#458: Fat loss or weight loss? The number one GLP-1 question

0:00Welcome to LTE Podcast. How are you, man? Thank you for having me. You're very welcome. It's been a long time coming, hasn't it? We connected on dad life being absolute chaos, robbing us of sleep and time in a beautiful way. But similarly, not great for the lifestyle medicine side of things in terms of our own probably performance in life. And I know that this is a huge part of what you do as a lifestyle medic, sports and exercise science, strength and conditioning. These are all things that you're part of. And obviously what you do now, boy, it's an absolute pleasure to have you, man. And so it'd be great to hear your story.

0:42So where does this all start for you? So I guess best place to start is that I didn't want to be a doctor. Oh, really? When I first started, this is back during secondary school, primary school. never I think Asian thing most terrible stereotypical thing absolutely not for me but then I Did one of these like you know these aptitude type tests and they're like actually be quite good at it Ah, and then I was like and I did some work experience and I was like wow Actually, this is quite cool. And so I was like one of these reluctant people of I didn't want to have this label But I accidentally earned it And then I went through medical school and it was like okay I don't want to be a GP absolutely everyone's a GP I don't want to do that but then I meandered through and I realized that actually I want to be a surgeon but then oh wait I like talking to people and you know your patients are asleep I really liked working with children but I realized actually some of the ethical decisions of that it becomes really tricky and then I realized actually I want to be in charge of my own life I have some autonomy and general practice was the way and I really like keeping well people well and that's just something you can't really do in any other sphere of medicine.

1:54It doesn't feel like that and it's just really resonated with me in that sense. Nice so you did some interesting things though as a GP where does lifestyle medicine start to come in? So it's one of these things that I think has got a really nice branding and like a nice package on lifestyle medicine it sounds so like. And you realize that actually it's something most of us as doctors, we just want to keep, you know, practice basics of changing your behavior from really like grassroots level. And I think it's great that we now have that label and it's an umbrella that we can, and there's a society we can be part of, people can do a diploma in it, and it is brilliant.

2:38But it's actually something a lot of us really love, and particularly in the general practice sphere and primary care sphere. I was quite really fortunate that I was working in Hearts and West Exics at a time when they had funding. And there was an ICB, which now has been merged with somewhere else. And I thought, oh, there's some funding. Let me apply to do a fellowship. And at that time, there was a team doing a lifestyle medicine fellowship. And I was like, this is incredible. Ironically, at the same time, the Tier 2 and Tier 3 weight management services had been cut in that area. So that was a really weird time to be doing that same sort of role.

3:12And this was geared towards something much more specialist. But as part of that team, we were able to develop like a whole course where we can train the trainers, train patients in terms of understanding. And you showed that actually there's some outcomes in terms of how we can actually improve lifestyle. It's called the Living Well course. I really loved it because actually you just got that understanding that there's so much more we can do than just prescribe things. And you don't want to start prescribing exercise or prescribing a diet. It feels a bit cringy. but actually one sense is just trying to at least get it on the table that people think about it as something that they can do.

3:49Yeah. So I think this is fascinating because, I mean, correct me if I'm wrong, there's no Royal College of Lifestyle Medicine. it's in this zone where at the minute it's complete and utter common sense that we need specialist physicians in 2026 to actually shine a light on this and help with this it's very clear to us and seems very obvious we know as medics that prevention is better than cure we know just as people interested in our health we know that we want to stay as healthy as possible but I guess it's never really had a home in medicine has it like it's never really it's never really felt right it's sort of in our lifetimes as clinicians it's sort of become something that has got more of a life of its own because we were just taught hey here's a disease here's a drug that treats it here's a condition here's a surgery that treats it and that was how we saw treatment and and cure as those things and and prevention I can't think of a single prevention lecture we had at med school or anything like that and so i i actually remember i um so i wanted to do public health at one point and i had in my mind that i wanted to be a professor of preventative health and i wanted to be like the first professor of preventative health because i just felt that surely we should be doing more of that stuff so it's always sort of been with me in in a part of part of my mind and if i had my time again i'd be i was going to say i don't want interview you but that seems like a really good it would have been a great idea it would have been a great idea but i've said this so many times like if i had my time again i'd have been a gp because everything i wanted to achieve would have been so much easier like if i just become a gp um and it was quick in that day as well you could have done it in three years but anyway all of that is to say i'm interested in like where lifestyle medicine sits as a specialty in inverted commas and like where you sort of perceive it and and what infrastructure in inverted commas are there more lifestyle medics are there i i know i know a few i i don't know where you guys centralize and and all of that sort of stuff so can you tell me like where that sits in uk healthcare and yeah where it might be going i can say from my own experience understanding there is the british society of lifestyle medicine that is like the like the flagship place they have a conference and they have a team and a whole committee and they're doing lots of things to do with education in that space.

