202. Metabolic Osteoarthritis: How Fat Tissue Talks to Your Joints

{"text":" Welcome to Medicine Redefined. I'm Dr. Altama Sharaja, and I'm Dr. Darsh Show. Let's put the help back in the healthcare. If you're a high performer who wants a clear plan for longevity, performance, and staying active with fewer setbacks, I'm now seeing patients through my telemedicine practice refining health and performance. I'm opening a limited number of founding member spots at refininghealthrx.com. All right, let's jump in. Is osteoarthritis a metabolic disease? What do you think? Now, I feel like we've touched on this in a previous episode, haven't we? Kind of, right away. Preferably. Yeah, we kind of said yes, but yes. Why do we say yes? Tell me this. Well, try to think of why it's metabolic disease at this current time. Yeah, so I think like, so we're trained on, let's say, in the medical institution primarily, is that OA is a structural disease, right? We think about the cartilage being lost. We think about the mechanics of it. We look at the x-ray findings and there's things to actual see, right? When we think metabolic disease, we don't always see structural disease, right? Those are always complications of it, but with metabolic disease, we look at the connection between maybe two organ systems, right? So in this case, maybe hormones from an endocrinology standpoint and osteoarthritis. And I think what, at least, what probably what we'll go down is the rabbit hole of how OA now is being seen also primarily as metabolic disease because of the hormonal changes. Of course, the papers we're going to be talking about include GLP1s and the effective weight loss on OA. And again, not necessarily from just the weight reduction standpoint, but also just from a metabolic standpoint. But that's, at least, if I can tell the audience, our understanding of how we get trained when we look at OA, even as physiatrist, but I think this is a new frontier and way of thinking about how to treat the disease. Yeah, I think that our biases looking at the whole system were both osteopaths by nature. We've talked about that before, as well as fitness oriented health first, right? Talk about health not being the absence of disease. We recognize that the system doesn't work in isolation. I didn't know these discussions, these murmurings, if you will, there was actually some evidence behind it. And had these conversations have been actually reported in literature for a long time. And so maybe I'll just set the stage. The precedent was set back in 2012. So there was this paper in Nature Reviews Germanology in 2012, Zowadael. They talked about metabolic syndrome. The title of paper actually is metabolic syndrome meets osteoarthritis. And what they proposed was that metabolic osteoarthritis is the fifth component of metabolic syndrome. So those who remember or don't remember metabolic syndrome. So you have central obesity, insulin resistant, dyslipidemia, hypertension. Those are like the four main arms. And so they said, hey, there's a component of arthritis as well in these people. And it's this quartet. And each quartet member has its own joint damaging right? And so we'll link this for people to read, but hypertension causes subcontract ischemia. So that's the bone underneath the cartilage. And we'll look at the knee. I think a lot of this literature is looking at the knee. When you start looking at other joints with the load bearing combined with the inflammatory metabolic component doesn't really pan out. And so we can talk about some of the limitations of this. But hypertension coming back to it causes subcontract ischemia. So that's a blood flow in that area. We've talked about how blood flow historically is a good thing. And so when you have, that's going to be damaging to the tissue. And dyslipidemia causes these ectopic lipid causes formation of ectopic lipid incontrocytes, which is problematic. Hyperglycemia, high blood glucose causes glycation. We've talked about advanced or glycation end products that cause problematic problem. Excuse me. And the obesity releases these cytokines in inflammatory cytokines. And so it's not just one mechanism they talked about. It's a convergence of all these mechanisms for metabolic syndrome that actually progress the disease burden and cause some structural issues too. So this idea that metabolism drive the subset of OA is 13 plus years old. What's new that in the last two to three years in 2024 to 26 is that we can now intervene from ecologically and watch how the job responds. And that's what I think has been more exciting. And actually, when I was even doing this literature, I think that in the literature review rather, people are even describing multiple phenotypes of osteoarthritis. So you listed a couple, but here's a little quiz moment for you. What would be some of the main phenotypes of osteoarthritis if you could describe for the listener? Maybe my phenotype. Because I'm like mild, mild, severe. Are you talking about what type of people present with? No, so when we think about it, it's got a sports room, right? So there is the classic, when you think wear and tear, what does that mean to you? That's more of an age-related process, right? Sure. It almost seems inevitable. Do you remember learning about the fact that when somebody has trauma, like a fracture or an ACL tear, a meniscus tear, accelerates arthritis. Sure. So we'll bucket that into post-traumatic arthritis. So if you've got the age-related senescence, you've got the post-traumatic arthritis. The other one, the one that you might center rheumatologist would be which one? Intoid arthritis or inflammatory. Yeah, inflammatory. Yeah, so we would put that into the inflammatory bucket. The other one is called the mechanical malalignment model. So we talked a little bit about this, Dr. Alison Grimalti, right? When somebody's got, maybe let's say they have a really wide pelvis. And they've got more knock knee presentation versus a bone-legged presentation. So that would be a malalignment. Those types of burnt stresses onto the knee joint is going to cause some more structural degradation in certain parts of the joint. There's this pain-central desensitization pathway, pain-sensitization dominant, either they say, where you don't, might necessarily have a lot of structural issues, but you might have a lot of a heavy symptom. And so this last phenotype is what we're going to talk about. It's called the, so I'm sort of the metabolic syndrome. Now, here's where the smoking gum gun came up for all this, right? So the clue that started breaking this whole purely mechanical idea is that we've noted over the last 15 years, maybe two decades, that obesity is modest, just strongly associated with hand-ostered arthritis. And not many people, so maybe some, are walking around their hands, right? So there's not a lot of load being dispersed with the hands. And so there's no way, why is there an excess or why is there an increased correlation with osteoarthritis? Because that backpack analogy, damaging the joint through load alone, it should have zero effect. Again, caveat, because initially when it started learning and reading about this, it was like, oh, maybe there's two to three times more likely to happen. And that's really not the case, because when you look at the observational studies, when you look at the Mendelian randomization studies, it's really an odds ratio of 1.21 versus 1.91, which is, okay, the odds are going to be 1.91 greater, right? And then I mean, for hip is a little bit less. And so some of this, I think, is even though it's modest, it's still debated. Got us thinking, okay, there must be something, because it's too weak to be a mechanical load only, but it's too real to be nothing. And there has to be somewhat of a systemic signal reaching a joint that carries no weight, like your hands. And that's what we're trying to fish out. Maybe now, I think, do you have anything to add to that? Or should I just get into the studies that actually incited this whole discussion here? Yeah, let's also get into it. I think that was a good preview of kind of what. Now to think about it away, yeah. And I'll talk a little bit more about mechanisms. If that's interesting to you, interesting to the audience. But I think that the two main studies for the drug evidence, so you talked about GLP1. So semi-glutide in particular, that's a govi ozemic, how people recognize it. This is the step nine trial. So this was published in the New England Journal Medicine in 2024. And what they looked at is the max dose of semi-glutide, 2.4 milligrams weekly, and given at 107 people, randomized control trial, lasted 68 weeks, so a little over a year. And the BMI cut off was 30, 81% female population, and the KL score. So that's the killer again, Lawrence school. I think I'm gonna get that right, KL. That stands for again. By the way, it's rating severity of osteoarthritis. So that's two to three. So moderate to somewhat severe arthritis. And what they wanted to look for is what's the percent weight change? And the Womac pain scores. So Womac is the Western Rantart O something arthritis. No, Western. I forget what it is. Look up Womac real quick. Womac pain scale. Yes, Western, Ontario, and McMastery universities. So serving you is that evaluate severity of hip and knee away, and ask specific question by your daily life, including pain stiffness, physical functioning. Essentially, it is checking what the disease burden is for osteoarthritis. What they found was between the treatment group, semi-glutide versus the placebo group, that was a 14.1 greater improvement in the treatment group. I think the treatment group has a school improvement of 41 points, something, versus I forget what the other one was. So 27 point, right? And so that exceeded the threshold of what they thought with them, minimally clinically important difference would be. And that's a pretty large clinical effect, right? The way change in the treatment group was 13.7%. And the placebo group was 3.2% less. And so, yeah, you had a meaningful weight reduction. And you had a meaningful improvement in your symptoms, right? The Womac scores as well. They had some secondary outcomes as well. They had something called the SF-36, which had also improved in favor of the treatment group. No, a couple of biases with this one, or caveats pointing. It was industry funded. So, Novan Ordersk, which is the company, had funded this, whatever that means to you, right? We always want to make sure that we're looking at that stuff. And you had this improvement, but I did point out the fact that there was substantial weight change, right? So it doesn't necessarily prove that the effect was because of some magical component of GLP1s, because, again, you could just say, hey, listen, you had a significant weight loss, and that's why these people did better, right? 13.7 versus 3.2%. So, this metabolic intervention, we know had a big clinical improvement, but why did it happen? Is it the drug, or is it, again, the backpack? All right. So, let's fast forward. So, that's the GLP1, right? The other study that I think is worth mentioning here, is the Pan et al. paper that was published in JAMA 2025. So, in this study, they looked at different drugs. Metformin, good old diabetes drug, right? Penies on the dollar at this point. So, they took a little smaller study. They took 107 people, randomized control trial, six months long. Here, they had the overweight population. So, the BMI cut up was 25 or greater, and you had to have symptomatic knee, okay? And they gave them 2,000 milligrams of metformin every single day. What they looked at is these things called the VS knee pain score. So, this is just your classic visual analog scale, your pain score, how much your pain improved. And what they noted was that there was an 11.4 millimeter difference. What's important, worth noting, what they thought to the MCID prior to the study with the mean clinically important difference would be 15 millimeters. And that didn't actually achieve that, but there was an improvement. Weight change, this is the important. Treatment group was negative 1.2 kilograms versus 1.2 kilograms. Really not much of a difference at all. So, the interesting thing here is that the treatment group had benefit despite no excess weight loss, right? So, no significant changes in weight loss. They also looked at the Wormack pain stiffness, function, quality of life, all these were unchanged and nothing got three months, but at six months, they did have a little bit of improvement. Have the outs here? This was a small study, right? A hundred and seven total people. A lot of that was via telemedicine, self-reporting, barely any significant secondary effect. So, I think big takeaway from this was that got a lot of people excited, was, hey, you can actually see some changes happen even though they're modest, but it can happen despite no changes in weight. So, there must be something with these prediabetes drugs, these diabetes drugs, these metabolic drugs, if you will, that are affecting the joint health, the joint milieu, in favor of improving disease burden. I will pause there to see what your takeaway is. And did you come across this? Because they definitely caused some headlines and a lot of my colleagues were sending it to me. So, I think one of them had pointed out that, hey, they're, she's seeing some of our colleagues or maybe patients talking about this. Is this something that's been your on your radar? No, this is, the first time I've heard of this is when you sent it to me. The only thing that I recently saw, it was on Instagram, it was funny, on Polymarket, the page about GLP1's and both mineral density loss, and how rapid weight loss is causing that. So, that was something that was going back by my mind as I was looking at these papers. As much as the GLP1 standpoint is, while we look at OA, and then we look at other phenotype when you talk about rapid bone loss and osteoporosis, again, we could talk about this coming up in terms of who are the best candidates when you look at these papers to really ask your doctor and say, is it beneficial for me to be able to do the GLP1 because, again, if you're a frail, elderly individual, then these papers may not exactly have the right idea from weight loss perspective, but for a minute again, it depends on kind of the goals. But for me, really, as I'm reading this, I've had people that have been talking to where colleagues, friends, who are in this position where they could make a benefit from a GLP1. They have arthritis, and they're asking me questions, and oftentimes we're looking at standard treatment, which is, I'd be profan, Tylenol, Abraise, Therapy, Corticosteroid injections, maybe PRP. So, these are the things that kind of get brought up to me, but to think about it from this standpoint, I think is really fascinating. Yeah, all those are amazing options, right? For somebody, I think I treat osteoarthritis probably more so than any other thing I treat in my practice. Everything that you're talking, I think, is looking at the symptom burden of the disease. I think this is still true, that knee osteoarthritis is the leading cause of disability worldwide, at this point, at least from a musculoskeletal standpoint. That might not, maybe not overall, but from a musculoskeletal standpoint, that's the number one. When somebody is filing for disability, symptoms is really the main thing for play they're going to have. And so, if you can modulate those symptoms with everything that you mentioned, and other options that we haven't covered, you're going to potentially improve their quality of light, which is the main thing that you and I care about, certainly in our practice, right? But then there is another way to look at something. Something could be disease modifying as well, something could be structurally modifying as well. So, disease modifying is what we're looking at here. Because certainly, step nine trial showed that symptoms has significantly improved, right? We've