Protein, protein, protein. Not just exercising, but progressive overload, consistent resistance training. When we go on vacation, our muscles don't care. I do. that's a really hard thing for people to realize is i have people businessmen and women who travel for three months out of the year during the summer i hear only poor people stay in miami over the summer my sister and i are always here uh over the summer in miami but um people travel for a couple of months and they may go on cruises or they're walking around in europe and they literally stop resistance training for three months and they assume they're going to be able to maintain all of their muscle mass.

1:42:05And that's just not the way the body works. So I want people to feel strong. A lot of my patients, they have the financial means, they have a great family support, they retire, they want to travel the world and do whatever they want. I know you ask a lot of your guests on here, what does forever strong mean to them? And to me, it means being able to do whatever, whenever you want, you know, and to have nothing hold you back, whether that's mentally, physically, it doesn't matter. It is freedom. It is independence. And people work their butts off their whole life. For what? They retire at 65 and then they can't travel because they're too frail?

1:42:49That is awful to me. One out of two postmenopausal women develop osteoporosis. That doesn't have to happen. Once they fall in fracture and they break a hip at the age of 70, their one-year mortality is outrageously high. These things are preventable if we talk to people in their 20s and 30s, when they're still able to build bone, and when building muscle is easier. These are the times the conversations should start, not when we get their first DEXA scan at the age of 65. We have missed the boat in another realm when it comes to that. And I'm sure you saw that when you were doing geriatrics as well.

1:43:26We are missing so many things that can be prevented.

1:43:30Dr. Gabrielle Lyon:You mentioned something about the maintenance, that you have patients that are in maintenance. Now, GLP-1s, there are no guidelines for a maintenance strategy. Take me through your maintenance strategy. Yeah. So I always ask people, how do they define success as far as their health and wellness? And oftentimes, they'll tell me a number on the scale, like, oh, I want to hit 130. And the reality is there's nothing magical about 130. 130, they were happier because they were 22 years old without a husband and without kids and had less responsibility. So I really want to figure out like what is really their ultimate goal, right?

1:44:06But sometimes it is weight based. Once they get to their goal, then I tell them, okay, before we start tapering out or tapering off the GLP-1 medication, the majority of my patients, honestly, they've done so well and they're thrilled and they're happy and healthy, they say, doc, if I need to continue this medication weekly for the rest of my life, I will absolutely do that to help prevent the yo-yos of the weight up and down for the rest of my life. So for a lot of my patients, they're basically still on the weekly dosing for weight loss maintenance. But I do have some patients that say, okay, I don't want to inject myself every week.

1:44:42Can we try to at least space it out? So my weight maintenance strategy for those folks is I start to space it out. Let's say they are initially doing weekly dosing. I'll say, let's space it out to every 10 days, or let's space it out to every 14 days. It's typically going to be the dose that they reach their goal on. So if they're on ZEP bound 15 milligrams a week, I'll say, let's keep you on 15. Let's space it out to every two weeks. Cause at least at higher doses, some of the medication is still in your body at that point. And then I'll tell them, tell me when you start to feel more hunger and cravings.

1:45:14And they'll say, oh, you know, at day 14, I feel fine. So I'll keep them every two weeks on that. If they say, well, around day 10, I really start to struggle with portion control. Then I'll say, okay, then why don't we do injections every 10 days? So it's a very dynamic thing. Just because someone reached their goal at one dose doesn't mean that's going to be the dose, the frequency, the regimen that they're going to be on for the next couple of years and beyond.

1:45:39Dr. Gabrielle Lyon:Okay. And you found that that way of doing a dosing strategy is really successful. Yeah, but it will vary because I have some people that, you know, they're in maintenance, they're on injections every two weeks, then the holidays come around and they're traveling and they're less consistent with their protein and they aren't working with their trainer. Then we have to say, okay, you gained 10 pounds over the holidays. Let's get you back to every week. So I think that can be frustrating for people because people really worry, obviously, about that weight regain. There's a lot of anxiety that's invoked with that.