6:20There's also, I mean, Brungan Chatterjee and his team in terms of, they've got a course called Prescribing Lifestyle Medicine, so PLM. Interesting. And they also have their own slightly different course. And that's also very similar and also slightly different in the terms of approach. As you can imagine, the main things being diet, exercise, sleep, stress. It's common in both of those, but the way they approach it, the way they package it maybe slightly different. And I think what the education does and CPD does for people is it gives them more confidence so they can talk about it. Interesting.

6:58And that's what my experience is. And speaking to people that have gone through the course and peers that have gone through the course and actually gone, I've done the PLM, the online short course. And I realized that actually people get to the end of it and then it's like that, what now? Because your day-to-day general practice, and this is what I struggled with, is actually most people are not coming to try and prevent an illness. Interesting. And they're coming because they're slightly broken, or they're broken in with a shopping list of problems. And that's really hard, because you don't...

7:31How do you bring that in? Yeah. But actually, those skills and those soft skills can be really transformative. Yeah. And arguably, those patients that you have no idea what to do with them. If you can go back to those grassroots or those foundational skills, my mentors that practice that, those ones are really trying to emulate. They do that so well. That's so interesting. So give me some practical examples then of how that has changed your practice. So let's say, I mean, you've been doing this a long time. some you know maybe there isn't a before situation but how would conventionally someone be treated treated for something versus how might someone in lifestyle medicine go about it differently can you point to the difference between those two things so i guess a good example would be someone who hasn't had their bloods done in a long period of time and then they come in and they think okay I'm 40 plus let me have an NHS well person check and they get their cholesterol done their sugars done and they realize okay well, they're pre-diabetic their cholesterol is high and the way person who's got some extra training in lifestyle medicine was just someone who is actually the training is less important It's just thinking in that regard is Rather than just thinking okay, we're gonna get your bloods done in a year And if it's no better just do here's a statin for you, here's some metformin for you, is think about it in a much more, how are you going to change your diet?

9:01What steps are you going to do? How are we going to improve your HDL? How are we going to improve your LDL? Like, have you thought about your sugars? All those potatoes you're eating, in my case, they're really causing some real issues in your blood sugars. And actually, it's meaning that you're eating a bag of sugar, even though it's a bag of chips it's different but it's all the same so it's actually like and giving to that i mean giving patients that in a really digestible way because it's really easy to just in that 10 minutes or if you're lucky if you work in practice maybe that's 15 minutes 12 minutes people are trying to move across to that model but things can feel really rushed yeah so what i'm getting there so it's actually in part it's like a permission and a confidence thing as a clinician to actually be talking about it in the right way and coaching people through it as well and the how isn't it yeah so it is it's not you just feel it by out the door it's that sort of okay how can we check in with you can we give you some tools and a lot a lot of practices now through um ars funding have health coaches that work on site and the way that money's been used differently according to region but i've worked practices that have that and actually you can start that journey with someone and then you can have someone who maybe has a bit more time and the time isn't so like pressured to to see all the other things in the realm of health and undifferentiated health problems.

10:21And they can see, okay, this person has this specific issue with the alcohol, this specific issue with trying to cut smoking. Yeah, and they can handhold people through that much better. This is brilliant. I mean, is there an argument for this is what modern healthcare is? And is there not an argument that... Surely you go through something like this and you're like, hold on a minute, I think every single one of my colleagues would benefit from this training, right? Absolutely. But then arguably say, like, when you had your anesthetics background. Yeah. What there, right? But actually, I still know some anesthetists have done this.

