Dr. Rekha Kumar on GLP-1s, Metabolic Health, and the Power of Personalized Weight Care

29:37So I think that there's a lot of, you know, people are getting these meds in all sorts of ways, taking forms that we don't always know about because people want to get healthy and stay healthy. There are many people that would benefit from these meds that don't meet the textbook criteria to get coverage. And in the United States, what is unique is we have employer-based health insurance. So what determines our health coverage is whether our HR benefits manager has opted in to cover these. And for small companies, small businesses, they can't afford to. For large employers, they can. And so, again, it's this health disparities issue.

30:20But why are they so expensive? Like it's like$1 ,000 a month or something like that? Yeah, I think this is one of the biggest concerns with these meds. And it's really a policy problem where in the United States, these medicines are very expensive, like a thousand dollars a month. They are maybe, you know, a tenth to the cost in other countries. And there was a congressional hearing on this, actually, kind of grilling the pharma executives on why these drugs cost this. And their response was that they put billions of dollars into the research and development of these drugs that they have to make back.

31:01I would say that if they lowered the price and could treat more people, they would still make as much money, I would think. I mean, I'm not a health economist, but - It makes sense, right? I mean, there's certainly the demand. And there's the need. And if we're finding all these new indications for it, and one of the reluctancies to cover the meds is that people need to be on them long term. So everyone is like, well, we can't cover this. We can't afford it because people have to take it their whole life. It's possible that if we started preventatively and early, that if anyone has a chance of getting off these meds, it would be people that we start earlier on it.

31:35Is there such a thing as GLP-1 resistance, like people starting it and not losing weight? Yep. So I would call them non-responders. I wouldn't say it's GLP-1 resistance because GLP-1 is a hormone we naturally make. So perhaps they have GLP-1 resistance. That's actually an interesting way to say it. But in terms of the drug category, I would say that there are non-responders. As the drugs have gotten better, the percentage of patients that don't respond is less and less. So right now, like the gold standard medicine is Munjaro or ZepBound. And if you look at who in the clinical trial achieves 5 % loss of total body weight or greater, it's 90 % of people.

32:19But that's 10 % of the US population is still 33 million people that aren't responding. So we need many drugs that work in many ways to help those people. You know, it's funny because obviously, I think there have been a few times throughout history where a class of drugs have come out and everyone is like, this is the miracle drug like statins, which apparently really aren't that effective. And I can think of a few other examples, but this certainly in my lifetime has been the class of drugs that's been sort of touted as being able to do everything from lowering BMI to significant inflammation, et cetera, et cetera.

33:01Are there also concerns about the long-term impacts or side effects of these drugs that we should be aware of? So we should always be asking that question when we're putting things in our body. What people don't realize when they're very skeptical of this class and the long-term side effects is that we have been prescribing these meds for 20 years with about 40 years of research. Again, that's not a hundred years. So we need to keep our eye on these things. We should make sure that we're prescribing appropriately and people aren't just like liberally, you know, getting these off of the internet without any oversight.

33:43So although they are being touted as miracle drugs, I agree with you. I think we need to continue to look at safety signals and things as the years go on. But as of right now, there are no new concerns in the post-marketing analyses. Interesting. So, you know, I think, well, I guess I'll ask it this way. What are the multifactorial other ways that we need to be addressing metabolic health, right? So if we are, say for somebody who meets the criteria for GLP-1, you know, at found, for example, you're looking at things from in a multifactorial way. So what are the what are the other things that we need to be doing for true health span around weight loss and metabolic health?

34:40So something we would care about at found is that patients aren't just there for a prescription. Are they engaging with the health coach? Are they engaging with the app? Are they, you know, logging their fitness and activity? Because found does not want to just be a, dispenser of drugs and prescriptions. That's not the point. And so I would say one of the ways to ensure we're doing this correctly is to make sure that people are engaging in other ways and that they are actually coming to see the doctor if they're getting a prescription and being evaluated and all of those other important things are being addressed, sleep, exercise, stress, hydration, alcohol intake.

35:18I know in my practice that if this office staff notices that someone has requested GLP-1s for several months and hasn't been seen, they say, we can't fill this prescription. You need to see the doctor. Which I think is very, like, obviously highly responsible. And in terms of, like, long-term sustainability, what do you recommend? I mean, you hear a lot about, especially, you know, people losing weight in general, not only GLP-1 assisted, but really needing to focus on protein intake and lifting heavy weights. Is that all part of the philosophy? It's all part of the philosophy. It's a way to keep your metabolism high despite weight loss.