got a clear signal here that's happening. The question is if disease modifying, and if so, how is that happening? So, I think at this point, maybe we take a step back, right? And try to understand some of the ways how excess adiposity can be toxic to the joint. And why some of the arguments are being made. And why we should actually, I think, that really pay attention to this. So, the reality is that that is, adipose, particularly, is an endocrine and immune organ. We know this. We've talked about this, right? How it's communicating. And this way, it's just touching so many different things. So, the GLP ones, like not only do they have indication for diabetes and weight loss, but trizipotite is FDA approved for sleep apnea. And you, I think, one of them has level one data and FDA approval for a mash, right? Another one has cardio metabolic as well, heart failure. So, you're getting all these things because it turns out that metabolism seems to touch on multiple systems of the body. So, it's an endocrine and an immune organ. So, you have these things called adipocines, leptin, resistant, visfat, and in particular, they cause a lot of this condrocyte inflammation. Condrocytes are the cells of the cartilage. And they're going to increase this majorce-metalloprotinase activity, which is going to ultimately lead to degrading the cartilage. Insulin resistance, the other canary in the guanma. It's going to impair cartilage homeostasis, right? So, those advanced glycation end products that we talked about intended up, but they're either implicated as well. They tend to accumulate and are problematic for the joint because instead of going through oxidative phosphorylation, which is a more efficient mechanism energy production, we're going more through glycolysis, and that's more inefficient for your cartilage and your joint health. And then you have synovium, which is what the joints are bathing. So, you have the synovium through all of your joints and circulating. You'll have a lot of these M1 macrophage infiltration, which is going to cause IL-6. These are inflammatory cytokines, TNF alpha, MMP, matrix degradation, all that's going to happen. So, it's not just an autoimmune thing, like rheumatoid arthritis is, but it's also not inflammation-free. So, maybe this is one of the reasons why we'll say, oh, take NSAIDs for 10 days, let's kill the inflammation, when maybe there's a small component to that, but there's also the component that those are really good analgesics. But when somebody injures their knee, they might have some local swelling and stuff. So, you know, there is some inflammation happening. Now, NSAIDs, you brought it up, and I just brought it up again. There is a little bit of an interesting paradox, because if we say that always not in inflammatory, or we are saying if always in inflammatory, then why are NSAIDs not working better? Because it's the type of the local inflammation. So, it's not necessarily the way NSAIDs work with on your prostate gland in system. I'm not going to get too deep into the immune pathway here. But this is a different type of inflammation. So, this is coming from those adipocines, like I talked about, right? It's coming from the insulin resistance. What other interesting thing that I learned during this research here is half-as-fat fat. You familiar with this one? No, I've told you about it. I know half-as-fat fat, at least. Yeah. So, everybody, underneath your kneecap, that's the patella. It's called the infra-patella fat pad. So, you have the little tendon, if you're listening, and you're driving or something like that, you can feel underneath your kneecap. It's going to be this roby little structure. That's called your patella tendon. That's going to get hurt. Right underneath that, deeper to that layer, is a big fat, everybody has this, called half-as-fat pad or infra-patella fat pad. So, this is directly overlying your joint. And this actually turns out, is a local inflammatory source as well. So, just like you have, maybe central adiposity, you have visceral fat. That local fat is going to put a lot of those inflammatory cytokines and those, quote, unquote, bad cells, into the joint directly. And so, that's maybe another reason, why the knee, in particular, is subject to this metabolic ill-health system, and actually these medications tend to work better. So, that's one thought as well. The one thing I should say about the glucose piece, I know we've talked about the antenna knob, but when I came to, dig a little bit deeper into this, that the biology at the bench level is pretty real, but the human causality contribution, can't really be separated from body fat. And when you look at the RCTs, there's one thing you look rather to observational studies, that's one thing, but the Mendelian randomization studies will show that adiposity is the lead actor. And because even people who have elevated glucose, they've not had an elevated risk osteoarthritis burden. Does that make sense right there? Cool. Anything interesting there, anything that you've learned with the mechanism, specifically, exercise at aposity is problematic for joints? No, I think it makes sense to me. I think even for our listeners, I think as they listen, and they can relate it to themselves or their patients. To me, I don't know if you have more to go, but a lot of this, how does this affect the future? How does this affect practice in the future? But if you have more mechanisms right there, I'd go for it. I'm going to get to that. I promise I will. We want to make it actionable. I think more important than, as sexy as these things are, which, to be honest, the further I get into it, the more patients that treat, it's not that sexy. It's fun. It's exciting. And then the question is, one of my college room is used to say, and then what? I have information that's what we do on about this. But one thing I do want to plug in, because my buddy, Amek, I shout out to you if you're listening, he had sent this, right? So this isn't a paper that was published in Selma Tapasam. I think March this year, 2026, and to piggyback off of that step nine trial, looking at semiconductor, they wanted to see, hey, is it actually a weight dependent effect or weight independent effect? So what they did was, they had somewhat elegant mice study, but they took high-fat diet, obese mice, right? And they destabilized the needle miniscus. So the meat miniscus is the cartilage between the knee, it provides cushioning and stabilization of the knee, and resectated it, injured it, and the one side on the mice got weekly stomach lose hide, versus a control, and they were a pair-fat group. And so both of them had restricted food to try to get them to lose the same exact amount of weight, which they did. Now, what they noted was the mice with the semi-glutide versus the mice who did not get them medication, but still lost the same amount of weight, they had no meaningful cartilage protection. The semi-glutide mice did have that. So now, you've taken the weight out of the picture because both of them lost weight, right? So there's something happening here, where semi-glutide is causing, or offering some type of protection is what they think. How did they measure that, right? So they measured the cartilage loss and protection with micro CT, histology, and pain behavior testing as well. They went in a step further. Then they knocked out, so they knocked out the GLP-1 receptor gene, and what they noted was the effect was gone. So that's cool. Again, this is not human studies, but what it is able to show is that maybe that this medication, this medication, enough familiar if metformat has done something like that, but in observation of large trials, they've been able to pick up a similar signal. I think that kind of is really exciting, and that's the type of stuff that you need to get this pushing forward. Now, I know, no minor risk, and I think Eli Lilly has a register to try to call stop, Neostruth, and Neostruth, right? As well, that the register to try to really get indication, because right now, these medications are not FDA-approved for osteoarthritis. So it's not the medication that you're going in, because of osteoarthritis that should be on this medication, because they might be better medications out there. If you're going to use this medication, you want to think about, look, why are we doing it? And I guess maybe the question that maybe you're getting at is, who is the right person who we can identify that, hey, we got to look at that. So given everything that I've presented to you at this point, one, do you have any questions about this study? And then two, how would this change your practice? And how would you use this information to try to identify or profile that person, if I can use that word, who maybe this is a conversation for? Yeah, I guess, I think the questions the listeners might have is, do we know if osteoarthritis is reversible? So these medications are helping, and there's an inflammatory process that is disease-modifying. Are we able to then go back on the class patients? Can we go from the severe osteoarthritic knee joint to now moderate? Yeah. That's an unanswered question. We don't know that yet, right? So that would be the whole disease and structural modifying thing that we have to look at, because like we talked about is, yeah, you would have to look at this for long enough. We know that osteoarthritis is a progressive disease at this point. I tell people when they come in with osteoarthritis, and they're like, man, I got really bad away, and I say, hey, congratulations, they look at me. Really weird, I'm like, that means you've lived long enough to accumulate them. So there is an accumulation. It might not necessarily be wear and tear. There is some level wear and tear, but it might necessarily be all wear and tear, but it is a progressive, right? Processed, probably, as what we say about heart disease and hypertension, the number one risk factor is age. People in their 70s are more likely to have it in their 20s. But disease modifying is the interesting question which we have to ask. And I think this cell study, this mice study, is one piece of the puzzle. Metformin is similar. I think the one thing I didn't mention is, both of them are converging on the similar mechanism. And that mechanism is looking at AMPK, which is the AMP protein kinase. People have heard that, the MTOR pathway as well, and that's really how Metform is working. That part of the list sells. And GLP1 also is going mediated through the AMPK pathway as well. I think there is a conversation about the gut joint pathway, everything, as other people have said starts with the gut, right? As you would know. But really, its AMPK modulation is what's happening. You have some GLP, one receptors into the joint. So these questions, these studies, as recent as two months ago, are starting to put some information out there that we have to test a little bit more to see what's going on. Cool. This. So, go back there, try to figure out who the right patient is. That's the question now. For you. Given this information I give you, how would you think about, hey, should I consider this, where you would open the conversation? Yeah. So I think what's interesting again, is the first headline is, OA Metabolic Disease. So regardless of who has the OA, let's say they're elderly, sure we might think it's more age related, like you said. If they're younger, we put up a little bit more top of mind to make it okay. Especially if they have a higher BMI, they have an ASCVD risk, they've got things like fatty liver, they do show the side of the symptoms of metabolic syndrome. Is that something that we go and look for, right? That's also the question. So we're trained that you don't necessarily order something unless you're going to do something about it. And even when you do order something, sometimes you don't, because it can put you in trouble, because now you're responsible for kind of treating that, right? And I don't think a lot of patients understand that, but it's always a tough discussion. It's okay. The best way I explain it is getting a full body MRI, right? The reason why you don't do it is sometimes is you see something, you want to treat it, but in the end it's actually benign. And so that can go for all sorts of imaging from the back to the knee, and et cetera. That being said, does the astute physician now say, okay, you have knee OA? Should we go out and also look for things like fatty liver syndrome? Should we go out and get a lipid panel again if you haven't done it? Check your A1C. Do all these things that seem pretty standard, but actually do more of a little bit of a deep dive on it to see if metabolic syndrome in its totality kind of exists? Probably, yes. Like I would say, I think that I've changed up my documentation a little bit. And so there are certain people what I think that, like the idea of precision medicine, then subclassifying osteoarthritis is the big takeaway for me on this. And so certain people, which I can tell you, who I think I'm going to start labeling this for, is where I would say, oh, this patient probably has the METS dash away. It's a metabolic syndrome away. And either we already know that they have fatty liver disease, right? Or we know that they are prediabetic. We can see, and we know that they're dealing with exoscientiposity right there, and that could be waste, waste to height circumference. And those races we can look at, maybe they already have hypertension, those other metabolic symptoms that I talked about. And now we're diagnosing with osteoarthritis, which is either later, or we're seeing, actually, now that we're talking about it, I'm not sure that you can diagnose osteoarthritis and then go the other way, unless you have these other signals. Like somebody just comes in with osteoarthritis in isolation. And I think there would be one hint that would give that, right? And that would be, if somebody has osteoarthritis in multiple joints. Typically, when you hear somebody has osteoarthritis in multiple joints, what did medical students teach us? That's going to be the, what type of pattern that we talked about, the phenotypes. I know you love when I put you on the side. Yeah, I know, I'm like, we don't like it here, man. I don't think I'm dull with this. Well, you talk about bilateral, or just, you know, wrist bilateral. Okay, then, yeah, we're thinking to play a tutorial, right? Yeah, we're thinking to say, I think, yeah. What was interesting is, when, for our step one, and stuff like, oh, is, you know, if somebody comes in the morning and they're knee pain worsens throughout the day, it's more osteoarthritis. Somebody comes up, they have bilateral wrist, and like, that's, it's in temperature. So it's like, those are the two buckets. It's a fork in the road. And that's actually not the case here. The reason I say that is, if somebody just comes in with a unilateral knee away, then why would a metabolic component be only affecting them? But if somebody comes in with a little bit more of a, oh, man, my hands are a little bit achy, and both knees are aching, and two knees, and a hip and stuff like that. Okay. Yes, you could think about an inflammatory component, but there could be a metabolic component too, which we know is causing a little bit of inflammation, but different type of an inflammation, right? So within the inflammatory pathway, I suppose you could have another fork in the road. But now, especially, especially if all those, especially if a lot of the autoimmune stuff is negative, right? Which we see all the time. That's a brilliant thing. This is one of those things where, yeah, patients come up to, like, everything hurts, and I have, I'm guilty of this, right? Because I won't do this anymore. Well, I just try not to, is they'll come in, everything hurts. I'm like, you got to go see rheumatology. They go to rheumatology, and they get the full rheumatological workout. And what's interesting is a lot of times people will come back with a