10:56They just find it personally so interesting. When it's an education you do, the first person who benefits is you, right? And you've seen that. And I've done a few courses and stuff, but some of it's useful for my patients, but it's really interesting for me. Yeah. And I think that's the thing. As doctors, we love learning. Yeah. and so that's why we're constantly trying to churn like okay what next what next and it's really nice when that aligns in terms of your career goals your big why all these things but even if it doesn't at least you can learn to be a better yeah be a better person interesting what's your relationship with um obviously we're going to talk about everything else that you do and void all the rest of it but based on the fact you're a lifestyle medic what's your relationship with the prevention space at the moment and you know the necos of the world and you know the nhs health check as you say 40 plus doing a lot of what neco can do but neco obviously packing a jip very differently and selling it b2c in a much more kind of appealing way and i've also got the voice i've also got do health as well right yeah and everyone else doing this so much this is more of like a movement and there's so many people doing this now and and invite inviting the public in different ways to do this stuff that i'm interested in like what your is are there any contentions for you is there any is there any difficulty in you seeing it happen outside the nhs obviously you you're at void and so you clearly believe in it from that perspective so i'm just interested in your relationship with it with all of that in mind because i have i hold both hats so i still work in the general practice sphere as well.

12:37And if someone comes to me and they're, even if they're in their twenties and I'm not feeling quite right, I'd be like, let's do your bloods and have this weird conversation where I'm like, I'm pushing from my side. Have you thought about your cholesterol? They're like, no, why do I want to do my cholesterol? I'm only in my twenties. But actually, how do you know? We often do it when you're 40 plus the ship's held. Like if you can pick things up earlier, why didn't you do your baseline HbA1c? Why don't we see where sugars are? And for me, that's like, I love it. Because actually, and if a patient comes to me wanting that, even from a younger age, I'm really open to it.

13:09But I appreciate a lot of doctors aren't. And people don't see the investment of that 10-pound panel worth of blood tests then and how much you impact. And you're giving so much autonomy to the patient, giving them so much power to do something with that. Even if you don't coach them at all in that consultation, you've just given them a lot of information and a real kick up the backside to do something. should they find something and i think with commercializing preventative health care it's really like it's really tricky because businesses want to grow they're trying to find a way to have an annualized revenue and like what model they're going to choose how they're going to do that bloods is often the way um i think it's just really fascinating because there's so many interesting ways you can pick up health problems beyond just what the nhs do so i think it's just a great place to innovate and the markets obviously it's the whole of the uk could well this is it the expectations there for people that's that's what's changed people's expectations of what they want from health care has moved from i'm sick i'm ill i'm hurt i need health care to actually going i'm completely fine but i want a version of health care that keeps me completely fine and then comes the question of okay who pays for it and that's where this gray area of is it health care is it wellness is it is it preventative health care is it optimization of health and that's creating this gray area but it has as you say a market has people willing to pay for it and it's it's a strange one isn't it because i i see all the arguments and i've talked about them you know on stage here and all the rest of them about access and and this time the other and it's and it's all fair it's all fair and i know that as medics like we try and hold all of this we try and we try and come up with a solution ourselves and it's and it's so tricky because you've got all these people willing willing to pay and companies willing to build on the back of that and they're they're solving a problem for those people and actually those insights are then helping are then coming to health care proper things are moving forwards innovation is therefore happening downstream.

15:25It's just tricky to hold all of it together. And I know that the access conversation particularly is what I find tough of going, yeah, it's all right for people to pay for it. And you're like, yeah, it is. Is it the fault of those companies? No. So can I simultaneously be working on widening access? Yes. And so that's how I kind of hold it in my mind of, okay, I can be supportive over here to these companies that are that are helping and and you know helping us all learn i can do that to some extent as long as in my mind i'm also helping on the access side and that's kind of how i deal with it and that's why i imagine you still practice right and so how is your how often do you still practice it's one day a week so just keep my hand in it just so i can feel like i'm still part of it yeah but just going back to your original just point you just made is i just came off a call with my aunt just earlier this afternoon.

16:20And speaking to her, she's from the generation where they're not really assertive in what their health needs are. And I had this interesting conversation where it was like, you pay national insurance, you paid it for your entire life. Although you think it's free, you have paid for this, you've earned a right to ask the question, does your GP know? If they don't, do they know someone else who knows? And it's like actually giving people the power that actually they can push, they can ask. And we as doctors have to become more comfortable with maybe saying we don't know, maybe having to think about it from a slightly different angle.

16:58Each A &E visit costs hundreds, each hospital admission costs thousands. These people who are proactive and maybe their biological age, that's the thing, that's the buzz thing right now, right? Maybe it's 10 years less than their actual age, they never get to that point, you know, or maybe they don't need that admission, they don't need that. And later on, maybe 10, 20 years around down the line, that's a huge investment we're making these people. Yeah. So for me, it's like that motive, that keeps me alive. Do you know what? We did the preventative health event here a few weeks ago, and it was so interesting because in the sort of networking, chatty stuff afterwards, I was chatting to a few people about that would have been eligible for an NHS health check.