36:01So one of the things that happens when people lose weight that make it so hard to keep weight off is that metabolism slows. So that means when someone loses weight, in order to keep that weight off, they need to eat less and exercise more, which is very difficult for people because they're hungry. And it's like holding your breath. It's like you can hold your breath for a period of time, but eventually your biology wins. And that's why people that are chronic dieters always feel like they fail because they eventually give in and eat because restricting your calories like that is so difficult. And so one of the ways to counteract that metabolic slowing is by having lots of muscle.

36:43And as we get older, we lose muscle. And I know there's so much discussion in like the women's health literature these days about perimenopause and menopause and muscle loss there. So especially for women, I think we need to work on building muscle and maintaining muscle, whether we're on a weight journey or not, but essential for a weight journey. Right. Because I mean, certainly for me, you know, my I've no I've there's been a marked decrease in my metabolism, you know, as I've gone into perimenopause. And, you know, I was one of those assholes that could eat like a cheeseburger and like, and it would make no difference.

37:21And now it's like, if I do that, it's like, I've gained six pounds, and I can't get it off, you know? Yes. Can I tell you when I was a young doctor and was like a 30 year old doctor and my patients would say to me, Dr. Kumar, just wait and see, like when you turn 30, like these things are going to happen to you. And although I was like, you know, empathetic and helping them on their health journeys, in my mind, I was like, well, I exercise, I do everything right. And I, I, but literally like early to mid forties, I'm like, oh my gosh, like you could do everything right. And it feels like your body is against you.

37:56Yeah. And I think that's what's sort of the harder part, you know, and it's not only about aging, but it's about like anybody struggling with their metabolism or their metabolic health is that it can just be so demoralizing. You know, sometimes your body will just kind of change course or take over or get on a different time. And it's like you're beholden to these, I don't know, endocrine changes. And you just find yourself, you know, like no matter what you do, that's the part that's so hard, right? Whether it's like, OK, I can't lose the 10 pounds that I want to lose or at this age or I can't lose the last, you know, X amount of pounds after having my baby, or I'm just always been resistant to losing weight.

38:42Like it can be a very demoralizing thing, especially again, like we live in this culture that sort of prizes this certain shape and we're all inculcated with this very, you know, prescribed idea of what we're supposed to look like. And then social media compounds it. And so I don't know, for me personally, I've just, I've been trying to find a little bit ease around, you know, okay, my metabolism is different. Like here are the things that I can do to, to help. Right. And it is, it's like eat, I eat so much fucking protein. It's like, I want to gag. I never want to eat protein again. I never liked lifting heavy weights.

39:22I'm trying to do all this stuff and it's still hard, right? It's not like perfect. Yeah. Yeah. I saw this meme on Instagram, which was like a, I don't know, 40 something year old woman that was wearing baggy jeans and a weighted vest. And it was basically like, if you are trying to wear baggy jeans, like a teenager eating protein and creatine all day and wearing a weighted vest, welcome to middle age bitches. And I'm like, I'm, and I showed it to my husband and he goes, Rika, you're doing all four of those. I know. Oh my God. Me too. Me, me, me too. I mean, because I talk to people about this stuff all day, I do think that there's some amount of acceptance that we need to have that our bodies change.

40:04Like we're not necessarily meant to reverse or treat every sign of aging and metabolic change. There are parts that come with healthy aging and, and then there are parts that are making us prone to disease. So I think that like, personally, I would encourage people to be accepting of the 10 extra pounds that come after children and perimenopause, assuming they're healthy, and rather than taking a medicine for that. It's one thing if you're 30 pounds, gain 30 pounds and develop prediabetes, but we always have to weigh the risks and benefits of taking medicine to reverse something that is potentially a normal part of aging.

40:56so I guess that that that leads me to another question I'm curious about which is so taking these class of of drugs for that kind of vanity right it's like I have so many friends who are like I'm just doing it to lose the 10 pounds or the eight pounds I'm like really for eight pounds so what is the sort of general thinking around that and is that safe I mean I see this all day and you're in LA and I'm in New York, it's hard to see a group of friends or people where there's people aren't doing this. My feeling on that is that they're probably never going to be satisfied, right? Like if you're willing to take that risk for eight pounds or like, because there is a risk involved, right?