1:46:10But the reality is our bodies were only, you know, for most of us, not you, but for most of us, we are getting older, um, that we have to work harder actually in the weight maintenance phase. Now, when it comes to exercise recommendations, we recommend 150 minutes of moderate exercise per week for weight loss, but for weight maintenance, it's 300 minutes a week. So we shouldn't actually get more lax in the maintenance phase. That's actually when we have to work harder to maintain, which people need to realize with or without GLP-1 medications. The dosing is, like you said, it's different for

1:46:46Dr. Gabrielle Lyon:everybody. Do you ever find that if a patient is like, okay, I want to come off this because the two-year recidivism rate is I think 73 % of people end up going off the medication. Is there a place where instead of, say, staying on the 15 milligrams, do you have them in essence microdose ever or it's not just a really great strategy for you? Not necessarily microdose where people are injecting every day, but I have some people that are on the minimal doses, like 0.25 milligrams of Ozempic once a week or once every two weeks. Typically though, those are gonna be the patients that were always on low doses, that they were able to minimize their dose to 0.25 weekly, lose 10, 20 pounds, and then we just maintain them at that.

1:47:38Typically, you're not going to go from someone on 2.4 milligrams of Wagovi to 0.25 in their maintenance.

1:47:45Dr. Gabrielle Lyon:I have also found that if a patient does really well, that people do well on various doses, which is why compounding is so great. And to do a maintenance dose, you can't just go back down to this small microdose. I found that that is not very... Yeah, and it's not gender-specific, and it's not age-specific. And I have some people who are my larger patients who are men that you would think would need higher doses, and they are actually more sensitive to the medication than some of my more petite women. So you just cannot predict it in advance. It makes me... It begs the question, are there things that people can do, and I don't think we know this answer, to make these medications more effective?

1:48:27Well, I think it comes down to, well, how do we also harness our natural GLP-1 in addition to the synthetic medication that we're giving ourselves? We know that fiber and protein are very satiating. So if we focus on those two things, then we're really throwing everything at those satiety hormones to help with hunger and reduce cravings.

1:48:47Dr. Gabrielle Lyon:You feel very passionately about this. Yes. Did something happen? Did you witness someone get sick? So I kind of went through it myself, actually. Now, I've been a bodybuilder on and off since I was 18 in undergrad, and I did it the unhealthy way and the healthy way. So my first show, I lost 30 pounds in three months. I was doing two hours of cardio every single day. They had to kick my butt out of the gym when they were closing because I was very OCD about it. I had female athlete triad. I would miss periods. I kind of took that as, you know, like a medal. Like, oh, I'm so lean, I'm missing my period, right?

1:49:25That's a good thing. So I kind of went through that on and off for a couple of years. I did bodybuilding shows in medical school. It was kind of like my badge of honor. I am 39 years old. I went to my gynecologist a year ago and I said, I want to get a bone density scan. My mom has osteoporosis. I kind of had to convince her to order one for me. So I went in to get my bone density scan and the technologist said, your bones look great. I walk out. I text my mom. I said, mom, my bones are strong as hell. I pull up the report in my portal. Michelle Perlman, osteoporosis of the lumbar spine. I was devastated.

1:50:00I said, this can't happen. I'm a bodybuilder. I've been lifting heavy shit since I was 13 years old. I eat 160 grams of protein a day. I'm super active. I counsel my patients on reducing risk of frailty and fracture. This has to be wrong, right? So my gynecologist said, oh, they make mistakes all the time. Let's get another DEXA scan. So I ordered another bone density scan. I went to the hospital this time. Went to the hospital, got my bone density scan, same damn thing. Osteoporosis of the lumbar spine, osteopenia of the hip. So not only is this something I see in my patients every single day, this is personal.

1:50:35Because I thought I could do, I did everything to minimize my risk. Now I went to see an endocrinologist and I said, I thought I was doing everything I could to help prevent this. What should I be doing differently? Clearly I'm missing something. Should I be doing X, Y, and Z for exercise? And he looked at me and he said, I don't know what to tell you. And I said, well, hell, I didn't say this verbally, but in my brain, I'm thinking, if you as the bone specialist don't know what to tell me as far as nutrition guidelines, as far as exercise, then what are people who aren't doing what I'm doing, who are struggling, where are they going for help?