diagnosis, you have RA negative. Seronegative. Seronegative. Yeah. Seronegative rheumatology arthritis, or seronegative. Maybe they don't have rheumatology arthritis. How about that? There's nothing. Right. It's very interesting. Any, like, 60 to 70% of people, sorry, I think, like, 30% of people have seronegative RA. I believe that's, yeah, 30% or so. Good amount of people that are... Maybe for the listener, who doesn't know what that means? Tell them what seronegative means. Seronegative. So essentially, you have these types of complaints and you go, and if you do have autoimmune disease, you get an A&A, a rheumatoid factor. These are all different markers. Now, typically, one of those would be positive, which, if one of them are positive, then you can go down the rabbit hole to check out which markers are super sensitive, or super specific, for certain diseases. In about 30% of these patients, nothing comes up with an answer. You might have an A&A, let's say, that's positive, but that still is just... It's so general that it doesn't really point to inflammation. Yeah. It just says you have information. So a lot of these patients, they actually can't find a marker that is specific for their complaint, that can be generalized with population. So even though it seems like they have rheumatoid arthritis, and that's exactly the type of pattern they're showing, they don't have the marker to show for it, so they automatically are classified as seronegative rheumatoid arthritis. And oftentimes, they get started on those demards, disease-modifying drugs. Yeah. And those are not medications to be messing around with. Right? Those are some really intense medications with an intense side effect. So common ones people might have heard of methotrexate, plaquanal, things like that. Here is something that we need to start looking into. Right? Because I can think of 20 patients on top of my head where they've had some type of, which are maybe not 20, but I can definitely think of five or six right now, that I've had something like this. And let's explore this area a little bit more. These are difficult conversations to have, though. So here are some key messages that I would say for the clinicians listening that we need to start communicating with their patients when you have this type of disease burden. So one is identifying the person, right? If you have suspicion, they've got something like that going on, and you're not thinking, it's a rheumatoid condition, maybe there are some labs that we start getting. So certainly checking their blood pressure. That's going to be part of the process. I think we talked about getting their waist and waist to height, waist circumference to height ratio. It's probably better, because I think it's probably a better indicator of central out of hostility. That's going to be a big one. Checking their high sensitivity CRP, but HSCRP is going to be really good for inflammation. Fasting glucose, home IR, we've talked about that at the length, so people can check home IR as well, because I think it's a better indicator than just A1C. I would probably still get A1C, but I think home IR is going to be better. Anything else that I'm missing that you would put in your metabolic pattern? This lipid profile, A1C, I think we're going to question those. Just, yeah. I think that's pretty much it. I think I would start doing that. And if these are things flagging, now we can start having conversations with people that are really meaningful. Because you know what's interesting. We talk about this. If somebody comes in with elevated LDL, like that sometimes, and oftentimes is not enough for people to make a change. Because high LDL is not symptomatic. When it becomes symptomatic, it's a heart attack and it's a problem. So people are less likely to be proactive. What is symptomatic is knee arthritis. Pain is a really strong motivator. But now we can use this, right? So I think conversations that have with patients say, hey, your fat tissue is actually talking to your joints. Right? Because your fat tissue is releasing. These things like leptin and other inflammatory molecules that are causing destruction to the joint. So you want to help improve this and reverse some of this than you're talking about? We know that there is a signal here. We don't know how strong it is, but we know there's something going on. And this metabolic environment that's driving high blood sugar is also affecting a cartilage. And again, it's having some type of effect. Maybe it's not super, super strong, but it is having effect. And weight loss is going to treat the disease, not just the symptom. So like we talked about, the step nine trial showed that it's going to treat the symptom for sure. So every pound that you lose is about four pounds of loss, four pounds of force less, onto your knee joint per step. And it's helping with the inflammatory burden, like we talked about, right? So there is meaningful pain improvement. And these new medications that we're looking at, these could help. It could be a two-pronged approach. At the very least, it's going to know that it's going to solve the tried and true problem that we have. It's going to take care of the quote-unquote backpack. That's going to be amazing. And hopefully, if what we think is true, it's going to affect it independently as well. And that's not only going to affect your joints and make your overall disease burden from an osteoarthritis better and your quality of life better, but it's going to help your LDL get better, which is going to be less heart attacks and less kidney disease and the blood pressure and less strokes and all. So that's kind of how I would approach it, I think. What do you tell the patient who, and again, I see there's a lot of health care and people who want to do it the natural way, who are afraid of the GLP ones don't think it's the natural way of doing things. They are obese, and they want to stick to the Korgoceroid injections, the hyaluronic acid, just oral medication that they can do, which we've been doing for years. What's the conversation like with that? How do you kind of think about that? I'm all about, right? I think that if you are, I don't want to say necessarily anti-pharmacology, I think that if you're anti this specific medication for whatever reason that you have, great. We can try to solve this problem, just recognize it's going to be harder. I don't get to make the decision that you do. I think that if we want to do it whichever way we do it, if the end goal is that the person can have less body fat, their blood pressure is better managed, all those things that we're trying to get to, they're going to do better. Because what we're trying to do here is we're trying to reduce, if we talked about that you have less of a pack, that's one method that's going to improve, but if it's also an endocrine immune organ, we reduce that, and it has less of an inflammatory burn, they're still going to help. Now, that's why, if the signal was stronger that these medications were certainly causing disease protection from a disease modifying agent, that would be a different conversation, but we're not there yet at all. But what we do know is that being metabolically unhealthy is causing problems, right? From again, a double wami approach. So whatever way that it is they get there. So I guess maybe the analogy, something that I'll start refining, people don't, with this one medication, people don't say they want to do the natural way, by the way, with other medications they will say. This is the one that the insurance won't pay for. I don't know, have you had this? Has the insurance paying for this, and they don't want to be on it? I've had a few patients that are just, I don't want to touch it. I don't want to be near it. They've had bad experiences with it. Too much rapid weight loss. So I've had patients who have too rapid weight loss, and they're just like, they got sick from it. I don't know, I've also just had patients where I think they hear horror stories, or they have here about the risks. There's not enough long-term data. And so they could stay away. They think, I don't know, I think it's just that story that's been told about, hey, here's another drug that can just cure all in a way, right? Because think about what we're talking about. We're talking about all this different metabolic stuff and to some people, that's too good to be true. Exactly. Yeah, no, listen, there are downsides with it. Maybe actually, yeah, I'd be remiss if I didn't talk about this important one, but I want to come back to natural way. Yeah, I would tell them, hey, listen, like if you tell me I got to go down here, and we have to go to, I'm a jersey, and we got to go to the shore, like we could ride the bike there, or we could take the car there, and the bike's going to be a lot longer, and it's going to be a lot harder, but it'll get you there. Or you could walk there, that's a very natural. The car isn't, right? It's just going to be difficult, but understand that it's doable, and you get the decide at the end of the day. Now, I think the one important thing that we need to talk about, though, the rapid weight loss that you brought up, I'm glad that you brought up. Because interesting conversations happening on social media, I don't know if you see this, where a lot of my clinician colleagues, and I'm going to caveat this by saying, I have been on record saying that I think this is one of the most revolutionary drugs, certainly in my time practicing. I've said that multiple times, a big fan of it. I do see a lot of clinician colleagues jumping on and saying, oh no, this is like, even that excess lean body mass, that the studies have reported 25% to 40%, that's not really actual muscle. I agree, that's probably true. Because Dexas is not great at teasing out what's actual muscle loss, versus just water weight and bone content, et cetera. But I do know that lean body mass is better than fat mass, and I'd rather hold on lean body mass, so whatever it is. Here's the challenge. What they're saying is, when you compare it to people who are just on dietary restriction, it's about the same. That may be true, but the reality is people on dietary restriction don't lose it at first. It's not as accessible. People who are typically doing dietary restriction and can lose that much weight, where you have 25% to 40%, they're also going crazy with their exercise and resistance training. They're doing everything possible. The people who can lose that much weight, where they have the luxury of losing 25% lean body mass, those are some really competitive people who are committed. Whereas now it is so accessible that the person who does not have high intrinsic motivation to do this is now getting those results. So you are getting the weight loss without having the type of profile as a person who is going to continue training and exercising hard. And so that's why you're losing the good quality muscle. Why is that important with the relevant to what we're talking about? One of the best things that you can do to reduce the progression of the disease of osteoarthritis is to strengthen the periarticular structures. So I tell people, the reason we have works, the reason it works is because it's glorified strength training and joints, despite what we think, they're not great at tolerating stress. You know what it is greater at tolerating stress? Your muscles, your tendons, and you look at this, that surround those structures. So the more resilient and robust those structures are, the better people end up doing, the less pain that they have, because that force gets dispersed onto those structures. Now, if you have rapid weight loss and you lose those structures, you've taken your first defense mechanism and the most amazing defense mechanism for the osteoarthritis and you've taken it out or you made it weaker. Now, you got bigger problem. So that's a very real concern with this that we need to keep in mind as well. Yeah. It's interesting. I think about, we talk about how we're going to use this in practice and for both of us, we're in different settings, right? And for me, this is an educational piece that comes to my patients and I say, hey, after this rehab, after we try to build that muscle, after we try to do all these things, go talk to your entrepreneurs, or go talk to your sportsman, doctor, your PCP, and kind of these discussions with them. When you look at, after you get out of intense rehab, and you still have that pain, obviously for you, you're doing it, doing the injections and really having the discussion and thinking about initiating these patients on it. Yeah. I think these types of papers are, it's going to change the game of medicine. I put into chat, UBT, just get a summary and all and it says, are we now entering an era where like orthopedics and endocrine actually talk more and do more, more referrals and more back and forth and before we kind of look, I still think we do. We see medicine being very siloed. Now we're starting to see more across talk and more of referrals to the specialists who need to be involved. Yeah. This is exactly what PHS and Ghani talked about, how she is doing lectures, she's collaborating with the sports medicine department. I love it. In fact, did you see this that PCOS got renamed? No. Oh, maybe. That's something metabolic. Yeah. It's PMOS, polyendocrine metabolic ingredients to PMS. Yeah. Polyendocrine metabolic ac or something. Cause she has a strong point is people who get at ease of capsulitis, frozen shoulder for those who don't know. You've got these hormonal irregularities, a lot of times, there are going to be people who have some type of strong insulin-resistant diabetes, interesting correlation with epilepsy as well. But yeah. Yeah. There is a ton of cross-stop. Again, bodies don't repeat and they don't repeat and they don't repeat and they don't repeat and they don't repeat and they don't repeat and they don't repeat and they don't repeat and they don't repeat and they don't repeat bodies don't repeat text and they certainly don't do residency training in certain specialities. I say that much. Yeah, this wasn't the fun one. For me, hopefully the audience got something fun out of it and hopefully we answered them questions. So, we'll be sure to link all the show notes and the studies in here. I don't know if people are going to go deep dive. But, hopefully this answers all the questions. I think this is share with whoever you know needs to listen to this so that they can initiate that conversation. I think that's the biggest takeaway is like this is so relevant today. It's such a common disease like you were saying and so I just encourage people be sure to whoever you think it will help. And if you're a clinician, start looking into these things. I have those discussions. I love it. Awesome. All right, man. Until next time. Thanks for listening to another episode of Medicine Redefined. If you enjoyed this episode, please be sure to check out some of the additional resources in the show notes. Please also check out our social media platforms where you can find more content like this. You can follow us on Instagram, Twitter, and TikTok at Med Redefined. We also want to thank our team for the production of this podcast, specifically Ethan Jewel video, Harita Yeporian social media, Zana Blugmani on research and Sarah Hahn for newsletter. Oh, and if you want to get similar bite-sized information delivered to your inbox every Sunday, please be sure to sign up for our newsletter. Also, if you enjoyed the show, please be sure to subscribe, review, and share with anyone who you think will gain value from this as well. Now, time for the ever-so-important disclaimer. This podcast is intended for general public use and is for educational purposes only. It does not constitute the practice of medicine, nor should be construed as medical advice. No physician-patient relationship is formed, and anything discussed in this podcast does not represent the views of our employers. We recommend that