17:39And actually, one of the things that people were saying that I hadn't quite appreciated, actually, a reason that they hadn't been, they didn't want to bother the NHS. They were a healthy, relatively wealthy, all things considered that, you know, they've got some disposable income. They're healthy. They're relatively wealthy. They don't want to bother the NHS, which has got, you know, it would have been ages for them to get the appointment. But in their mind, they're like, well, there's other people trying to get these appointments. Why should me as a completely well person go and get a free wellness check when I could just pay a company to go and do it?

18:10And again, that just makes the whole thing more complex as well. Hold on a minute. You're right. We've paid our taxes and we do want that. But at the same time, they can afford this other thing. And by doing that, they kind of feel like they're doing the NHS a service and doing those people less fortunate a service by taking us out of the waiting list. So it's complex. It's messy. It's complex. It's messy. I really just don't want private health care to own preventative medicine just exclusively. And this is the thing. Yes. Because actually, there's no reason why it should. No. There's things that they can bring across from other parts of the world that are much more cutting edge.

18:50Maybe the NHS will sign off. But I still think that we should have at least our own offering. Yeah. NHS. I say we because I still feel part of it. I was going to call that out. You still said we. Yeah, I mean, I still I'd say probably like one day a week NHS, but 80 % of our week. Yeah. With Void, but I still say we to both. Yeah. Let's talk about the move to industry then. Obviously you're at Void now. Was that the first thing you did out of the NHS? Talk to me about the move, the move to industry. Yeah. I was really fortunate. I had some great mentors all throughout my life, but particularly when I was working in general practice.

19:25I was actually one of the people I used to locomatise practice. and he realized that my interests were beyond just seeing patients getting in and out the door and it's when you have people like that and willing to invest in you in that in their time because actually he had no reason to I wasn't even I wasn't working with him for him and I'd just do shifts periodically but he realized okay this person wants to do something more and so I would go through my work and I was feeling like my satisfaction personally with the system was just is become a bit of dysfunctional relationship. Best way I can describe it is I would have how many patient slots and I'd be like that supermarket attendant.

20:06Yeah. And the patient being that checkout item. Item. I don't know why I sounded so cockney there. Item that I'd be trying to get across in and out the door. I remember. Bing. Bing. Bing. And I'd feel uncomfortable. The patient knows. I mean, they have their guilt and maybe they have their shopping list And I might help some patients out with their second problem, their third problem. And I have to be really picky because otherwise, if I try and do that for every patient, then I'm going to be there till 8 o 'clock. And I also can't do that. It's not sustainable for me. And I realized that it just wasn't working for me.

20:42So I realized that at that point, I don't want to be like a salary GP and hold that as my hat forever. I want to do something a bit different. and that's when I started creating reopen my LinkedIn profile from about 10 years ago and I just realized that actually this is where if you want to do something different outside the NHS this is where you've got to exist yeah so I've invested some time in that and I realized over time applying to a few different things I was really fortunate Shaliza my first manager at then manual now for every brand she gave me a shot and the role was to do it was just called a men's health doctor and i found out in the interview itself it's a trt doctor because at that point like three four years ago just coming up to three years i'll be in october it was very new it's not something that anyone ever did my understanding is i would never do a test strong blood test if i was a gp i was like no i'm not going to do anything with this number you have to see your endocrinologist that that was my opinion at that time and it's it's fun how life does full circle on you yeah interesting just getting back to one thing that you said about your the the dysfunctional relationship that you ended up having because of your dissatisfaction with the system dude I remember this so well I used to say all the time I'm spread so thin I can't deliver the standard of care that I want to deliver and I think that's because I I remember GP and actually I don't know I I feel like this was wrong for me to do at the time because i didn't actually have the experience to to call this out properly yeah um but i i discounted gp because i hated the feeling that i was behind i'm always early for everything i hated the feeling of being late but it was every single patient so it wasn't just one instance of being late all day it was multiple instances and i had 15 20 minute appointments when I was an F2 doing GP and I still couldn't keep, I didn't, I just didn't like the feeling of being late.