41:46There's always a risk, but what has become a little bit challenging is that these meds are very safe. And so people are willing to take whatever risk there is. But unless you like see or experience a side effect, which could be very serious, we see people end up in the emergency room all the time, severe nausea, vomiting, dehydration. I personally don't want to take that risk, but for vanity weight, but for some people, Their mental health is so tied to their weight. And we should probably try to fix that in other ways that aren't GLP ones. But that is a bigger problem. Yeah. So what do you recommend, you know, like it found, for example, with your patients when you see somebody who is emotionally eating or is so incredibly hard on themselves and has that perfectionism thing, which I recover from, try to recover from.

42:46What are the ways that you help people or suggest that people address that? So I think if we find that there's truly an emotional, psychological component that is morphed into a body dysmorphia aspect of things, I would never try to tackle this on my own as an endocrinologist. I would always want a psychiatrist and a therapist helping me, I would address the health and metabolic part, but I would want to make sure that in this process that we are managing expectations of what a healthy person, a healthy woman and a healthy man should be that something that's happening with these meds along the way is that people are, are developing body dysmorphia, they get to a healthy weight for them, and then they want more.

43:36Can I can you raise the dose? Like, can you, I don't want to feel hungry at all. And those are not healthy behaviors. And so when we see things like that, I think a good doctor should really say, hey, I'm, you know, I'm concerned that we are, you know, going in the wrong direction. And something I do when I meet people is I always write down what they tell me their healthy adult weight is. Because then when we get there, I always point it out. Because now when we get there, people are like, well, five more pounds, 10 more pounds. And I'm like, that was never a weight you were meant to be in your adult life.

44:12Like, why are we forcing it with medicine? How do you help people point to that weight? Because that can be so subjective too. So do you just say like, what was the weight you felt the best or looked the best or how? Yeah, it's very tricky. And I always preface the question with you may not know the answer to this question, but what do you think is your healthy adult weight? And by that, I mean a weight that you felt good in your body. You didn't have medical problems. No doctor was telling you that you had high blood pressure or high blood sugar. And many of my patients will say, I'm so disordered and I've had so many issues with body image that I can't give you that answer.

44:49And in that case, I'll say, OK, let's start this together. Let's see where we get and where the natural plateaus are, which are assigned to us that your brain wants to just readjust to a new weight and we'll take it step by step. Is there kind of a spectrum of healthy weight? Like, you know, at what point can you have more weight on you than you would like to have, but you're still healthy? So I think that's entirely possible from a little bit of weight and to, for some people, actually a lot of weight extra and they could be healthy. And that's why BMI sucks and that people are getting rid of it because Arnold Schwarzenegger at his peak bodybuilding health had a body mass index that fell into class one obesity.

45:33He had 8 % body fat. So these things are not perfect, right? And people can carry extra fat and still be healthy. But that's also why it's important to like, know your numbers, go to the doctor, get a blood test. Because there are also lean people that are unhealthy. Right, right. Those would be around, you know, like I hear, for example, this, I've heard this phrase like skinny fat that you're, you're, you look thin, but you're, what does that mean, by the way? Yeah, that's fascinating. And I think we're going to start seeing more skinny fat amongst the women that are inappropriate or men inappropriately using the GLP one.

46:12So people that are like really just recreationally using the drugs to suppress their appetite without getting the protein and exercise. I think they're becoming skinny fat. So basically skinny fat is like a body composition where they look thin from the outside, but what they're actually made of is more fat than muscle. So like that visceral fat. It could be visceral fat. It could, yeah, it could be even the other kind of fat, but it's like skin and bones, no muscle, and that's not healthy. Right. Okay. So I have another question for you. Another one of my best friends from growing up, I was with her recently and she was like, I just have this new surface fat everywhere.

46:53She's like, it's almost like I have kind of cellulite all over my body. It's like just, you know, it's sort of, if you can imagine it all just being pushed to the surface kind of what, what kind of fat is that and how can she address that? So I've heard people complain about this in my office. I don't actually think it's a kind of fat. I think it's aging skin. Oh, interesting. Right. And I think it's loss of collagen. Yeah. And so, and people fixate on it and they notice it and they, it looks cellulite-y, but I don't think that it's a different kind of fad. I think it's that the skin's losing its elasticity and looking less tight.