you seek the guidance of your personal physician regarding any specific health-related issues.","word_count":9719,"segments":[{"start":0,"end":6,"text":" Welcome to Medicine Redefined. I'm Dr. Altama Sharaja, and I'm Dr. Darsh Show.","temperature":0,"avg_logprob":-0.24801136363636364,"compression_ratio":1.6126482213438735,"no_speech_prob":0.130615234375,"words":[]},{"start":6,"end":9,"text":" Let's put the help back in the healthcare.","temperature":0,"avg_logprob":-0.24801136363636364,"compression_ratio":1.6126482213438735,"no_speech_prob":0.130615234375,"words":[]},{"start":11,"end":17,"text":" If you're a high performer who wants a clear plan for longevity, performance, and staying active with fewer setbacks,","temperature":0,"avg_logprob":-0.24801136363636364,"compression_ratio":1.6126482213438735,"no_speech_prob":0.130615234375,"words":[]},{"start":17,"end":21,"text":" I'm now seeing patients through my telemedicine practice refining health and performance.","temperature":0,"avg_logprob":-0.24801136363636364,"compression_ratio":1.6126482213438735,"no_speech_prob":0.130615234375,"words":[]},{"start":21,"end":26,"text":" I'm opening a limited number of founding member spots at refininghealthrx.com.","temperature":0,"avg_logprob":-0.24801136363636364,"compression_ratio":1.6126482213438735,"no_speech_prob":0.130615234375,"words":[]},{"start":26,"end":28,"text":" All right, let's jump in.","temperature":0,"avg_logprob":-0.2475792253521127,"compression_ratio":1.6293706293706294,"no_speech_prob":0.061767578125,"words":[]},{"start":28,"end":33,"text":" Is osteoarthritis a metabolic disease? What do you think?","temperature":0,"avg_logprob":-0.2475792253521127,"compression_ratio":1.6293706293706294,"no_speech_prob":0.061767578125,"words":[]},{"start":33,"end":36,"text":" Now, I feel like we've touched on this in a previous episode, haven't we?","temperature":0,"avg_logprob":-0.2475792253521127,"compression_ratio":1.6293706293706294,"no_speech_prob":0.061767578125,"words":[]},{"start":36,"end":37,"text":" Kind of, right away.","temperature":0,"avg_logprob":-0.2475792253521127,"compression_ratio":1.6293706293706294,"no_speech_prob":0.061767578125,"words":[]},{"start":37,"end":40,"text":" Preferably. Yeah, we kind of said yes, but yes.","temperature":0,"avg_logprob":-0.2475792253521127,"compression_ratio":1.6293706293706294,"no_speech_prob":0.061767578125,"words":[]},{"start":40,"end":41,"text":" Why do we say yes?","temperature":0,"avg_logprob":-0.2475792253521127,"compression_ratio":1.6293706293706294,"no_speech_prob":0.061767578125,"words":[]},{"start":41,"end":42,"text":" Tell me this.","temperature":0,"avg_logprob":-0.2475792253521127,"compression_ratio":1.6293706293706294,"no_speech_prob":0.061767578125,"words":[]},{"start":42,"end":45,"text":" Well, try to think of why it's metabolic disease at this current time.","temperature":0,"avg_logprob":-0.2475792253521127,"compression_ratio":1.6293706293706294,"no_speech_prob":0.061767578125,"words":[]},{"start":45,"end":50,"text":" Yeah, so I think like, so we're trained on, let's say, in the medical institution primarily,","temperature":0,"avg_logprob":-0.2475792253521127,"compression_ratio":1.6293706293706294,"no_speech_prob":0.061767578125,"words":[]},{"start":50,"end":52,"text":" is that OA is a structural disease, right?","temperature":0,"avg_logprob":-0.2475792253521127,"compression_ratio":1.6293706293706294,"no_speech_prob":0.061767578125,"words":[]},{"start":52,"end":54,"text":" We think about the cartilage being lost.","temperature":0,"avg_logprob":-0.11383928571428571,"compression_ratio":1.77491961414791,"no_speech_prob":0.0255279541015625,"words":[]},{"start":54,"end":56,"text":" We think about the mechanics of it.","temperature":0,"avg_logprob":-0.11383928571428571,"compression_ratio":1.77491961414791,"no_speech_prob":0.0255279541015625,"words":[]},{"start":56,"end":59,"text":" We look at the x-ray findings and there's things to actual see, right?","temperature":0,"avg_logprob":-0.11383928571428571,"compression_ratio":1.77491961414791,"no_speech_prob":0.0255279541015625,"words":[]},{"start":59,"end":63,"text":" When we think metabolic disease, we don't always see structural disease, right?","temperature":0,"avg_logprob":-0.11383928571428571,"compression_ratio":1.77491961414791,"no_speech_prob":0.0255279541015625,"words":[]},{"start":63,"end":66,"text":" Those are always complications of it, but with metabolic disease,","temperature":0,"avg_logprob":-0.11383928571428571,"compression_ratio":1.77491961414791,"no_speech_prob":0.0255279541015625,"words":[]},{"start":66,"end":70,"text":" we look at the connection between maybe two organ systems, right?","temperature":0,"avg_logprob":-0.11383928571428571,"compression_ratio":1.77491961414791,"no_speech_prob":0.0255279541015625,"words":[]},{"start":70,"end":74,"text":" So in this case, maybe hormones from an endocrinology standpoint and osteoarthritis.","temperature":0,"avg_logprob":-0.11383928571428571,"compression_ratio":1.77491961414791,"no_speech_prob":0.0255279541015625,"words":[]},{"start":74,"end":81,"text":" And I think what, at least, what probably what we'll go down is the rabbit hole of how OA now is being seen","temperature":0,"avg_logprob":-0.11383928571428571,"compression_ratio":1.77491961414791,"no_speech_prob":0.0255279541015625,"words":[]},{"start":81,"end":85,"text":" also primarily as metabolic disease because of the hormonal changes.","temperature":0,"avg_logprob":-0.14575,"compression_ratio":1.6524590163934427,"no_speech_prob":0.006687164306640625,"words":[]},{"start":85,"end":90,"text":" Of course, the papers we're going to be talking about include GLP1s and the effective weight loss on OA.","temperature":0,"avg_logprob":-0.14575,"compression_ratio":1.6524590163934427,"no_speech_prob":0.006687164306640625,"words":[]},{"start":90,"end":93,"text":" And again, not necessarily from just the weight reduction standpoint,","temperature":0,"avg_logprob":-0.14575,"compression_ratio":1.6524590163934427,"no_speech_prob":0.006687164306640625,"words":[]},{"start":93,"end":95,"text":" but also just from a metabolic standpoint.","temperature":0,"avg_logprob":-0.14575,"compression_ratio":1.6524590163934427,"no_speech_prob":0.006687164306640625,"words":[]},{"start":95,"end":99,"text":" But that's, at least, if I can tell the audience, our understanding of how we get trained","temperature":0,"avg_logprob":-0.14575,"compression_ratio":1.6524590163934427,"no_speech_prob":0.006687164306640625,"words":[]},{"start":99,"end":103,"text":" when we look at OA, even as physiatrist, but I think this is a new frontier","temperature":0,"avg_logprob":-0.14575,"compression_ratio":1.6524590163934427,"no_speech_prob":0.006687164306640625,"words":[]},{"start":103,"end":105,"text":" and way of thinking about how to treat the disease.","temperature":0,"avg_logprob":-0.14575,"compression_ratio":1.6524590163934427,"no_speech_prob":0.006687164306640625,"words":[]},{"start":105,"end":113,"text":" Yeah, I think that our biases looking at the whole system were both osteopaths by nature.","temperature":0,"avg_logprob":-0.14152018229166666,"compression_ratio":1.5755102040816327,"no_speech_prob":0.65966796875,"words":[]},{"start":113,"end":118,"text":" We've talked about that before, as well as fitness oriented health first, right?","temperature":0,"avg_logprob":-0.14152018229166666,"compression_ratio":1.5755102040816327,"no_speech_prob":0.65966796875,"words":[]},{"start":118,"end":120,"text":" Talk about health not being the absence of disease.","temperature":0,"avg_logprob":-0.14152018229166666,"compression_ratio":1.5755102040816327,"no_speech_prob":0.65966796875,"words":[]},{"start":120,"end":125,"text":" We recognize that the system doesn't work in isolation.","temperature":0,"avg_logprob":-0.14152018229166666,"compression_ratio":1.5755102040816327,"no_speech_prob":0.65966796875,"words":[]},{"start":125,"end":129,"text":" I didn't know these discussions, these murmurings, if you will,","temperature":0,"avg_logprob":-0.14152018229166666,"compression_ratio":1.5755102040816327,"no_speech_prob":0.65966796875,"words":[]},{"start":129,"end":131,"text":" there was actually some evidence behind it.","temperature":0,"avg_logprob":-0.14152018229166666,"compression_ratio":1.5755102040816327,"no_speech_prob":0.65966796875,"words":[]},{"start":131,"end":135,"text":" And had these conversations have been actually reported in literature for a long time.","temperature":0,"avg_logprob":-0.17844626168224298,"compression_ratio":1.7088122605363985,"no_speech_prob":0.129150390625,"words":[]},{"start":135,"end":137,"text":" And so maybe I'll just set the stage.","temperature":0,"avg_logprob":-0.17844626168224298,"compression_ratio":1.7088122605363985,"no_speech_prob":0.129150390625,"words":[]},{"start":137,"end":140,"text":" The precedent was set back in 2012.","temperature":0,"avg_logprob":-0.17844626168224298,"compression_ratio":1.7088122605363985,"no_speech_prob":0.129150390625,"words":[]},{"start":140,"end":144,"text":" So there was this paper in Nature Reviews Germanology in 2012, Zowadael.","temperature":0,"avg_logprob":-0.17844626168224298,"compression_ratio":1.7088122605363985,"no_speech_prob":0.129150390625,"words":[]},{"start":144,"end":146,"text":" They talked about metabolic syndrome.","temperature":0,"avg_logprob":-0.17844626168224298,"compression_ratio":1.7088122605363985,"no_speech_prob":0.129150390625,"words":[]},{"start":146,"end":150,"text":" The title of paper actually is metabolic syndrome meets osteoarthritis.","temperature":0,"avg_logprob":-0.17844626168224298,"compression_ratio":1.7088122605363985,"no_speech_prob":0.129150390625,"words":[]},{"start":150,"end":156,"text":" And what they proposed was that metabolic osteoarthritis is the fifth component of metabolic syndrome.","temperature":0,"avg_logprob":-0.17844626168224298,"compression_ratio":1.7088122605363985,"no_speech_prob":0.129150390625,"words":[]},{"start":157,"end":161,"text":" So those who remember or don't remember metabolic syndrome.","temperature":0,"avg_logprob":-0.16061373873873874,"compression_ratio":1.6254826254826256,"no_speech_prob":0.43896484375,"words":[]},{"start":161,"end":164,"text":" So you have central obesity, insulin resistant, dyslipidemia, hypertension.","temperature":0,"avg_logprob":-0.16061373873873874,"compression_ratio":1.6254826254826256,"no_speech_prob":0.43896484375,"words":[]},{"start":164,"end":167,"text":" Those are like the four main arms.","temperature":0,"avg_logprob":-0.16061373873873874,"compression_ratio":1.6254826254826256,"no_speech_prob":0.43896484375,"words":[]},{"start":167,"end":171,"text":" And so they said, hey, there's a component of arthritis as well in these people.","temperature":0,"avg_logprob":-0.16061373873873874,"compression_ratio":1.6254826254826256,"no_speech_prob":0.43896484375,"words":[]},{"start":171,"end":173,"text":" And it's this quartet.","temperature":0,"avg_logprob":-0.16061373873873874,"compression_ratio":1.6254826254826256,"no_speech_prob":0.43896484375,"words":[]},{"start":173,"end":177,"text":" And each quartet member has its own joint damaging right?","temperature":0,"avg_logprob":-0.16061373873873874,"compression_ratio":1.6254826254826256,"no_speech_prob":0.43896484375,"words":[]},{"start":177,"end":182,"text":" And so we'll link this for people to read, but hypertension causes subcontract ischemia.","temperature":0,"avg_logprob":-0.16061373873873874,"compression_ratio":1.6254826254826256,"no_speech_prob":0.43896484375,"words":[]},{"start":182,"end":186,"text":" So that's the bone underneath the cartilage.","temperature":0,"avg_logprob":-0.12930782710280375,"compression_ratio":1.6892430278884463,"no_speech_prob":0.08990478515625,"words":[]},{"start":186,"end":187,"text":" And we'll look at the knee.","temperature":0,"avg_logprob":-0.12930782710280375,"compression_ratio":1.6892430278884463,"no_speech_prob":0.08990478515625,"words":[]},{"start":187,"end":190,"text":" I think a lot of this literature is looking at the knee.","temperature":0,"avg_logprob":-0.12930782710280375,"compression_ratio":1.6892430278884463,"no_speech_prob":0.08990478515625,"words":[]},{"start":190,"end":198,"text":" When you start looking at other joints with the load bearing combined with the inflammatory metabolic component doesn't really pan out.","temperature":0,"avg_logprob":-0.12930782710280375,"compression_ratio":1.6892430278884463,"no_speech_prob":0.08990478515625,"words":[]},{"start":198,"end":201,"text":" And so we can talk about some of the limitations of this.","temperature":0,"avg_logprob":-0.12930782710280375,"compression_ratio":1.6892430278884463,"no_speech_prob":0.08990478515625,"words":[]},{"start":201,"end":204,"text":" But hypertension coming back to it causes subcontract ischemia.","temperature":0,"avg_logprob":-0.12930782710280375,"compression_ratio":1.6892430278884463,"no_speech_prob":0.08990478515625,"words":[]},{"start":204,"end":207,"text":" So that's a blood flow in that area.","temperature":0,"avg_logprob":-0.12930782710280375,"compression_ratio":1.6892430278884463,"no_speech_prob":0.08990478515625,"words":[]},{"start":207,"end":209,"text":" We've talked about how blood flow historically is a good thing.","temperature":0,"avg_logprob":-0.16655092592592594,"compression_ratio":1.8357142857142856,"no_speech_prob":0.032501220703125,"words":[]},{"start":209,"end":212,"text":" And so when you have, that's going to be damaging to the tissue.","temperature":0,"avg_logprob":-0.16655092592592594,"compression_ratio":1.8357142857142856,"no_speech_prob":0.032501220703125,"words":[]},{"start":212,"end":220,"text":" And dyslipidemia causes these ectopic lipid causes formation of ectopic lipid incontrocytes, which is problematic.","temperature":0,"avg_logprob":-0.16655092592592594,"compression_ratio":1.8357142857142856,"no_speech_prob":0.032501220703125,"words":[]},{"start":220,"end":223,"text":" Hyperglycemia, high blood glucose causes glycation.","temperature":0,"avg_logprob":-0.16655092592592594,"compression_ratio":1.8357142857142856,"no_speech_prob":0.032501220703125,"words":[]},{"start":223,"end":228,"text":" We've talked about advanced or glycation end products that cause problematic problem.","temperature":0,"avg_logprob":-0.16655092592592594,"compression_ratio":1.8357142857142856,"no_speech_prob":0.032501220703125,"words":[]},{"start":228,"end":229,"text":" Excuse me.","temperature":0,"avg_logprob":-0.16655092592592594,"compression_ratio":1.8357142857142856,"no_speech_prob":0.032501220703125,"words":[]},{"start":229,"end":232,"text":" And the obesity releases these cytokines in inflammatory cytokines.","temperature":0,"avg_logprob":-0.16655092592592594,"compression_ratio":1.8357142857142856,"no_speech_prob":0.032501220703125,"words":[]},{"start":232,"end":234,"text":" And so it's not just one mechanism they talked about.","temperature":0,"avg_logprob":-0.16655092592592594,"compression_ratio":1.8357142857142856,"no_speech_prob":0.032501220703125,"words":[]},{"start":235,"end":243,"text":" It's a convergence of all these mechanisms for metabolic syndrome that actually progress the disease burden and cause some structural issues too.","temperature":0,"avg_logprob":-0.1729628164556962,"compression_ratio":1.5407725321888412,"no_speech_prob":0.2413330078125,"words":[]},{"start":243,"end":251,"text":" So this idea that metabolism drive the subset of OA is 13 plus years old.","temperature":0,"avg_logprob":-0.1729628164556962,"compression_ratio":1.5407725321888412,"no_speech_prob":0.2413330078125,"words":[]},{"start":251,"end":260,"text":" What's new that in the last two to three years in 2024 to 26 is that we can now intervene from ecologically and watch how the job responds.","temperature":0,"avg_logprob":-0.1729628164556962,"compression_ratio":1.5407725321888412,"no_speech_prob":0.2413330078125,"words":[]},{"start":260,"end":263,"text":" And that's what I think has been more exciting.","temperature":0,"avg_logprob":-0.1740171370967742,"compression_ratio":1.7314487632508835,"no_speech_prob":0.62353515625,"words":[]},{"start":263,"end":272,"text":" And actually, when