1:51:15I think we need more research when it comes to how to optimize our bones and muscle health and everything, really it starts in our teens and 20s. And I think that's a big population we need to target because those are our bone forming years. And what I see, and you had mentioned the term earlier, we are over-training and under-fueling. And again, we take that as a badge of honor that we're not eating that much, that we're training really hard, we're getting away, we're getting away with five hours of sleep a night. and our body tells us at some point, that's not gonna work for you. And that was my wake-up call.

1:51:52Dr. Gabrielle Lyon:And what are you doing about it? So I had to actually beg my gynecologist to start me on hormones. I said, listen, I've had the IUD for years. I have no clue what my ovulatory status is, but I wanna start on estradiol. I need to throw everything in the kitchen sink at my bones because I am 39 years old. And she's like, okay, well, yeah, I guess we can do that. Okay, so we started on estradiol. And I said, and I would also like to be started on testosterone because there is data to support that that will also help with bone density. And obviously, it's a musculoskeletal unit. The stronger our muscles, the stronger our bones.

1:52:28And she said, well, that's just not part of the guidelines. I said, F the guidelines. So I got the testosterone elsewhere. you know but it's crazy that myself in health care as what i would consider myself an expert in hormone replacement therapy and in bone and muscle health that not even i could advocate for myself to get what i thought i needed because the guidelines didn't say it and you and i know the guidelines are often 10 20 30 years behind what we're actually seeing in clinical practice

1:53:02Dr. Gabrielle Lyon:What do you want people to know? What do you want to see? For example, to protect your bones, we need, and I know that we don't have this number, estrogen to be 75 in the blood. And there's various, this is just an example, there's various ways that someone could measure it in terms of the metric units. But what, as a physician who is an expert, and obviously your sister is an expert, you didn't have answers. And this one thing can change the trajectory of your life, your survivability. Where do you, where do we go? What do you want? I think one of the biggest things is education, right? We have to educate ourselves.

1:53:55And this is where podcasts and platforms like yours are extremely helpful, right? Because you are educating the larger population on the metrics that matter, on muscle-centric medicine. You always say muscle is the longevity organ, and I was never taught that in medical training or in fellowship or in the first four years of my career. I learned it because in my clinical practice, I was looking at the data and I was saying something doesn't make sense and things are not lining up, right? And what are we missing? Why are all these women at the age of 40 coming in with osteopenia, right? It's because no one had that foundational conversation when they were in their teens, right?

1:54:40These conversations weren't coming up in pediatrics and they weren't coming up in their twenties or thirties. So we're picking it up and we're being more reactive than proactive. The nice thing is these things don't have to be super complicated or expensive, but it requires education. Through platforms like yours, it's talking about what are the metrics that matter. Muscle and bone, they are longevity organs, right? We know that patients with osteoporosis have worsening brain function and cognitive ability. So it's not just about having that six pack or being able to do a heavy bicep curl or 20 push-ups.

1:55:16it literally affects our health span and lifespan. So I think it's reforming or rephrasing the conversation on what matters, not just getting people on an old school scale, right? I don't care when people say, what is my ideal body weight? I tell them, I don't really know what that is, right? But if you lose 10 pounds and it's eight pounds of muscle, you nor I are gonna be happy 10 pounds less, right? So it really goes back to what are you made of? and how are we going to improve your quality of life six, 10, 20, 40 years from now. And a big part of that is the musculoskeletal system.

1:55:57Dr. Gabrielle Lyon:Do you think we are going to get to a place where it's equal opportunity for muscle as an organ system from the healthcare provider standpoint? I'm not sure it's going to enter the typical healthcare scenario. I think where we're going to see it is in providers who are kind of going outside of the typical box and thinking more outside of the box, practices like my sister and I and yours, where we're able to practice medicine the way we think it should be done. We are evidence-based, but we're not bounded by guidelines, right? And we're having these conversations both in our clinic and our sterile white walls, but also out on these social media platforms where people are hearing about it.

1:56:39Now, the fascinating yet scary part is what we're seeing, especially in the hormone and the GLP-1 space, is now that the population, the public, is getting more educated, they are now advocating for themselves, and they're more aggressive at advocating for themselves. The people who need to be watching your podcast are not only the patients, they are the providers. And the problem is the providers who are against these things are never gonna watch your podcast because they've been in practice for decades, and they are not willing to change their practice because whatever they're doing is kind of still working for them.