47:32And is there anything we can do about that? Probably out of my scope of expertise, but I'd imagine that just moisturizing hyaluronic acid, those kind of collagen, but it's not perfect. I think that that's also where some of the exceptions comes. Right.

47:55Is there any kind of correlation between gut health, microbiome balance and health and weight gain or loss? Yes. And it is a huge area of study that I think we'll learn more about in the future. We have learned that there are, if you look at lean metabolically healthy people versus people with obesity and obesity-related chronic disease, their gut microbiomes are different. There are species of bacteria in healthy, lean people's guts that are predominant that we don't see in the guts of, or we see lower populations of certain bacterial species in metabolically unhealthy people. And this has been seen in humans.

48:46It's been seen in rodents. And when This is like acromantia and stuff like that? Acromantia is one of them. There's a couple different families of bacteria, but acromantia has become the most known one with companies like Pendulum and things like that. Right, right. That's so interesting. So is that part of your work as well? Are you assessing overall health of microbiome and dysbiosis? And so I would say in terms of testing stool and making interventions, I just don't think that like there's clinically validated science yet to say, like, based on this stool, this is the probiotic you should take to be lean.

49:25So we're not. Will that come? I think it will come. And how what what do you think is the kind of time horizon for, you know, and obviously I have like I I'm just a layman who reads a lot and has a lot of curiosity about this stuff. You are not a lay woman. You know a lot. I mean, I just find it also interesting and I, you know, and I do hold this maybe highly naive belief that if you give the body the right conditions, like the body's pretty smart and can find center and reorient itself in a lot of ways. And so to me, the idea of, you know, being able to identify like a particular strain of probiotic that's able to impact metabolic health and, you know, in a more natural way than a pharmaceutical, like I just find that super compelling.

50:27Absolutely. And I think that, yes, and that that would be the less side effects and less risky and all of those things. And I think that would be the ideal scenario and that we should put more efforts at those things. I think we're starting to get there. Yeah. What about you? I'm curious about your own health. You know, you're an incredibly accomplished physician and mother. And so like, I'm just curious how you, I always love to know how, how women like you are kind of approaching your health. Do you have, you know, certain things that you do, certain rituals? Like, I'd love to know a little bit about how you approach your own health and longevity.

51:08Well, thank you. Thank you for asking that. I think it's a difficult balance. I'd say I've prioritized health and wellness, even through my medical training when I was working nights and, you know, 24 hour shifts, it was, I was somebody that, you know, the day after like a 24, 30 hour shift, I would literally like take a shower and sleep for six hours. Like I would basically be like, okay, this is my nighttime. And then I would like wake up and do something in the afternoon. I always prioritize sleep. Even when I was like working in an ICU, I would like bring my own pillow and like wash my face.

51:42And I think routines are important because I have two kids age 10 and 13. I really try to model like proper behavior rather than just like telling them, you know, what to do. So I think if children see their moms and dads exercising and prioritizing sleep and not drinking a lot of alcohol, that they will more naturally develop those patterns. So I really would say I practice what I preach and that I am very much a consistency over intensity person. I never run a marathon. I don't consider myself like super athletic, but I would say I'm fit and I like to get movement into my every day. I sadly have no secrets like doing all the stuff that we're supposed to do.

52:25I guess I'm doing the weighted vest and the baggy jeans and the protein. And mixing protein powder into your Greek yogurt. That's what I do. All of it. You just reminded me of a question. So I hear a lot, you know, it's a little bit confusing this exercise thing, like especially around high intensity exercise and that it actually deleteriously impacts our cortisol production, which makes us gain more weight. Like, can you, like how much exercise is the right amount? How much is the wrong amount? What, what is like, what, what classifies as H as hit? And like, what is that really? And I don't know if I'm doing that or not doing that.

53:08Yeah. And you don't have to do hit, but is hit bad for you? It is not bad for you, but it could be bad for certain people. I've seen men in my practice with pelvic stress fractures from orange theory. Like some people. Yeah. So I think we have to listen to our bodies. Like I, I did more hit when I was younger. I, and I'm not old, obviously I'm 44 and I, I don't do as much hit. I'm more like Pilates, weightlifting, walking with my weighted vest and, you know, that. But there are people whose joints and bodies can keep up better. I don't believe that you have to do the same thing at 50 as you did at 40 as you did at 30.