I was even doing this literature, I think that in the literature review rather, people are even describing multiple phenotypes of osteoarthritis.","temperature":0,"avg_logprob":-0.1740171370967742,"compression_ratio":1.7314487632508835,"no_speech_prob":0.62353515625,"words":[]},{"start":272,"end":276,"text":" So you listed a couple, but here's a little quiz moment for you.","temperature":0,"avg_logprob":-0.1740171370967742,"compression_ratio":1.7314487632508835,"no_speech_prob":0.62353515625,"words":[]},{"start":276,"end":281,"text":" What would be some of the main phenotypes of osteoarthritis if you could describe for the listener?","temperature":0,"avg_logprob":-0.1740171370967742,"compression_ratio":1.7314487632508835,"no_speech_prob":0.62353515625,"words":[]},{"start":281,"end":283,"text":" Maybe my phenotype.","temperature":0,"avg_logprob":-0.1740171370967742,"compression_ratio":1.7314487632508835,"no_speech_prob":0.62353515625,"words":[]},{"start":283,"end":285,"text":" Because I'm like mild, mild, severe.","temperature":0,"avg_logprob":-0.1740171370967742,"compression_ratio":1.7314487632508835,"no_speech_prob":0.62353515625,"words":[]},{"start":285,"end":288,"text":" Are you talking about what type of people present with?","temperature":0,"avg_logprob":-0.1740171370967742,"compression_ratio":1.7314487632508835,"no_speech_prob":0.62353515625,"words":[]},{"start":288,"end":291,"text":" No, so when we think about it, it's got a sports room, right?","temperature":0,"avg_logprob":-0.19761029411764705,"compression_ratio":1.5485232067510548,"no_speech_prob":0.0714111328125,"words":[]},{"start":291,"end":297,"text":" So there is the classic, when you think wear and tear, what does that mean to you?","temperature":0,"avg_logprob":-0.19761029411764705,"compression_ratio":1.5485232067510548,"no_speech_prob":0.0714111328125,"words":[]},{"start":297,"end":299,"text":" That's more of an age-related process, right?","temperature":0,"avg_logprob":-0.19761029411764705,"compression_ratio":1.5485232067510548,"no_speech_prob":0.0714111328125,"words":[]},{"start":299,"end":300,"text":" Sure.","temperature":0,"avg_logprob":-0.19761029411764705,"compression_ratio":1.5485232067510548,"no_speech_prob":0.0714111328125,"words":[]},{"start":300,"end":301,"text":" It almost seems inevitable.","temperature":0,"avg_logprob":-0.19761029411764705,"compression_ratio":1.5485232067510548,"no_speech_prob":0.0714111328125,"words":[]},{"start":301,"end":311,"text":" Do you remember learning about the fact that when somebody has trauma, like a fracture or an ACL tear, a meniscus tear, accelerates arthritis.","temperature":0,"avg_logprob":-0.19761029411764705,"compression_ratio":1.5485232067510548,"no_speech_prob":0.0714111328125,"words":[]},{"start":311,"end":312,"text":" Sure.","temperature":0,"avg_logprob":-0.1946875,"compression_ratio":1.8144329896907216,"no_speech_prob":0.67724609375,"words":[]},{"start":312,"end":314,"text":" So we'll bucket that into post-traumatic arthritis.","temperature":0,"avg_logprob":-0.1946875,"compression_ratio":1.8144329896907216,"no_speech_prob":0.67724609375,"words":[]},{"start":314,"end":318,"text":" So if you've got the age-related senescence, you've got the post-traumatic arthritis.","temperature":0,"avg_logprob":-0.1946875,"compression_ratio":1.8144329896907216,"no_speech_prob":0.67724609375,"words":[]},{"start":318,"end":321,"text":" The other one, the one that you might center rheumatologist would be which one?","temperature":0,"avg_logprob":-0.1946875,"compression_ratio":1.8144329896907216,"no_speech_prob":0.67724609375,"words":[]},{"start":321,"end":324,"text":" Intoid arthritis or inflammatory.","temperature":0,"avg_logprob":-0.1946875,"compression_ratio":1.8144329896907216,"no_speech_prob":0.67724609375,"words":[]},{"start":324,"end":325,"text":" Yeah, inflammatory.","temperature":0,"avg_logprob":-0.1946875,"compression_ratio":1.8144329896907216,"no_speech_prob":0.67724609375,"words":[]},{"start":325,"end":328,"text":" Yeah, so we would put that into the inflammatory bucket.","temperature":0,"avg_logprob":-0.1946875,"compression_ratio":1.8144329896907216,"no_speech_prob":0.67724609375,"words":[]},{"start":328,"end":331,"text":" The other one is called the mechanical malalignment model.","temperature":0,"avg_logprob":-0.1946875,"compression_ratio":1.8144329896907216,"no_speech_prob":0.67724609375,"words":[]},{"start":331,"end":334,"text":" So we talked a little bit about this, Dr. Alison Grimalti, right?","temperature":0,"avg_logprob":-0.1946875,"compression_ratio":1.8144329896907216,"no_speech_prob":0.67724609375,"words":[]},{"start":334,"end":336,"text":" When somebody's got, maybe let's say they have a really wide pelvis.","temperature":0,"avg_logprob":-0.1946875,"compression_ratio":1.8144329896907216,"no_speech_prob":0.67724609375,"words":[]},{"start":337,"end":340,"text":" And they've got more knock knee presentation versus a bone-legged presentation.","temperature":0,"avg_logprob":-0.16835585585585586,"compression_ratio":1.7328244274809161,"no_speech_prob":0.517578125,"words":[]},{"start":340,"end":342,"text":" So that would be a malalignment.","temperature":0,"avg_logprob":-0.16835585585585586,"compression_ratio":1.7328244274809161,"no_speech_prob":0.517578125,"words":[]},{"start":342,"end":349,"text":" Those types of burnt stresses onto the knee joint is going to cause some more structural degradation in certain parts of the joint.","temperature":0,"avg_logprob":-0.16835585585585586,"compression_ratio":1.7328244274809161,"no_speech_prob":0.517578125,"words":[]},{"start":349,"end":355,"text":" There's this pain-central desensitization pathway, pain-sensitization dominant, either they say, where you don't,","temperature":0,"avg_logprob":-0.16835585585585586,"compression_ratio":1.7328244274809161,"no_speech_prob":0.517578125,"words":[]},{"start":355,"end":360,"text":" might necessarily have a lot of structural issues, but you might have a lot of a heavy symptom.","temperature":0,"avg_logprob":-0.16835585585585586,"compression_ratio":1.7328244274809161,"no_speech_prob":0.517578125,"words":[]},{"start":361,"end":363,"text":" And so this last phenotype is what we're going to talk about.","temperature":0,"avg_logprob":-0.20628156565656566,"compression_ratio":1.5291828793774318,"no_speech_prob":0.025543212890625,"words":[]},{"start":363,"end":366,"text":" It's called the, so I'm sort of the metabolic syndrome.","temperature":0,"avg_logprob":-0.20628156565656566,"compression_ratio":1.5291828793774318,"no_speech_prob":0.025543212890625,"words":[]},{"start":366,"end":370,"text":" Now, here's where the smoking gum gun came up for all this, right?","temperature":0,"avg_logprob":-0.20628156565656566,"compression_ratio":1.5291828793774318,"no_speech_prob":0.025543212890625,"words":[]},{"start":370,"end":378,"text":" So the clue that started breaking this whole purely mechanical idea is that we've noted over the last 15 years,","temperature":0,"avg_logprob":-0.20628156565656566,"compression_ratio":1.5291828793774318,"no_speech_prob":0.025543212890625,"words":[]},{"start":378,"end":384,"text":" maybe two decades, that obesity is modest, just strongly associated with hand-ostered arthritis.","temperature":0,"avg_logprob":-0.20628156565656566,"compression_ratio":1.5291828793774318,"no_speech_prob":0.025543212890625,"words":[]},{"start":385,"end":390,"text":" And not many people, so maybe some, are walking around their hands, right?","temperature":0,"avg_logprob":-0.17419554455445543,"compression_ratio":1.65234375,"no_speech_prob":0.0335693359375,"words":[]},{"start":390,"end":392,"text":" So there's not a lot of load being dispersed with the hands.","temperature":0,"avg_logprob":-0.17419554455445543,"compression_ratio":1.65234375,"no_speech_prob":0.0335693359375,"words":[]},{"start":392,"end":398,"text":" And so there's no way, why is there an excess or why is there an increased correlation with osteoarthritis?","temperature":0,"avg_logprob":-0.17419554455445543,"compression_ratio":1.65234375,"no_speech_prob":0.0335693359375,"words":[]},{"start":398,"end":404,"text":" Because that backpack analogy, damaging the joint through load alone, it should have zero effect.","temperature":0,"avg_logprob":-0.17419554455445543,"compression_ratio":1.65234375,"no_speech_prob":0.0335693359375,"words":[]},{"start":404,"end":409,"text":" Again, caveat, because initially when it started learning and reading about this,","temperature":0,"avg_logprob":-0.17419554455445543,"compression_ratio":1.65234375,"no_speech_prob":0.0335693359375,"words":[]},{"start":409,"end":412,"text":" it was like, oh, maybe there's two to three times more likely to happen.","temperature":0,"avg_logprob":-0.1141593992248062,"compression_ratio":1.6629213483146068,"no_speech_prob":0.1273193359375,"words":[]},{"start":412,"end":416,"text":" And that's really not the case, because when you look at the observational studies,","temperature":0,"avg_logprob":-0.1141593992248062,"compression_ratio":1.6629213483146068,"no_speech_prob":0.1273193359375,"words":[]},{"start":416,"end":423,"text":" when you look at the Mendelian randomization studies, it's really an odds ratio of 1.21 versus 1.91,","temperature":0,"avg_logprob":-0.1141593992248062,"compression_ratio":1.6629213483146068,"no_speech_prob":0.1273193359375,"words":[]},{"start":423,"end":426,"text":" which is, okay, the odds are going to be 1.91 greater, right?","temperature":0,"avg_logprob":-0.1141593992248062,"compression_ratio":1.6629213483146068,"no_speech_prob":0.1273193359375,"words":[]},{"start":426,"end":428,"text":" And then I mean, for hip is a little bit less.","temperature":0,"avg_logprob":-0.1141593992248062,"compression_ratio":1.6629213483146068,"no_speech_prob":0.1273193359375,"words":[]},{"start":428,"end":433,"text":" And so some of this, I think, is even though it's modest, it's still debated.","temperature":0,"avg_logprob":-0.1141593992248062,"compression_ratio":1.6629213483146068,"no_speech_prob":0.1273193359375,"words":[]},{"start":433,"end":438,"text":" Got us thinking, okay, there must be something, because it's too weak to be a mechanical load only,","temperature":0,"avg_logprob":-0.12230603448275862,"compression_ratio":1.7088607594936709,"no_speech_prob":0.72802734375,"words":[]},{"start":438,"end":440,"text":" but it's too real to be nothing.","temperature":0,"avg_logprob":-0.12230603448275862,"compression_ratio":1.7088607594936709,"no_speech_prob":0.72802734375,"words":[]},{"start":440,"end":446,"text":" And there has to be somewhat of a systemic signal reaching a joint that carries no weight, like your hands.","temperature":0,"avg_logprob":-0.12230603448275862,"compression_ratio":1.7088607594936709,"no_speech_prob":0.72802734375,"words":[]},{"start":446,"end":448,"text":" And that's what we're trying to fish out.","temperature":0,"avg_logprob":-0.12230603448275862,"compression_ratio":1.7088607594936709,"no_speech_prob":0.72802734375,"words":[]},{"start":448,"end":451,"text":" Maybe now, I think, do you have anything to add to that?","temperature":0,"avg_logprob":-0.12230603448275862,"compression_ratio":1.7088607594936709,"no_speech_prob":0.72802734375,"words":[]},{"start":451,"end":455,"text":" Or should I just get into the studies that actually incited this whole discussion here?","temperature":0,"avg_logprob":-0.12230603448275862,"compression_ratio":1.7088607594936709,"no_speech_prob":0.72802734375,"words":[]},{"start":455,"end":458,"text":" Yeah, let's also get into it. I think that was a good preview of kind of what.","temperature":0,"avg_logprob":-0.12230603448275862,"compression_ratio":1.7088607594936709,"no_speech_prob":0.72802734375,"words":[]},{"start":458,"end":460,"text":" Now to think about it away, yeah.","temperature":0,"avg_logprob":-0.12230603448275862,"compression_ratio":1.7088607594936709,"no_speech_prob":0.72802734375,"words":[]},{"start":460,"end":463,"text":" And I'll talk a little bit more about mechanisms.","temperature":0,"avg_logprob":-0.172375,"compression_ratio":1.56993006993007,"no_speech_prob":0.04736328125,"words":[]},{"start":463,"end":465,"text":" If that's interesting to you, interesting to the audience.","temperature":0,"avg_logprob":-0.172375,"compression_ratio":1.56993006993007,"no_speech_prob":0.04736328125,"words":[]},{"start":465,"end":469,"text":" But I think that the two main studies for the drug evidence, so you talked about GLP1.","temperature":0,"avg_logprob":-0.172375,"compression_ratio":1.56993006993007,"no_speech_prob":0.04736328125,"words":[]},{"start":469,"end":474,"text":" So semi-glutide in particular, that's a govi ozemic, how people recognize it.","temperature":0,"avg_logprob":-0.172375,"compression_ratio":1.56993006993007,"no_speech_prob":0.04736328125,"words":[]},{"start":474,"end":476,"text":" This is the step nine trial.","temperature":0,"avg_logprob":-0.172375,"compression_ratio":1.56993006993007,"no_speech_prob":0.04736328125,"words":[]},{"start":476,"end":481,"text":" So this was published in the New England Journal Medicine in 2024.","temperature":0,"avg_logprob":-0.172375,"compression_ratio":1.56993006993007,"no_speech_prob":0.04736328125,"words":[]},{"start":481,"end":486,"text":" And what they looked at is the max dose of semi-glutide, 2.4 milligrams weekly,","temperature":0,"avg_logprob":-0.172375,"compression_ratio":1.56993006993007,"no_speech_prob":0.04736328125,"words":[]},{"start":486,"end":491,"text":" and given at 107 people, randomized control trial, lasted 68 weeks,","temperature":0,"avg_logprob":-0.2169836956521739,"compression_ratio":1.54,"no_speech_prob":0.2139892578125,"words":[]},{"start":491,"end":493,"text":" so a little over a year.","temperature":0,"avg_logprob":-0.2169836956521739,"compression_ratio":1.54,"no_speech_prob":0.2139892578125,"words":[]},{"start":493,"end":499,"text":" And the BMI cut off was 30, 81% female population, and the KL score.","temperature":0,"avg_logprob":-0.2169836956521739,"compression_ratio":1.54,"no_speech_prob":0.2139892578125,"words":[]},{"start":499,"end":502,"text":" So that's the killer again, Lawrence school.","temperature":0,"avg_logprob":-0.2169836956521739,"compression_ratio":1.54,"no_speech_prob":0.2139892578125,"words":[]},{"start":502,"end":504,"text":" I think I'm gonna get that right, KL.","temperature":0,"avg_logprob":-0.2169836956521739,"compression_ratio":1.54,"no_speech_prob":0.2139892578125,"words":[]},{"start":504,"end":505,"text":" That stands for again.","temperature":0,"avg_logprob":-0.2169836956521739,"compression_ratio":1.54,"no_speech_prob":0.2139892578125,"words":[]},{"start":505,"end":508,"text":" By the way, it's rating severity of osteoarthritis.","temperature":0,"avg_logprob":-0.2169836956521739,"compression_ratio":1.54,"no_speech_prob":0.2139892578125,"words":[]},{"start":508,"end":509,"text":" So that's two to three.","temperature":0,"avg_logprob":-0.2169836956521739,"compression_ratio":1.54,"no_speech_prob":0.2139892578125,"words":[]},{"start":509,"end":512,"text":" So moderate to somewhat severe arthritis.","temperature":0,"avg_logprob":-0.2169836956521739,"compression_ratio":1.54,"no_speech_prob":0.2139892578125,"words":[]},{"start":512,"end":515,"text":" And what they wanted to look for is what's the percent weight change?","temperature":0,"avg_logprob":-0.2613407258064516,"compression_ratio":1.6245353159851301,"no_speech_prob":0.0645751953125,"words":[]},{"start":515,"end":517,"text":" And the Womac pain scores.","temperature":0,"avg_logprob":-0.2613407258064516,"compression_ratio":1.6245353159851301,"no_speech_prob":0.0645751953125,"words":[]},{"start":517,"end":521,"text":" So Womac is the Western Rantart O something arthritis.","temperature":0,"avg_logprob":-0.2613407258064516,"compression_ratio":1.6245353159851301,"no_speech_prob":0.0645751953125,"words":[]},{"start":521,"end":522,"text":" No, Western.","temperature":0,"avg_logprob":-0.2613407258064516,"compression_ratio":1.6245353159851301,"no_speech_prob":0.0645751953125,"words":[]},{"start":522,"end":523,"text":" I forget what it