1:57:11That's the problem. So now we have this big mismatch where we have patients advocating for themselves. They go to their provider, their provider's not up to date, and now they're being gaslit. And then patients are like, well, why am I going to go to a doctor? Because no one's listening to me anyways. That's where we, I think, can also improve.

1:57:28Dr. Gabrielle Lyon:The evolution has to come. Yeah. Because what's going to happen is we're going to go from an epidemic of obesity to one of sarcopenia. Yep. And we're going to accelerate the age. sarcopenia osteoporosis we're going to accelerate that earlier because these medications are available and then it begs the question beyond hormones and i'll say it this way beyond estrogen progesterone and testosterone are there other anabolic agents that we can use to treat muscle And I think there are, because they are doing clinical trials looking at myostatin antagonists and things like that, where I think those medications can be very powerful.

1:58:18My argument, though, would be if you're not doing the resistance training to stimulate those contractile forces, I imagine you can have very large, beefy muscles. Whether or not those muscles actually can have the contractile forces you need to help prevent a fall is a whole other story.

1:58:36Dr. Gabrielle Lyon:You bring up a really good point. With obesity, you don't necessarily have to work for that. Meaning, in order to build strong muscles, there's only one way to get it. anabolic agents various other hormones various other selective androgen receptor modulators are not going to take away the fact that work has to be done and within that process of doing the work the body systemically becomes healthier yeah that is a really good point that it is medications they have to be there i mean it would be the same as saying well you're going to go lose weight and the way that you're going to do it is through diet and exercise.

1:59:20Dr. Gabrielle Lyon:And then people struggle and then people struggle and it affects their confidence, it affects all of these things. And then on the same hand, if we think about building muscle... The foundation is critical. You're not going to get away from doing the hard work. And no drug is going to change that? And no drug is going to change that. If we can get people to do meaningful practices, meaningful ways to lean into the harder thing, and then they have access to other anabolic agents just as they would have access to something to help them lose weight, this is what is going to have to happen otherwise right before our eyes as healthcare providers as fellowship trained healthcare providers we are watching the world trade one epidemic for another yeah yeah and it's a it's a multi-system approach right we can't just do one without the other it's kind of throwing everything at it i think you know a big way that we can harness technology because a lot of providers, right, who don't have their own practice, they get 15 minutes.

2:00:28So how the hell am I going to have a nuanced conversation on what are you eating in a typical day? What are your portions look like? What does your budget look like? Your family unit? What are your baseline gastro symptoms? Okay, let me educate you all about nutrition. Now let's start a GLP-1. How am I going to educate you on minimizing all these GI symptoms in a 15-minute visit, right? That is very overwhelming. And then, you know, one of the reasons why I left my prior practice is that I would have patients say, I'll see you next month. And I'd say, I'll see you back in six because I didn't have the access.

2:00:57So where technology, I think, can be very helpful is integrating wearable data, right? The metrics that matter, whether that's at-home bioimpedance testing, heart rate, blood pressure, all of those different sensors, sleep. I use the Oura Ring all the time. Looking at step count. How can we integrate that data into other platforms? So I'm actually, I'm also a tech entrepreneur. I'm building out a nutrition platform called BiteMD where it's actually gonna harness all the things about GI health, nutritional intake, and GLP-1. So you're able to actually talk to an avatar. It's gonna pick up what you're eating without you having to track, okay, I'm eating chicken.

2:01:34It's gonna see you're eating chicken. It's gonna see how fast you're eating the chicken. It's gonna look at your emotional state while you're eating the chicken. Holy cow. Yeah, and then you're gonna say, okay, I just did my Zet-bound injection, 12.5 milligrams. I'm feeling kind of nauseous. It's gonna start to pull up these patterns And it's going to say, okay, it looks like you're nauseated because you ate barbecue chicken at 8 o 'clock at night, then you went to bed at 10. So how about the next time you do your injection, why don't we have a lighter dinner and eat it at 6 instead of 10? So I think it's using technology to fill in the gap of that nutritional coach where we know we're not going to find that in most healthcare systems.

2:02:11Dr.

2:02:12Dr. Gabrielle Lyon:Michelle Perlman, not only are you an extraordinary physician, but now tech entrepreneur, it is physicians like you that really can help shift the way our culture sees medicine. Thank you so much. Thank you so much for having me.