22:48I hated the feeling that I had people in the waiting room that needed me. And it was, I felt like it was reflecting on me and it was like, I wasn't good enough to do this appointment short enough. Right. But I just hated that feeling so much that I actually genuinely, I discounted GP on that basis and didn't consider it again because of that. I actually now look back and i think that was really wrong because i think i could have like i think i could have been a good gp i think i could have got over that um but i i understand what you mean i hated the feeling of being spread too thin i couldn't deliver the right standard but that really upset me and it's not the system's fault either no it's not and i think we have to internally check ourselves to some extent because i still have colleagues who love it and they still don't mind they stay late they do their home visits they do all the things and they they they're so passionate about general practice but for me personally i realized that that wasn't my path and uh what my mentor said at that time was you need to create space in your week to be able to explore something new and so at that point the the job climate was such that i could local pretty much full time and then there's a point where i realized okay suddenly that the opportunities was really drying up really fast at that point just after covid and then i was like i need to find something fast and then i was almost at that point my run my runway so to speak of my little experiment to see i could do something else was running out and then yeah and then that opportunity manual came interesting let me just tell you a little story so yesterday um i was at a i was i was presenting at an event yesterday and i got there got there a little bit early and i was sat in the room that i was presenting it in and the person speaking before me was talking about advances in technology in primary care and they were talking about uh blood results specifically and they were talking about how with an automated system bloods that are normal will can get pushed straight to the patient if they're normal within certain things and it's observed and blah blah blah and safe and yeah you know taking all of that for for gospel um and there was a clinical director of a pcn there that had been doing this job a very long time and had been a gp a very long time and he stuck his hand up and just expressed how upset he was about that this is where we were because he he doesn't he does not care at the weekend he will spend his weekends and his bank holidays bringing patients telling them that their blood results are okay because he wants continuity of care because that's what his patients deserve and it was so interesting that i i was sat i was sat there just i felt bad for people presenting because because they were that yeah they were getting a hard time from the room but i'm sat there holding both beliefs going i get it i get it that that's the that's what we want but actually we're all spread so thin that we can't deliver the standard of care that we want to deliver so actually this is the kind of technology that we do need and people's expectations have changed and actually a big part of you know my generation and younger generations do just want that they don't actually care so much about the local gp giving them that stuff and so times are changing things are moving but it was so it was just such an interesting moment for me to kind of actually see those two things play out in colliding colliding yeah exactly the sort of romanticized view of what we want healthcare to be versus kind of what it has to be yeah but also the convenience install rest of it you're getting from that it was it was absolutely fascinating trt you went from position of not really knowing what it was and as a clinician being like that's the endocrinologist's job to where you are now yeah trt at the moment is fascinating because um there's legit people that need of course there's legit people there's legit uh times where people need uh testosterone replacement therapy yeah because their testosterone is low clinically and they are experiencing clinical uh issues because of it there's also loads of bro science and loads of i just want a raging trt because it affects how i perceive myself as a man or whatever because i'm going to go and brag about it down at the pub so i just want to actually start the beginning here yeah and go i am i'm genuinely one of those people actually that kind of doesn't really know what trt is at all yeah where to start actually i'm being like being real with you yeah um mark you know some of my friends will talk about it in whatsapp groups and i'm kind of pretending i know what it is yeah and i'm like i feel like i'm the doctor in that group so i should kind of know a lot more than i do yeah um but i don't if i'm honest i don't know what a normal what testosterone numbers should be.

27:42I don't know what mine is. I know somewhat of the symptoms of low testosterone because I get it fed to me on Instagram. But I'm super interested, man. If you start at the beginning about TRT, tell me all about it. In a nutshell, it's replacing testosterone in someone who's got low testosterone to a normal level. So it's not like we're giving someone more than what they need. It's just going back to, let's say, in the same way you've got an underactive thyroid we're giving you thyroxine to get you back to normal. And I think that's like, in a nutshell, that's, if I could frame it, that would be it.

28:19What would cause it? So the most common things we see is age, obesity. Oh. Yeah, it's a big one. It's a really big one. Okay. And it has a bit of a dual and a bit of a catch-22 effect is with that as well. As you have more body fat, you end up converting more of your testosterone to estrogen and therefore and the symptoms are low t often for many people are low energy low motivation they've reduced muscle mass they're feeling like they can't live the life they want low you know loss of morning erections they're really struggling with feeling like their vigor and general quality of life is there but the reason why particularly in obesity can be quite challenging is because then you end up putting on more weight.