is.","temperature":0,"avg_logprob":-0.2613407258064516,"compression_ratio":1.6245353159851301,"no_speech_prob":0.0645751953125,"words":[]},{"start":523,"end":524,"text":" Look up Womac real quick.","temperature":0,"avg_logprob":-0.2613407258064516,"compression_ratio":1.6245353159851301,"no_speech_prob":0.0645751953125,"words":[]},{"start":524,"end":528,"text":" Womac pain scale.","temperature":0,"avg_logprob":-0.2613407258064516,"compression_ratio":1.6245353159851301,"no_speech_prob":0.0645751953125,"words":[]},{"start":528,"end":532,"text":" Yes, Western, Ontario, and McMastery universities.","temperature":0,"avg_logprob":-0.2613407258064516,"compression_ratio":1.6245353159851301,"no_speech_prob":0.0645751953125,"words":[]},{"start":532,"end":535,"text":" So serving you is that evaluate severity of hip and knee away,","temperature":0,"avg_logprob":-0.2613407258064516,"compression_ratio":1.6245353159851301,"no_speech_prob":0.0645751953125,"words":[]},{"start":535,"end":539,"text":" and ask specific question by your daily life, including pain stiffness, physical functioning.","temperature":0,"avg_logprob":-0.2613407258064516,"compression_ratio":1.6245353159851301,"no_speech_prob":0.0645751953125,"words":[]},{"start":540,"end":544,"text":" Essentially, it is checking what the disease burden is for osteoarthritis.","temperature":0,"avg_logprob":-0.17463235294117646,"compression_ratio":1.7168458781362008,"no_speech_prob":0.1497802734375,"words":[]},{"start":544,"end":547,"text":" What they found was between the treatment group,","temperature":0,"avg_logprob":-0.17463235294117646,"compression_ratio":1.7168458781362008,"no_speech_prob":0.1497802734375,"words":[]},{"start":547,"end":549,"text":" semi-glutide versus the placebo group,","temperature":0,"avg_logprob":-0.17463235294117646,"compression_ratio":1.7168458781362008,"no_speech_prob":0.1497802734375,"words":[]},{"start":549,"end":554,"text":" that was a 14.1 greater improvement in the treatment group.","temperature":0,"avg_logprob":-0.17463235294117646,"compression_ratio":1.7168458781362008,"no_speech_prob":0.1497802734375,"words":[]},{"start":554,"end":558,"text":" I think the treatment group has a school improvement of 41 points, something,","temperature":0,"avg_logprob":-0.17463235294117646,"compression_ratio":1.7168458781362008,"no_speech_prob":0.1497802734375,"words":[]},{"start":558,"end":560,"text":" versus I forget what the other one was.","temperature":0,"avg_logprob":-0.17463235294117646,"compression_ratio":1.7168458781362008,"no_speech_prob":0.1497802734375,"words":[]},{"start":560,"end":561,"text":" So 27 point, right?","temperature":0,"avg_logprob":-0.17463235294117646,"compression_ratio":1.7168458781362008,"no_speech_prob":0.1497802734375,"words":[]},{"start":561,"end":564,"text":" And so that exceeded the threshold of what they thought with them,","temperature":0,"avg_logprob":-0.17463235294117646,"compression_ratio":1.7168458781362008,"no_speech_prob":0.1497802734375,"words":[]},{"start":564,"end":566,"text":" minimally clinically important difference would be.","temperature":0,"avg_logprob":-0.17463235294117646,"compression_ratio":1.7168458781362008,"no_speech_prob":0.1497802734375,"words":[]},{"start":566,"end":568,"text":" And that's a pretty large clinical effect, right?","temperature":0,"avg_logprob":-0.11348998091603053,"compression_ratio":1.718978102189781,"no_speech_prob":0.05999755859375,"words":[]},{"start":568,"end":571,"text":" The way change in the treatment group was 13.7%.","temperature":0,"avg_logprob":-0.11348998091603053,"compression_ratio":1.718978102189781,"no_speech_prob":0.05999755859375,"words":[]},{"start":571,"end":575,"text":" And the placebo group was 3.2% less.","temperature":0,"avg_logprob":-0.11348998091603053,"compression_ratio":1.718978102189781,"no_speech_prob":0.05999755859375,"words":[]},{"start":575,"end":579,"text":" And so, yeah, you had a meaningful weight reduction.","temperature":0,"avg_logprob":-0.11348998091603053,"compression_ratio":1.718978102189781,"no_speech_prob":0.05999755859375,"words":[]},{"start":579,"end":583,"text":" And you had a meaningful improvement in your symptoms, right?","temperature":0,"avg_logprob":-0.11348998091603053,"compression_ratio":1.718978102189781,"no_speech_prob":0.05999755859375,"words":[]},{"start":583,"end":584,"text":" The Womac scores as well.","temperature":0,"avg_logprob":-0.11348998091603053,"compression_ratio":1.718978102189781,"no_speech_prob":0.05999755859375,"words":[]},{"start":584,"end":585,"text":" They had some secondary outcomes as well.","temperature":0,"avg_logprob":-0.11348998091603053,"compression_ratio":1.718978102189781,"no_speech_prob":0.05999755859375,"words":[]},{"start":585,"end":587,"text":" They had something called the SF-36,","temperature":0,"avg_logprob":-0.11348998091603053,"compression_ratio":1.718978102189781,"no_speech_prob":0.05999755859375,"words":[]},{"start":587,"end":591,"text":" which had also improved in favor of the treatment group.","temperature":0,"avg_logprob":-0.11348998091603053,"compression_ratio":1.718978102189781,"no_speech_prob":0.05999755859375,"words":[]},{"start":591,"end":595,"text":" No, a couple of biases with this one, or caveats pointing.","temperature":0,"avg_logprob":-0.11348998091603053,"compression_ratio":1.718978102189781,"no_speech_prob":0.05999755859375,"words":[]},{"start":595,"end":596,"text":" It was industry funded.","temperature":0,"avg_logprob":-0.15871147260273974,"compression_ratio":1.6090909090909091,"no_speech_prob":0.0176849365234375,"words":[]},{"start":596,"end":599,"text":" So, Novan Ordersk, which is the company, had funded this,","temperature":0,"avg_logprob":-0.15871147260273974,"compression_ratio":1.6090909090909091,"no_speech_prob":0.0176849365234375,"words":[]},{"start":599,"end":600,"text":" whatever that means to you, right?","temperature":0,"avg_logprob":-0.15871147260273974,"compression_ratio":1.6090909090909091,"no_speech_prob":0.0176849365234375,"words":[]},{"start":600,"end":603,"text":" We always want to make sure that we're looking at that stuff.","temperature":0,"avg_logprob":-0.15871147260273974,"compression_ratio":1.6090909090909091,"no_speech_prob":0.0176849365234375,"words":[]},{"start":603,"end":609,"text":" And you had this improvement, but I did point out the fact that there was substantial weight change, right?","temperature":0,"avg_logprob":-0.15871147260273974,"compression_ratio":1.6090909090909091,"no_speech_prob":0.0176849365234375,"words":[]},{"start":609,"end":617,"text":" So it doesn't necessarily prove that the effect was because of some magical component of GLP1s,","temperature":0,"avg_logprob":-0.15871147260273974,"compression_ratio":1.6090909090909091,"no_speech_prob":0.0176849365234375,"words":[]},{"start":617,"end":619,"text":" because, again, you could just say, hey, listen,","temperature":0,"avg_logprob":-0.15871147260273974,"compression_ratio":1.6090909090909091,"no_speech_prob":0.0176849365234375,"words":[]},{"start":619,"end":622,"text":" you had a significant weight loss, and that's why these people did better, right?","temperature":0,"avg_logprob":-0.15871147260273974,"compression_ratio":1.6090909090909091,"no_speech_prob":0.0176849365234375,"words":[]},{"start":622,"end":623,"text":" 13.7 versus 3.2%.","temperature":0,"avg_logprob":-0.15871147260273974,"compression_ratio":1.6090909090909091,"no_speech_prob":0.0176849365234375,"words":[]},{"start":624,"end":627,"text":" So, this metabolic intervention, we know had a big clinical improvement,","temperature":0,"avg_logprob":-0.15730574324324326,"compression_ratio":1.5921052631578947,"no_speech_prob":0.19384765625,"words":[]},{"start":627,"end":629,"text":" but why did it happen?","temperature":0,"avg_logprob":-0.15730574324324326,"compression_ratio":1.5921052631578947,"no_speech_prob":0.19384765625,"words":[]},{"start":629,"end":631,"text":" Is it the drug, or is it, again, the backpack?","temperature":0,"avg_logprob":-0.15730574324324326,"compression_ratio":1.5921052631578947,"no_speech_prob":0.19384765625,"words":[]},{"start":631,"end":632,"text":" All right.","temperature":0,"avg_logprob":-0.15730574324324326,"compression_ratio":1.5921052631578947,"no_speech_prob":0.19384765625,"words":[]},{"start":632,"end":633,"text":" So, let's fast forward.","temperature":0,"avg_logprob":-0.15730574324324326,"compression_ratio":1.5921052631578947,"no_speech_prob":0.19384765625,"words":[]},{"start":633,"end":634,"text":" So, that's the GLP1, right?","temperature":0,"avg_logprob":-0.15730574324324326,"compression_ratio":1.5921052631578947,"no_speech_prob":0.19384765625,"words":[]},{"start":634,"end":637,"text":" The other study that I think is worth mentioning here,","temperature":0,"avg_logprob":-0.15730574324324326,"compression_ratio":1.5921052631578947,"no_speech_prob":0.19384765625,"words":[]},{"start":637,"end":640,"text":" is the Pan et al. paper that was published in JAMA 2025.","temperature":0,"avg_logprob":-0.15730574324324326,"compression_ratio":1.5921052631578947,"no_speech_prob":0.19384765625,"words":[]},{"start":640,"end":643,"text":" So, in this study, they looked at different drugs.","temperature":0,"avg_logprob":-0.15730574324324326,"compression_ratio":1.5921052631578947,"no_speech_prob":0.19384765625,"words":[]},{"start":643,"end":646,"text":" Metformin, good old diabetes drug, right?","temperature":0,"avg_logprob":-0.15730574324324326,"compression_ratio":1.5921052631578947,"no_speech_prob":0.19384765625,"words":[]},{"start":646,"end":648,"text":" Penies on the dollar at this point.","temperature":0,"avg_logprob":-0.15730574324324326,"compression_ratio":1.5921052631578947,"no_speech_prob":0.19384765625,"words":[]},{"start":648,"end":650,"text":" So, they took a little smaller study.","temperature":0,"avg_logprob":-0.15730574324324326,"compression_ratio":1.5921052631578947,"no_speech_prob":0.19384765625,"words":[]},{"start":650,"end":653,"text":" They took 107 people, randomized control trial, six months long.","temperature":0,"avg_logprob":-0.14216382575757575,"compression_ratio":1.5980392156862746,"no_speech_prob":0.01425933837890625,"words":[]},{"start":653,"end":655,"text":" Here, they had the overweight population.","temperature":0,"avg_logprob":-0.14216382575757575,"compression_ratio":1.5980392156862746,"no_speech_prob":0.01425933837890625,"words":[]},{"start":655,"end":657,"text":" So, the BMI cut up was 25 or greater,","temperature":0,"avg_logprob":-0.14216382575757575,"compression_ratio":1.5980392156862746,"no_speech_prob":0.01425933837890625,"words":[]},{"start":657,"end":659,"text":" and you had to have symptomatic knee, okay?","temperature":0,"avg_logprob":-0.14216382575757575,"compression_ratio":1.5980392156862746,"no_speech_prob":0.01425933837890625,"words":[]},{"start":659,"end":663,"text":" And they gave them 2,000 milligrams of metformin every single day.","temperature":0,"avg_logprob":-0.14216382575757575,"compression_ratio":1.5980392156862746,"no_speech_prob":0.01425933837890625,"words":[]},{"start":663,"end":666,"text":" What they looked at is these things called the VS knee pain score.","temperature":0,"avg_logprob":-0.14216382575757575,"compression_ratio":1.5980392156862746,"no_speech_prob":0.01425933837890625,"words":[]},{"start":666,"end":669,"text":" So, this is just your classic visual analog scale,","temperature":0,"avg_logprob":-0.14216382575757575,"compression_ratio":1.5980392156862746,"no_speech_prob":0.01425933837890625,"words":[]},{"start":669,"end":671,"text":" your pain score, how much your pain improved.","temperature":0,"avg_logprob":-0.14216382575757575,"compression_ratio":1.5980392156862746,"no_speech_prob":0.01425933837890625,"words":[]},{"start":671,"end":676,"text":" And what they noted was that there was an 11.4 millimeter difference.","temperature":0,"avg_logprob":-0.14216382575757575,"compression_ratio":1.5980392156862746,"no_speech_prob":0.01425933837890625,"words":[]},{"start":677,"end":678,"text":" What's important, worth noting,","temperature":0,"avg_logprob":-0.15002648305084745,"compression_ratio":1.667844522968198,"no_speech_prob":0.01494598388671875,"words":[]},{"start":678,"end":680,"text":" what they thought to the MCID prior to the study","temperature":0,"avg_logprob":-0.15002648305084745,"compression_ratio":1.667844522968198,"no_speech_prob":0.01494598388671875,"words":[]},{"start":680,"end":683,"text":" with the mean clinically important difference would be 15 millimeters.","temperature":0,"avg_logprob":-0.15002648305084745,"compression_ratio":1.667844522968198,"no_speech_prob":0.01494598388671875,"words":[]},{"start":683,"end":685,"text":" And that didn't actually achieve that,","temperature":0,"avg_logprob":-0.15002648305084745,"compression_ratio":1.667844522968198,"no_speech_prob":0.01494598388671875,"words":[]},{"start":685,"end":687,"text":" but there was an improvement.","temperature":0,"avg_logprob":-0.15002648305084745,"compression_ratio":1.667844522968198,"no_speech_prob":0.01494598388671875,"words":[]},{"start":687,"end":689,"text":" Weight change, this is the important.","temperature":0,"avg_logprob":-0.15002648305084745,"compression_ratio":1.667844522968198,"no_speech_prob":0.01494598388671875,"words":[]},{"start":689,"end":694,"text":" Treatment group was negative 1.2 kilograms versus 1.2 kilograms.","temperature":0,"avg_logprob":-0.15002648305084745,"compression_ratio":1.667844522968198,"no_speech_prob":0.01494598388671875,"words":[]},{"start":694,"end":696,"text":" Really not much of a difference at all.","temperature":0,"avg_logprob":-0.15002648305084745,"compression_ratio":1.667844522968198,"no_speech_prob":0.01494598388671875,"words":[]},{"start":696,"end":699,"text":" So, the interesting thing here is that the treatment group","temperature":0,"avg_logprob":-0.15002648305084745,"compression_ratio":1.667844522968198,"no_speech_prob":0.01494598388671875,"words":[]},{"start":699,"end":704,"text":" had benefit despite no excess weight loss, right?","temperature":0,"avg_logprob":-0.15002648305084745,"compression_ratio":1.667844522968198,"no_speech_prob":0.01494598388671875,"words":[]},{"start":704,"end":706,"text":" So, no significant changes in weight loss.","temperature":0,"avg_logprob":-0.16693548387096774,"compression_ratio":1.6443148688046647,"no_speech_prob":0.0026302337646484375,"words":[]},{"start":706,"end":708,"text":" They also looked at the Wormack pain stiffness,","temperature":0,"avg_logprob":-0.16693548387096774,"compression_ratio":1.6443148688046647,"no_speech_prob":0.0026302337646484375,"words":[]},{"start":708,"end":711,"text":" function, quality of life, all these were unchanged","temperature":0,"avg_logprob":-0.16693548387096774,"compression_ratio":1.6443148688046647,"no_speech_prob":0.0026302337646484375,"words":[]},{"start":711,"end":712,"text":" and nothing got three months,","temperature":0,"avg_logprob":-0.16693548387096774,"compression_ratio":1.6443148688046647,"no_speech_prob":0.0026302337646484375,"words":[]},{"start":712,"end":714,"text":" but at six months, they did have a little bit of improvement.","temperature":0,"avg_logprob":-0.16693548387096774,"compression_ratio":1.6443148688046647,"no_speech_prob":0.0026302337646484375,"words":[]},{"start":714,"end":715,"text":" Have the outs here?","temperature":0,"avg_logprob":-0.16693548387096774,"compression_ratio":1.6443148688046647,"no_speech_prob":0.0026302337646484375,"words":[]},{"start":715,"end":717,"text":" This was a small study, right?","temperature":0,"avg_logprob":-0.16693548387096774,"compression_ratio":1.6443148688046647,"no_speech_prob":0.0026302337646484375,"words":[]},{"start":717,"end":719,"text":" A hundred and seven total people.","temperature":0,"avg_logprob":-0.16693548387096774,"compression_ratio":1.6443148688046647,"no_speech_prob":0.0026302337646484375,"words":[]},{"start":719,"end":722,"text":" A lot of that was via telemedicine, self-reporting,","temperature":0,"avg_logprob":-0.16693548387096774,"compression_ratio":1.6443148688046647,"no_speech_prob":0.0026302337646484375,"words":[]},{"start":722,"end":724,"text":" barely any significant secondary effect.","temperature":0,"avg_logprob":-0.16693548387096774,"compression_ratio":1.6443148688046647,"no_speech_prob":0.0026302337646484375,"words":[]},{"start":724,"end":728,"text":" So, I