53:50Like there's some amount of just degenerative stuff in the body. But I would say in terms of like recommendations, the American College of Sports Medicine says 150 minutes of exercise a week total. So you could do that. But within a certain heart rate band and why do they say that certain HIIT classes make our cortisol production go haywire if we're older and that it actually makes us retain weight? Yeah, it's probably a little bit of a stretch. Yes, bouts of HIIT will increase your cortisol, but that's temporary. But if that same person that is like going to the HIIT class, getting the temporary bout of cortisol spike is also staying up until three in the morning, like irregular sleep patterns, then having an espresso at 5 a.m.

54:36It's not the hit that's causing their cortisol problem. It's like everything else. So people might blame it on the hit, but I would never attribute high cortisol and dysregulated cortisol just to hit. And so is more than 120 minutes not good for any like certain cohort of people? Not necessarily. I would say that's considered the minimum. Okay, that's the minimum. For people that have lost weight, they probably actually need a minimum of 300 minutes of exercise a week. So that's double somebody that has been generally the same weight their whole life. Because of the metabolism issue that you highlighted.

55:15Does it ever recalibrate? That's a no. I can read that face. That's a no. Okay. And I'll tell you that the way we learned that was the biggest loser study. If you remember the show, The Biggest Loser, where people were put into this like super intensive on TV nutrition exercise program. I never saw it, but I know. Yeah, I didn't watch it myself. But nine years later, a researcher named Kevin Hall at the NIH studied these people and what happened to their metabolisms years after. And even the ones that regain the weight, their metabolism stayed slower than where they started. So that was very discouraging to learn.

55:54And I remember my patients were so upset. And this was in the New York Times about like what happened to the biggest loser people. And I would say for me, it just reassured me that there was real biology and science going on there. And for some people, they need more than just diet and exercise. Right. Quick question. What percentage of your body weight is your weighted vest? Okay, let me do the math here. Calculator. Yeah. It's probably like, it's not high. It's like 8 % maybe. And I was thinking maybe I'm actually not being so smart because the backpack I carry like every day to the hospital might be heavier than the weighted vest that I deliberately try to walk with.

56:40But I think - No, because I think it's also the distribution of the weight is important too, that it's not only on the back. I think it's for multiple reasons if, you know, from my Peter Etia research. I agree with you. It's good for, like, I noticed I can't really slouch in the weighted vest. Right. Right. You're, it's, it's incredible for the posture, I think. Yeah. Yeah. Rucking, that's what it's called. Yeah. I guess, I guess in closing, like just when you look forward in your, into your kind of realm of, of practice, like what, what are you excited about in terms of anything that's coming down the Pike or any emerging research?

57:21Like, is there anything exciting? I think it's exciting that doctors are wanting to care about this. So for me, I actually do a decent amount of primary care. And I love combining primary care with like preventative metabolic health. Those aren't really like things that are, you know, it's not a field of medicine necessarily, but I hope more doctors do that and that people can seek out an internist that cares about prevention. And I And I do think that that's going to be emphasized more. Do you think like, I mean, not to be too cynical, but like how, you know, we were talking before around how expensive these class of drugs are, for example, and how, you know, that as one data point and then, you know, how the kind of industrialization of food, for lack of a better word is another data point.

58:15Like, how are we going to change these systems such that the patient doesn't bear the burden and the brunt of all of this, you know, capitalistic structure? We have to change so many pieces of it so the patient doesn't bear the brunt of it. I think it comes like how we plan cities, how we regulate what goes into food. Like, we can't just do one piece of it. It's not just medicine. It's not just the food supply. It's not just people not moving. And I think that local and federal governments probably need to step in and help people get healthier with the way they set up cities, the way they regulate food.

59:00So I think it's all of it. And we shouldn't rely on pharmaceuticals to fix everything. My dog agrees with you, apparently. Okay. Well, on that note, I'm so incredibly grateful to you for joining. I've learned so much today and this has been such a fascinating discussion. Thank you. It was so fun being here and getting to see you again. Yeah, absolutely. I hope I see you soon again.

59:30Thank you so much for tuning in to today's episode of the Goop podcast. I hope this conversation inspires you to prioritize your health in ways that bring you both joy and balance. Wishing all of you a year filled with wellness, happiness, and the confidence to care for yourself in meaningful ways. Thank you so much for listening and see you next time. This has been a presentation of Cadence 13 Studios. I hope you'll listen, follow, rate, and review all of our episodes, which are available for free on Apple Podcasts, Spotify, Odyssey, or wherever you get your podcasts. Thank you.