29:08Your sleep's not great. You're feeling like you're feeling tough. You want to go into bed by 5 p.m. You don't really want to play with your kids anymore. And these are the stories that when I first started, I remember thinking, I really, I'm not sure if I want to prescribe this. This feels a bit uncomfortable. Yeah. Okay. And once you start hearing this story from a patient of, you know, I'm feeling like this, I've been sitting on these symptoms for a long period of time. And then you do that first six week review with them, that three-month review of them that six month and this is something that we do regularly with patients and the thing i found really fascinating was was those patients in general practice which were in their 40s nothing's really changed not really got any other medical conditions they just and they're not they're exercising somewhat their sleep's okay like almost what they call like a midlife they almost like we're trying to diagnose with something and as a gp i would be hoping that i could get a vitamin d blood test or something that would show that they can do something yeah but sometimes i'd be like i don't really know what's going on they just feel they just feel rubbish they feel really flat and with those that man i would now be able to test him and if if he had low testosterone replacing that suddenly he's like i've got my life back i'm feeling like my old james again yeah and it's it's it's a it was like it's an incredible feeling to be on that journey with that patient because actually when you're assessing someone, you're not just, here's your blood marker, this is it, see you later, goodbye.

30:34It's very much, there's a lot of regulation involved. You have to have two separate blood tests done at specific times. There's a very extensive blood panel that is required. We go through a lot of symptoms in terms of physical, psychological, sexual nature, and we're going through that and explore that really deeply. And any of the doctors that we train on on board, one of the things I discuss with them is you should know this patient's life. You understand what their day-to-day looks like. And if you can understand that, then you can understand whether TRT is actually the right thing for them.

31:11And it's not just a crutch for something else. And I think the things we're trying to always look out for is the obvious things that are reversible causes and things that we always talk about in terms of diet, exercise, sleep, stress. And generally people don't have such like big nutrient deficiencies that that's a cause, but sometimes people have low vitamin D. Sometimes we're talking like they're going through a divorce or they're going through some significant life event, life quake. And that's not the person you need to just start TRT for, you know? Got it. And as we bonded over the fact that, you know, my sleep's still terrible.

31:51I've got a three and a two-year-old and yours is one. Yeah, 18 months. 18 months. So it's still not quite there yet, right? The reason why is that often with men, well, with men, so if you go back to med school, the female menstrual cycle is over the course of a month, 28-day period. And with men, the FSHLH, which in women is coming in the first part of the luteal phase and follicular phase rather than going to luteal phase, with men, it's every three hours, you're having this peak from this little pulsatile release from the pituitary gland. so and that large part that's done during your sleep cycle and particularly during your rems cycles as well so if you're not having quality sleep or if you're a shift worker yeah then these are these are sorts of things that are going to really impact your testosterone level because actually it's a circadian hormone in that sense that it's much higher in first thing in the morning and that's why men who have good quality testosterone they wake up with a morning erection normal and that's one of the first things we ask is are you having an erection anymore because that is one of the things that brian johnson seems to be obsessed with obsessed about yeah not that we should but it's also trying to break out this idea that men's health is just about erections and sex because otherwise it's a rightly so it gives it a bit of a bad name yeah and it's about actually quality of life it's like for me it's like helping that man who wants to play with his six-year-old son who wants to be able to be functional at work because he can at least concentrate.

33:22It doesn't feel like he's just spacing out and having this brain fog all the time. And I didn't really understand what brain fog was like on a day-to-day basis until I had patients tell me like they're in a meeting and then suddenly they don't really know why they're there or what they're talking about. And they have these like senior high functioning execs and suddenly just really off their game. Wow. And that, when you can help those people, you know, who've not got an obvious reversible thing, go through that change. It's incredible. Why would someone with a normal testosterone want to abuse TRT?

33:59So this is a tricky one. I think it's become really like glamorized in media. It really has. We, we've become really focused on not how we feel about how we look and this is this is a huge thing to do with medicine in general gop one space everything right now and unfortunately media adds to that plus plus plus and you know we have so much social media social media a few more pluses and we have to be so careful in terms of how we can safeguard that because if you're someone with a normal testosterone and you're supplementing that above normal, then you're then taking them into a supraphysiological state.

34:40And in those situations, then the risk of clots is higher. Interesting. Okay. But in a normal, in a patient where you normalize testosterone, interestingly, if you have low testosterone, your risk of heart disease is much higher. If you normalize that, that actually there's, there's emerging evidence that actually that could improve things. so the the research was originally such to prove that okay so is testosterone dangerous yes or no and we now can categorically say multiple trials actually testosterone safe when replaced to a normal level and then we're trying to understand does is low t dangerous and is does that affect your all-cause mortality yes it does and now we realize actually trt is safe but then i was going to the point where actually can you say it's actually beneficial and we're trying to move the evidence and the research needs to catch up with that.