think big takeaway from this was that got a lot of people excited,","temperature":0,"avg_logprob":-0.16693548387096774,"compression_ratio":1.6443148688046647,"no_speech_prob":0.0026302337646484375,"words":[]},{"start":728,"end":730,"text":" was, hey, you can actually see some changes happen","temperature":0,"avg_logprob":-0.16693548387096774,"compression_ratio":1.6443148688046647,"no_speech_prob":0.0026302337646484375,"words":[]},{"start":730,"end":732,"text":" even though they're modest,","temperature":0,"avg_logprob":-0.16693548387096774,"compression_ratio":1.6443148688046647,"no_speech_prob":0.0026302337646484375,"words":[]},{"start":732,"end":735,"text":" but it can happen despite no changes in weight.","temperature":0,"avg_logprob":-0.08751433486238532,"compression_ratio":1.6705426356589148,"no_speech_prob":0.001987457275390625,"words":[]},{"start":735,"end":738,"text":" So, there must be something with these prediabetes drugs,","temperature":0,"avg_logprob":-0.08751433486238532,"compression_ratio":1.6705426356589148,"no_speech_prob":0.001987457275390625,"words":[]},{"start":738,"end":741,"text":" these diabetes drugs, these metabolic drugs, if you will,","temperature":0,"avg_logprob":-0.08751433486238532,"compression_ratio":1.6705426356589148,"no_speech_prob":0.001987457275390625,"words":[]},{"start":741,"end":745,"text":" that are affecting the joint health, the joint milieu,","temperature":0,"avg_logprob":-0.08751433486238532,"compression_ratio":1.6705426356589148,"no_speech_prob":0.001987457275390625,"words":[]},{"start":745,"end":749,"text":" in favor of improving disease burden.","temperature":0,"avg_logprob":-0.08751433486238532,"compression_ratio":1.6705426356589148,"no_speech_prob":0.001987457275390625,"words":[]},{"start":749,"end":753,"text":" I will pause there to see what your takeaway is.","temperature":0,"avg_logprob":-0.08751433486238532,"compression_ratio":1.6705426356589148,"no_speech_prob":0.001987457275390625,"words":[]},{"start":753,"end":755,"text":" And did you come across this?","temperature":0,"avg_logprob":-0.08751433486238532,"compression_ratio":1.6705426356589148,"no_speech_prob":0.001987457275390625,"words":[]},{"start":755,"end":757,"text":" Because they definitely caused some headlines","temperature":0,"avg_logprob":-0.08751433486238532,"compression_ratio":1.6705426356589148,"no_speech_prob":0.001987457275390625,"words":[]},{"start":757,"end":759,"text":" and a lot of my colleagues were sending it to me.","temperature":0,"avg_logprob":-0.08751433486238532,"compression_ratio":1.6705426356589148,"no_speech_prob":0.001987457275390625,"words":[]},{"start":760,"end":762,"text":" So, I think one of them had pointed out that, hey,","temperature":0,"avg_logprob":-0.2145220588235294,"compression_ratio":1.714705882352941,"no_speech_prob":0.413818359375,"words":[]},{"start":762,"end":764,"text":" they're, she's seeing some of our colleagues","temperature":0,"avg_logprob":-0.2145220588235294,"compression_ratio":1.714705882352941,"no_speech_prob":0.413818359375,"words":[]},{"start":764,"end":766,"text":" or maybe patients talking about this.","temperature":0,"avg_logprob":-0.2145220588235294,"compression_ratio":1.714705882352941,"no_speech_prob":0.413818359375,"words":[]},{"start":766,"end":768,"text":" Is this something that's been your on your radar?","temperature":0,"avg_logprob":-0.2145220588235294,"compression_ratio":1.714705882352941,"no_speech_prob":0.413818359375,"words":[]},{"start":768,"end":771,"text":" No, this is, the first time I've heard of this is when you sent it to me.","temperature":0,"avg_logprob":-0.2145220588235294,"compression_ratio":1.714705882352941,"no_speech_prob":0.413818359375,"words":[]},{"start":771,"end":773,"text":" The only thing that I recently saw,","temperature":0,"avg_logprob":-0.2145220588235294,"compression_ratio":1.714705882352941,"no_speech_prob":0.413818359375,"words":[]},{"start":773,"end":775,"text":" it was on Instagram, it was funny, on Polymarket,","temperature":0,"avg_logprob":-0.2145220588235294,"compression_ratio":1.714705882352941,"no_speech_prob":0.413818359375,"words":[]},{"start":775,"end":779,"text":" the page about GLP1's and both mineral density loss,","temperature":0,"avg_logprob":-0.2145220588235294,"compression_ratio":1.714705882352941,"no_speech_prob":0.413818359375,"words":[]},{"start":779,"end":781,"text":" and how rapid weight loss is causing that.","temperature":0,"avg_logprob":-0.2145220588235294,"compression_ratio":1.714705882352941,"no_speech_prob":0.413818359375,"words":[]},{"start":781,"end":783,"text":" So, that was something that was going back by my mind","temperature":0,"avg_logprob":-0.2145220588235294,"compression_ratio":1.714705882352941,"no_speech_prob":0.413818359375,"words":[]},{"start":783,"end":784,"text":" as I was looking at these papers.","temperature":0,"avg_logprob":-0.2145220588235294,"compression_ratio":1.714705882352941,"no_speech_prob":0.413818359375,"words":[]},{"start":784,"end":786,"text":" As much as the GLP1 standpoint is,","temperature":0,"avg_logprob":-0.2145220588235294,"compression_ratio":1.714705882352941,"no_speech_prob":0.413818359375,"words":[]},{"start":786,"end":787,"text":" while we look at OA,","temperature":0,"avg_logprob":-0.2145220588235294,"compression_ratio":1.714705882352941,"no_speech_prob":0.413818359375,"words":[]},{"start":787,"end":791,"text":" and then we look at other phenotype when you talk about rapid bone loss and osteoporosis,","temperature":0,"avg_logprob":-0.14030172413793104,"compression_ratio":1.7203947368421053,"no_speech_prob":0.0340576171875,"words":[]},{"start":791,"end":794,"text":" again, we could talk about this coming up in terms of","temperature":0,"avg_logprob":-0.14030172413793104,"compression_ratio":1.7203947368421053,"no_speech_prob":0.0340576171875,"words":[]},{"start":794,"end":796,"text":" who are the best candidates when you look at these papers","temperature":0,"avg_logprob":-0.14030172413793104,"compression_ratio":1.7203947368421053,"no_speech_prob":0.0340576171875,"words":[]},{"start":796,"end":798,"text":" to really ask your doctor and say,","temperature":0,"avg_logprob":-0.14030172413793104,"compression_ratio":1.7203947368421053,"no_speech_prob":0.0340576171875,"words":[]},{"start":798,"end":800,"text":" is it beneficial for me to be able to do the GLP1","temperature":0,"avg_logprob":-0.14030172413793104,"compression_ratio":1.7203947368421053,"no_speech_prob":0.0340576171875,"words":[]},{"start":800,"end":803,"text":" because, again, if you're a frail, elderly individual,","temperature":0,"avg_logprob":-0.14030172413793104,"compression_ratio":1.7203947368421053,"no_speech_prob":0.0340576171875,"words":[]},{"start":803,"end":806,"text":" then these papers may not exactly have the right idea","temperature":0,"avg_logprob":-0.14030172413793104,"compression_ratio":1.7203947368421053,"no_speech_prob":0.0340576171875,"words":[]},{"start":806,"end":808,"text":" from weight loss perspective,","temperature":0,"avg_logprob":-0.14030172413793104,"compression_ratio":1.7203947368421053,"no_speech_prob":0.0340576171875,"words":[]},{"start":808,"end":810,"text":" but for a minute again,","temperature":0,"avg_logprob":-0.14030172413793104,"compression_ratio":1.7203947368421053,"no_speech_prob":0.0340576171875,"words":[]},{"start":810,"end":812,"text":" it depends on kind of the goals.","temperature":0,"avg_logprob":-0.14030172413793104,"compression_ratio":1.7203947368421053,"no_speech_prob":0.0340576171875,"words":[]},{"start":812,"end":814,"text":" But for me, really, as I'm reading this,","temperature":0,"avg_logprob":-0.14030172413793104,"compression_ratio":1.7203947368421053,"no_speech_prob":0.0340576171875,"words":[]},{"start":814,"end":817,"text":" I've had people that have been talking to where colleagues, friends,","temperature":0,"avg_logprob":-0.1944224683544304,"compression_ratio":1.6676384839650147,"no_speech_prob":0.149658203125,"words":[]},{"start":817,"end":821,"text":" who are in this position where they could make a benefit from a GLP1.","temperature":0,"avg_logprob":-0.1944224683544304,"compression_ratio":1.6676384839650147,"no_speech_prob":0.149658203125,"words":[]},{"start":821,"end":823,"text":" They have arthritis, and they're asking me questions,","temperature":0,"avg_logprob":-0.1944224683544304,"compression_ratio":1.6676384839650147,"no_speech_prob":0.149658203125,"words":[]},{"start":823,"end":826,"text":" and oftentimes we're looking at standard treatment,","temperature":0,"avg_logprob":-0.1944224683544304,"compression_ratio":1.6676384839650147,"no_speech_prob":0.149658203125,"words":[]},{"start":826,"end":829,"text":" which is, I'd be profan, Tylenol, Abraise, Therapy,","temperature":0,"avg_logprob":-0.1944224683544304,"compression_ratio":1.6676384839650147,"no_speech_prob":0.149658203125,"words":[]},{"start":829,"end":831,"text":" Corticosteroid injections, maybe PRP.","temperature":0,"avg_logprob":-0.1944224683544304,"compression_ratio":1.6676384839650147,"no_speech_prob":0.149658203125,"words":[]},{"start":831,"end":833,"text":" So, these are the things that kind of get brought up to me,","temperature":0,"avg_logprob":-0.1944224683544304,"compression_ratio":1.6676384839650147,"no_speech_prob":0.149658203125,"words":[]},{"start":833,"end":835,"text":" but to think about it from this standpoint,","temperature":0,"avg_logprob":-0.1944224683544304,"compression_ratio":1.6676384839650147,"no_speech_prob":0.149658203125,"words":[]},{"start":835,"end":837,"text":" I think is really fascinating.","temperature":0,"avg_logprob":-0.1944224683544304,"compression_ratio":1.6676384839650147,"no_speech_prob":0.149658203125,"words":[]},{"start":837,"end":839,"text":" Yeah, all those are amazing options, right?","temperature":0,"avg_logprob":-0.1944224683544304,"compression_ratio":1.6676384839650147,"no_speech_prob":0.149658203125,"words":[]},{"start":839,"end":841,"text":" For somebody, I think I treat osteoarthritis probably more","temperature":0,"avg_logprob":-0.1944224683544304,"compression_ratio":1.6676384839650147,"no_speech_prob":0.149658203125,"words":[]},{"start":841,"end":843,"text":" so than any other thing I treat in my practice.","temperature":0,"avg_logprob":-0.14170258620689655,"compression_ratio":1.7854785478547854,"no_speech_prob":0.001064300537109375,"words":[]},{"start":843,"end":845,"text":" Everything that you're talking, I think,","temperature":0,"avg_logprob":-0.14170258620689655,"compression_ratio":1.7854785478547854,"no_speech_prob":0.001064300537109375,"words":[]},{"start":845,"end":848,"text":" is looking at the symptom burden of the disease.","temperature":0,"avg_logprob":-0.14170258620689655,"compression_ratio":1.7854785478547854,"no_speech_prob":0.001064300537109375,"words":[]},{"start":848,"end":850,"text":" I think this is still true,","temperature":0,"avg_logprob":-0.14170258620689655,"compression_ratio":1.7854785478547854,"no_speech_prob":0.001064300537109375,"words":[]},{"start":850,"end":853,"text":" that knee osteoarthritis is the leading cause of disability worldwide,","temperature":0,"avg_logprob":-0.14170258620689655,"compression_ratio":1.7854785478547854,"no_speech_prob":0.001064300537109375,"words":[]},{"start":853,"end":856,"text":" at this point, at least from a musculoskeletal standpoint.","temperature":0,"avg_logprob":-0.14170258620689655,"compression_ratio":1.7854785478547854,"no_speech_prob":0.001064300537109375,"words":[]},{"start":856,"end":858,"text":" That might not, maybe not overall,","temperature":0,"avg_logprob":-0.14170258620689655,"compression_ratio":1.7854785478547854,"no_speech_prob":0.001064300537109375,"words":[]},{"start":858,"end":861,"text":" but from a musculoskeletal standpoint, that's the number one.","temperature":0,"avg_logprob":-0.14170258620689655,"compression_ratio":1.7854785478547854,"no_speech_prob":0.001064300537109375,"words":[]},{"start":861,"end":863,"text":" When somebody is filing for disability,","temperature":0,"avg_logprob":-0.14170258620689655,"compression_ratio":1.7854785478547854,"no_speech_prob":0.001064300537109375,"words":[]},{"start":863,"end":866,"text":" symptoms is really the main thing for play they're going to have.","temperature":0,"avg_logprob":-0.14170258620689655,"compression_ratio":1.7854785478547854,"no_speech_prob":0.001064300537109375,"words":[]},{"start":866,"end":868,"text":" And so, if you can modulate those symptoms","temperature":0,"avg_logprob":-0.14170258620689655,"compression_ratio":1.7854785478547854,"no_speech_prob":0.001064300537109375,"words":[]},{"start":868,"end":870,"text":" with everything that you mentioned,","temperature":0,"avg_logprob":-0.1267123287671233,"compression_ratio":1.8753894080996885,"no_speech_prob":0.01168060302734375,"words":[]},{"start":870,"end":872,"text":" and other options that we haven't covered,","temperature":0,"avg_logprob":-0.1267123287671233,"compression_ratio":1.8753894080996885,"no_speech_prob":0.01168060302734375,"words":[]},{"start":872,"end":874,"text":" you're going to potentially improve their quality of light,","temperature":0,"avg_logprob":-0.1267123287671233,"compression_ratio":1.8753894080996885,"no_speech_prob":0.01168060302734375,"words":[]},{"start":874,"end":876,"text":" which is the main thing that you and I care about,","temperature":0,"avg_logprob":-0.1267123287671233,"compression_ratio":1.8753894080996885,"no_speech_prob":0.01168060302734375,"words":[]},{"start":876,"end":878,"text":" certainly in our practice, right?","temperature":0,"avg_logprob":-0.1267123287671233,"compression_ratio":1.8753894080996885,"no_speech_prob":0.01168060302734375,"words":[]},{"start":878,"end":880,"text":" But then there is another way to look at something.","temperature":0,"avg_logprob":-0.1267123287671233,"compression_ratio":1.8753894080996885,"no_speech_prob":0.01168060302734375,"words":[]},{"start":880,"end":882,"text":" Something could be disease modifying as well,","temperature":0,"avg_logprob":-0.1267123287671233,"compression_ratio":1.8753894080996885,"no_speech_prob":0.01168060302734375,"words":[]},{"start":882,"end":884,"text":" something could be structurally modifying as well.","temperature":0,"avg_logprob":-0.1267123287671233,"compression_ratio":1.8753894080996885,"no_speech_prob":0.01168060302734375,"words":[]},{"start":884,"end":886,"text":" So, disease modifying is what we're looking at here.","temperature":0,"avg_logprob":-0.1267123287671233,"compression_ratio":1.8753894080996885,"no_speech_prob":0.01168060302734375,"words":[]},{"start":886,"end":889,"text":" Because certainly, step nine trial showed that symptoms","temperature":0,"avg_logprob":-0.1267123287671233,"compression_ratio":1.8753894080996885,"no_speech_prob":0.01168060302734375,"words":[]},{"start":889,"end":891,"text":" has significantly improved, right?","temperature":0,"avg_logprob":-0.1267123287671233,"compression_ratio":1.8753894080996885,"no_speech_prob":0.01168060302734375,"words":[]},{"start":891,"end":894,"text":" We've got a clear signal here that's happening.","temperature":0,"avg_logprob":-0.1267123287671233,"compression_ratio":1.8753894080996885,"no_speech_prob":0.01168060302734375,"words":[]},{"start":894,"end":896,"text":" The question is if disease modifying,","temperature":0,"avg_logprob":-0.1267123287671233,"compression_ratio":1.8753894080996885,"no_speech_prob":0.01168060302734375,"words":[]},{"start":896,"end":898,"text":" and if so, how is that happening?","temperature":0,"avg_logprob":-0.15516826923076923,"compression_ratio":1.6539923954372624,"no_speech_prob":0.0005793571472167969,"words":[]},{"start":898,"end":901,"text":" So, I think at this point, maybe we take a step back, right?","temperature":0,"avg_logprob":-0.15516826923076923,"compression_ratio":1.6539923954372624,"no_speech_prob":0.0005793571472167969,"words":[]},{"start":901,"end":903,"text":" And try to understand some of the ways","temperature":0,"avg_logprob":-0.15516826923076923,"compression_ratio":1.6539923954372624,"no_speech_prob":0.0005793571472167969,"words":[]},{"start":903,"end":910,"text":" how