35:30Got it. Yeah so it's a really dynamic space. That was a heck of a tangent from where you started at Voi but an incredibly useful one. What is the job now at Voi and tell me all about Voi. So for me personally I mean first of all let's start at the beginning. So Voi we used to do manual and people asked me like why like why like how many years on is founded in 2018 why is it suddenly just become something else and actually its success was actually ultimately a little bit of his downfall in the sense of manual being very much an iconic men's health brand got it and the issue being is that if you are doing that so well then you by its very nature are alienating half the population and i think um from what i can see from our salt and the vision on much higher level is that we We want to be a healthcare brand for all, through all stages of life and to keep people well.

36:24And that's, for me, that's why I really align with what we do there. And that's why we've transitioned to VOI. And that's why very much in terms of things we do is also hair loss, weight loss, TRT, menopause. We're doing skincare as part of a brand in Germany. Also recently, I've acquired a business in India as well. It does weight loss. So it's this really dynamic space. I was there when we had about 200 employees. And actually, this is back in 2023. It's not like a long, long time ago. But now we have like 700, 800 people. And maybe more. I don't know what with all the new data headcount is.

37:06And it's just growing and growing. And it's actually really fascinating to see where it will be. I really can't say it will be in a year's time, two years' time, because I think the ambitions are such that we want to be there through every step of the journey. And particularly now do health as well, which is a huge one to be able to, you know, and that's something which I was actually one of the cool things about working in healthcare in this sort of space, consumer healthcare, specifically is you get to try things before. And it's not that you're trying TRT, but you're trying, you're trying specifically, let's get my blood test done.

37:36I had my blood test done in a couple of days ago. And I was like, oh, this has got better. This has got worse, which is quite stressful. But I've got my bloods done in December. And some of the panels, there's things I've never checked as a GP. We don't have access to that test. Things like uric acid, homocysteine, things like something called HOMA-IR, which is like your risk of diabetes, for example. Which is really cool because I realized that, oh, geez, if I continue on this path I'm on right now, I've been consistently strength training for years yeah like three four days a week solid no problem but my diet was all over the place i wasn't really tracking what i do and i i just never wanted to and then the big change for me has been that okay i need to take responsibility i'm i'm preaching this am i really practicing it so now i feel like i can you know um go to uh a patient and say hey you know have you thought about tracking your calories.

38:30There's that famous story of Mahatma Gandhi. A woman comes up to him and she says, can you tell my son to give up sugar, give up sweets? He said, come back in two weeks. And then two weeks later, the woman comes with her son. Can you tell him to give up, swap his sweets? And he says, you should swap your sweets. You shouldn't take it anymore. And she's like, why didn't you tell me two weeks ago? And he's like, I was having lots of sweets of that time but i've given it up now you know and i think so it's so important that as you know health practitioners we've got to actually practice what we do it's so true it's so true man sure what comes to mind for me is um i have been through a very similar journey myself uh and it's funny when you're strength training through your 20s you can eat whatever you like you can eat whatever without any sort of visible issue you can eat whatever you like because if you're burning through thousands of calories well i tell you what i'm gonna replace those and we we probably were doing that at a similar time where it was it was all about protein and it was all about minimizing carbs and you sort of did that bit you didn't care about fiber that word hadn't even and no the the the sphere um and so yeah it was it was a strange diet i think that we had failing our ranking today but of course when you're you're probably not lifting as much or not as frequently especially then you're a dad and you're not doing as much but then the diet never changes nope so and that's the issue is that then when you when you settle into being our age and for me it was like i was drinking pints and pints of milk per day whole milk per day i was having like just in the middle of the day i just ah let me just have a couple of crumpets with loads of butter on them like all these things and i just have a massive bag of doritos and all of a sudden and you feel like I'm doing all of this, I'm doing far less exercise.

40:23These things catch up with you. They do. These things, your cholesterol doesn't lie. It doesn't lie. And as much as you can keep lifting, your bench press keeps going up or these things going up, that you cannot hide from that number. I could not lift my way out of cholesterol over whatever number it was. I'm not gonna say it out loud. So yes, that is the case. And certainly was the case. What is the job now at manual? So what is it? What's the job title? What do you do? What's day in the light? Yeah, so I'm a boy. Yeah, no, a boy. I'm a medical lead there. And what that involves is a really agile role.

40:54Because actually, in a sense, we're training up new doctors to learn how to be TRT doctors and clinicians themselves. And you have to own becoming an expert in a space that you previously didn't. And it does take some time. And we want people to feel confident and actually really own what they do, which is really fun. We look at things from an operational perspective. How can you make things safer? how can things make things more streamlined i'm i'm fascinated by things in terms of like external leadership as well like us talking about this today is really something i'm really passionate about um and actually just you know representing not only my personal value but voice personal values as well which is i think is a really cool thing um and that can go from that looking in terms of quality improvement so any given day is there's so many different things you can do clinical pathway is this the best treatment is this best way we can do it is this safest thing we can do and you know any given day i can't say any two days of the same and because you're liaising with so many different people as well and the team's growing yeah and we're trying to solve problems in more complex it's a complex problem anyway yeah healthcare yeah they make it digital they make it a problem that people were doing making a remote and added more layers and layers and layers but we still want to keep it safe we still want to keep a bit patient-centric we still want to uh keep people moving in the right direction and improve the experience whilst doing so yeah i got it so it's it's like a it's a it's a very addictive problem to try and solve um but for me it's uh i love the fact that no two days are the same and also no two weeks it's just i feel like okay something's just changed yeah another policy has just changed yeah and it's like if some people working in sort of healthcare space and of our new new doctors that join yeah they they find it a bit like whoa this is like like cap are you like this is too much and i'm like this is what you you complain the nhs moves at a glacial speed yeah be careful what you wish for and so that's one thing that i've become sort of a bit more comfortable with the uncomfortable yeah and our doctors have to to some extent we're trying to give them shelter them to some degree but actually uh it's different before i let you go man i'm i'm so i really enjoyed like listening to you about especially trt because you hold this nhs gp nhs medic you're you're you're one of us type thing you you hold that but then you also are navigating this through industry as well and you're obviously doing that through trt the other thing can i ask you about glp1s and weight loss and strength and conditioning you've got a history of this right because you you did sports and exercise science as well yeah at loughborough you you've done strength and conditioning stuff qualifications etc as well so this obviously it's been part of your life yeah and so you've got this i guess deep understanding of of that side of the world glp ones and weight loss is something voy does something voy does well absolutely and so you're you're involved in it to some extent there as well or at least at least alongside it there so where do you what's your opinion of what what on earth is going on in the world with all of glp ones and and and i'm particularly interested because of your background and where you where you see them a third of the world is overweight so unsurprisingly this this drug this intervention is like is revolutionizing healthcare yeah it's going to become its own thing it already is becoming its own category yeah yeah and everyone's chasing something related to it and trying to see the scope in which it can help people the difficulty is is that if we're in a world right now where people are chasing the look rather than how they feel and the aesthetics is the goal rather than actually what you can perform what you can do then the risk is is that you lose body weight you can do it really fast and actually the faster you lose body weight the more likely you are to lose all your muscle mass on the way and muscle is so important and it's not important so much now i mean yeah to some extent you can lift up your son and you can throw him up in the air no problem but it's gonna be really important for you and really important for me when i'm trying to piggyback both my girls both at the same time but in 10 years in 20 years and something that patient told me that really resonates with me is that how i look after myself now will affect the next 20 years yep and what we do now although glp1's absolutely transforming revolutionizing the space is doing that alongside like there has to be some sort of coaching there has to be some sort of understanding that you can't just do that in a cutting all the calories and in a protein deficit as well you just you know people are going to become emaciated you know and you're not trying to lose things as fast as possible people and unfortunately we complement each other so much on like how we look straight away you know i've lost maybe five kilos since december and i'm so it's curious so many people like cap you've lost so much weight and in myself i have to like check myself because it's like am i getting am i feeling some like dopamine in that compliment yeah you know and i know there's going to be a common point where like if you keep losing weight cap are you taking something and then there's this like hellish condition patients are in where they their health's not in a good space being overweight and because their joints hurt their back hurts they can't really haven't got any energy can't do the thing live the life they want and if they do something do an intervention to take a glp one they become criticized for that and and if they don't they're criticized for that it's like there's like a no win you know but i think for me like having this space alongside that coaching support alongside actually fat loss is the goal not just indiscriminate weight loss you know that for me has got to be the ultimate goal it's nice to hear man it's nice to hear that um you know medical lead at a place in industry is thinking that way because i think one of the things that obviously we worry about in healthcare is the kind of demand-led prescribing, I guess you could call it.