excess adiposity can be toxic to the joint.","temperature":0,"avg_logprob":-0.15516826923076923,"compression_ratio":1.6539923954372624,"no_speech_prob":0.0005793571472167969,"words":[]},{"start":910,"end":912,"text":" And why some of the arguments are being made.","temperature":0,"avg_logprob":-0.15516826923076923,"compression_ratio":1.6539923954372624,"no_speech_prob":0.0005793571472167969,"words":[]},{"start":912,"end":914,"text":" And why we should actually, I think,","temperature":0,"avg_logprob":-0.15516826923076923,"compression_ratio":1.6539923954372624,"no_speech_prob":0.0005793571472167969,"words":[]},{"start":914,"end":916,"text":" that really pay attention to this.","temperature":0,"avg_logprob":-0.15516826923076923,"compression_ratio":1.6539923954372624,"no_speech_prob":0.0005793571472167969,"words":[]},{"start":916,"end":920,"text":" So, the reality is that that is,","temperature":0,"avg_logprob":-0.15516826923076923,"compression_ratio":1.6539923954372624,"no_speech_prob":0.0005793571472167969,"words":[]},{"start":920,"end":923,"text":" adipose, particularly, is an endocrine and immune organ.","temperature":0,"avg_logprob":-0.15516826923076923,"compression_ratio":1.6539923954372624,"no_speech_prob":0.0005793571472167969,"words":[]},{"start":923,"end":925,"text":" We know this. We've talked about this, right?","temperature":0,"avg_logprob":-0.15516826923076923,"compression_ratio":1.6539923954372624,"no_speech_prob":0.0005793571472167969,"words":[]},{"start":925,"end":926,"text":" How it's communicating.","temperature":0,"avg_logprob":-0.19028253424657535,"compression_ratio":1.6446540880503144,"no_speech_prob":0.01471710205078125,"words":[]},{"start":926,"end":928,"text":" And this way, it's just touching so many different things.","temperature":0,"avg_logprob":-0.19028253424657535,"compression_ratio":1.6446540880503144,"no_speech_prob":0.01471710205078125,"words":[]},{"start":928,"end":930,"text":" So, the GLP ones, like not only do they have indication","temperature":0,"avg_logprob":-0.19028253424657535,"compression_ratio":1.6446540880503144,"no_speech_prob":0.01471710205078125,"words":[]},{"start":930,"end":933,"text":" for diabetes and weight loss,","temperature":0,"avg_logprob":-0.19028253424657535,"compression_ratio":1.6446540880503144,"no_speech_prob":0.01471710205078125,"words":[]},{"start":933,"end":936,"text":" but trizipotite is FDA approved for sleep apnea.","temperature":0,"avg_logprob":-0.19028253424657535,"compression_ratio":1.6446540880503144,"no_speech_prob":0.01471710205078125,"words":[]},{"start":936,"end":940,"text":" And you, I think, one of them has level one data","temperature":0,"avg_logprob":-0.19028253424657535,"compression_ratio":1.6446540880503144,"no_speech_prob":0.01471710205078125,"words":[]},{"start":940,"end":942,"text":" and FDA approval for a mash, right?","temperature":0,"avg_logprob":-0.19028253424657535,"compression_ratio":1.6446540880503144,"no_speech_prob":0.01471710205078125,"words":[]},{"start":942,"end":945,"text":" Another one has cardio metabolic as well, heart failure.","temperature":0,"avg_logprob":-0.19028253424657535,"compression_ratio":1.6446540880503144,"no_speech_prob":0.01471710205078125,"words":[]},{"start":945,"end":948,"text":" So, you're getting all these things because it turns out","temperature":0,"avg_logprob":-0.19028253424657535,"compression_ratio":1.6446540880503144,"no_speech_prob":0.01471710205078125,"words":[]},{"start":948,"end":951,"text":" that metabolism seems to touch on multiple systems of the body.","temperature":0,"avg_logprob":-0.19028253424657535,"compression_ratio":1.6446540880503144,"no_speech_prob":0.01471710205078125,"words":[]},{"start":951,"end":954,"text":" So, it's an endocrine and an immune organ.","temperature":0,"avg_logprob":-0.19028253424657535,"compression_ratio":1.6446540880503144,"no_speech_prob":0.01471710205078125,"words":[]},{"start":955,"end":957,"text":" So, you have these things called adipocines,","temperature":0,"avg_logprob":-0.25483870967741934,"compression_ratio":1.7170418006430868,"no_speech_prob":0.1077880859375,"words":[]},{"start":957,"end":959,"text":" leptin, resistant, visfat, and in particular,","temperature":0,"avg_logprob":-0.25483870967741934,"compression_ratio":1.7170418006430868,"no_speech_prob":0.1077880859375,"words":[]},{"start":959,"end":962,"text":" they cause a lot of this condrocyte inflammation.","temperature":0,"avg_logprob":-0.25483870967741934,"compression_ratio":1.7170418006430868,"no_speech_prob":0.1077880859375,"words":[]},{"start":962,"end":965,"text":" Condrocytes are the cells of the cartilage.","temperature":0,"avg_logprob":-0.25483870967741934,"compression_ratio":1.7170418006430868,"no_speech_prob":0.1077880859375,"words":[]},{"start":965,"end":969,"text":" And they're going to increase this majorce-metalloprotinase","temperature":0,"avg_logprob":-0.25483870967741934,"compression_ratio":1.7170418006430868,"no_speech_prob":0.1077880859375,"words":[]},{"start":969,"end":972,"text":" activity, which is going to ultimately lead to degrading the cartilage.","temperature":0,"avg_logprob":-0.25483870967741934,"compression_ratio":1.7170418006430868,"no_speech_prob":0.1077880859375,"words":[]},{"start":972,"end":975,"text":" Insulin resistance, the other canary in the guanma.","temperature":0,"avg_logprob":-0.25483870967741934,"compression_ratio":1.7170418006430868,"no_speech_prob":0.1077880859375,"words":[]},{"start":975,"end":978,"text":" It's going to impair cartilage homeostasis, right?","temperature":0,"avg_logprob":-0.25483870967741934,"compression_ratio":1.7170418006430868,"no_speech_prob":0.1077880859375,"words":[]},{"start":978,"end":980,"text":" So, those advanced glycation end products","temperature":0,"avg_logprob":-0.25483870967741934,"compression_ratio":1.7170418006430868,"no_speech_prob":0.1077880859375,"words":[]},{"start":980,"end":981,"text":" that we talked about intended up,","temperature":0,"avg_logprob":-0.25483870967741934,"compression_ratio":1.7170418006430868,"no_speech_prob":0.1077880859375,"words":[]},{"start":981,"end":983,"text":" but they're either implicated as well.","temperature":0,"avg_logprob":-0.25483870967741934,"compression_ratio":1.7170418006430868,"no_speech_prob":0.1077880859375,"words":[]},{"start":983,"end":987,"text":" They tend to accumulate and are problematic for the joint","temperature":0,"avg_logprob":-0.11001016260162602,"compression_ratio":1.7735849056603774,"no_speech_prob":0.025146484375,"words":[]},{"start":987,"end":990,"text":" because instead of going through oxidative phosphorylation,","temperature":0,"avg_logprob":-0.11001016260162602,"compression_ratio":1.7735849056603774,"no_speech_prob":0.025146484375,"words":[]},{"start":990,"end":994,"text":" which is a more efficient mechanism energy production,","temperature":0,"avg_logprob":-0.11001016260162602,"compression_ratio":1.7735849056603774,"no_speech_prob":0.025146484375,"words":[]},{"start":994,"end":996,"text":" we're going more through glycolysis,","temperature":0,"avg_logprob":-0.11001016260162602,"compression_ratio":1.7735849056603774,"no_speech_prob":0.025146484375,"words":[]},{"start":996,"end":999,"text":" and that's more inefficient for your cartilage","temperature":0,"avg_logprob":-0.11001016260162602,"compression_ratio":1.7735849056603774,"no_speech_prob":0.025146484375,"words":[]},{"start":999,"end":1000,"text":" and your joint health.","temperature":0,"avg_logprob":-0.11001016260162602,"compression_ratio":1.7735849056603774,"no_speech_prob":0.025146484375,"words":[]},{"start":1000,"end":1004,"text":" And then you have synovium, which is what the joints are bathing.","temperature":0,"avg_logprob":-0.11001016260162602,"compression_ratio":1.7735849056603774,"no_speech_prob":0.025146484375,"words":[]},{"start":1004,"end":1007,"text":" So, you have the synovium through all of your joints","temperature":0,"avg_logprob":-0.11001016260162602,"compression_ratio":1.7735849056603774,"no_speech_prob":0.025146484375,"words":[]},{"start":1007,"end":1008,"text":" and circulating.","temperature":0,"avg_logprob":-0.11001016260162602,"compression_ratio":1.7735849056603774,"no_speech_prob":0.025146484375,"words":[]},{"start":1008,"end":1011,"text":" You'll have a lot of these M1 macrophage infiltration,","temperature":0,"avg_logprob":-0.11001016260162602,"compression_ratio":1.7735849056603774,"no_speech_prob":0.025146484375,"words":[]},{"start":1011,"end":1013,"text":" which is going to cause IL-6.","temperature":0,"avg_logprob":-0.13408203125,"compression_ratio":1.6385542168674698,"no_speech_prob":0.01448822021484375,"words":[]},{"start":1013,"end":1015,"text":" These are inflammatory cytokines, TNF alpha,","temperature":0,"avg_logprob":-0.13408203125,"compression_ratio":1.6385542168674698,"no_speech_prob":0.01448822021484375,"words":[]},{"start":1015,"end":1017,"text":" MMP, matrix degradation, all that's going to happen.","temperature":0,"avg_logprob":-0.13408203125,"compression_ratio":1.6385542168674698,"no_speech_prob":0.01448822021484375,"words":[]},{"start":1017,"end":1019,"text":" So, it's not just an autoimmune thing,","temperature":0,"avg_logprob":-0.13408203125,"compression_ratio":1.6385542168674698,"no_speech_prob":0.01448822021484375,"words":[]},{"start":1019,"end":1021,"text":" like rheumatoid arthritis is,","temperature":0,"avg_logprob":-0.13408203125,"compression_ratio":1.6385542168674698,"no_speech_prob":0.01448822021484375,"words":[]},{"start":1021,"end":1024,"text":" but it's also not inflammation-free.","temperature":0,"avg_logprob":-0.13408203125,"compression_ratio":1.6385542168674698,"no_speech_prob":0.01448822021484375,"words":[]},{"start":1024,"end":1027,"text":" So, maybe this is one of the reasons why we'll say,","temperature":0,"avg_logprob":-0.13408203125,"compression_ratio":1.6385542168674698,"no_speech_prob":0.01448822021484375,"words":[]},{"start":1027,"end":1031,"text":" oh, take NSAIDs for 10 days, let's kill the inflammation,","temperature":0,"avg_logprob":-0.13408203125,"compression_ratio":1.6385542168674698,"no_speech_prob":0.01448822021484375,"words":[]},{"start":1031,"end":1034,"text":" when maybe there's a small component to that,","temperature":0,"avg_logprob":-0.13408203125,"compression_ratio":1.6385542168674698,"no_speech_prob":0.01448822021484375,"words":[]},{"start":1034,"end":1037,"text":" but there's also the component that those are really good analgesics.","temperature":0,"avg_logprob":-0.13408203125,"compression_ratio":1.6385542168674698,"no_speech_prob":0.01448822021484375,"words":[]},{"start":1037,"end":1038,"text":" But when somebody injures their knee,","temperature":0,"avg_logprob":-0.13408203125,"compression_ratio":1.6385542168674698,"no_speech_prob":0.01448822021484375,"words":[]},{"start":1038,"end":1040,"text":" they might have some local swelling and stuff.","temperature":0,"avg_logprob":-0.13408203125,"compression_ratio":1.6385542168674698,"no_speech_prob":0.01448822021484375,"words":[]},{"start":1040,"end":1042,"text":" So, you know, there is some inflammation happening.","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1042,"end":1044,"text":" Now, NSAIDs, you brought it up,","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1044,"end":1045,"text":" and I just brought it up again.","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1045,"end":1047,"text":" There is a little bit of an interesting paradox,","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1047,"end":1050,"text":" because if we say that always not in inflammatory,","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1050,"end":1052,"text":" or we are saying if always in inflammatory,","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1052,"end":1054,"text":" then why are NSAIDs not working better?","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1054,"end":1056,"text":" Because it's the type of the local inflammation.","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1056,"end":1058,"text":" So, it's not necessarily the way NSAIDs work with","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1058,"end":1060,"text":" on your prostate gland in system.","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1060,"end":1062,"text":" I'm not going to get too deep into the immune pathway here.","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1062,"end":1065,"text":" But this is a different type of inflammation.","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1065,"end":1067,"text":" So, this is coming from those adipocines,","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1067,"end":1068,"text":" like I talked about, right?","temperature":0,"avg_logprob":-0.1320358187134503,"compression_ratio":1.8095238095238095,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1068,"end":1070,"text":" It's coming from the insulin resistance.","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1070,"end":1072,"text":" What other interesting thing that I learned","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1072,"end":1074,"text":" during this research here is half-as-fat fat.","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1074,"end":1076,"text":" You familiar with this one?","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1076,"end":1077,"text":" No, I've told you about it.","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1077,"end":1079,"text":" I know half-as-fat fat, at least.","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1079,"end":1080,"text":" Yeah.","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1080,"end":1082,"text":" So, everybody, underneath your kneecap,","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1082,"end":1084,"text":" that's the patella.","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1084,"end":1086,"text":" It's called the infra-patella fat pad.","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1086,"end":1088,"text":" So, you have the little tendon, if you're listening,","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1088,"end":1090,"text":" and you're driving or something like that,","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1090,"end":1092,"text":" you can feel underneath your kneecap.","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1092,"end":1094,"text":" It's going to be this roby little structure.","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1094,"end":1096,"text":" That's called your patella tendon.","temperature":0,"avg_logprob":-0.20265718562874252,"compression_ratio":1.8026755852842808,"no_speech_prob":0.00984954833984375,"words":[]},{"start":1096,"end":1098,"text":" That's going to get hurt.","temperature":0,"avg_logprob":-0.19093528368794327,"compression_ratio":1.6870503597122302,"no_speech_prob":0.0026721954345703125,"words":[]},{"start":1098,"end":1100,"text":" Right underneath that, deeper to that layer,","temperature":0,"avg_logprob":-0.19093528368794327,"compression_ratio":1.6870503597122302,"no_speech_prob":0.0026721954345703125,"words":[]},{"start":1100,"end":1102,"text":" is a big fat, everybody has this,","temperature":0,"avg_logprob":-0.19093528368794327,"compression_ratio":1.6870503597122302,"no_speech_prob":0.0026721954345703125,"words":[]},{"start":1102,"end":1104,"text":" called half-as-fat pad or infra-patella fat pad.","temperature":0,"avg_logprob":-0.19093528368794327,"compression_ratio":1.6870503597122302,"no_speech_prob":0.0026721954345703125,"words":[]},{"start":1104,"end":1107,"text":" So, this is directly overlying your joint.","temperature":0,"avg_logprob":-0.19093528368794327,"compression_ratio":1.6870503597122302,"no_speech_prob":0.0026721954345703125,"words":[]},{"start":1107,"end":1109,"text":" And this actually turns out,","temperature":0,"avg_logprob":-0.19093528368794327,"compression_ratio":1.6870503597122302,"no_speech_prob":0.0026721954345703125,"words":[]},{"start":1109,"end":1111,"text":" is a local inflammatory source as well.","temperature":0,"avg_logprob":-0.19093528368794327,"compression_ratio":1.6870503597122302,"no_speech_prob":0.0026721954345703125,"words":[]},{"start":1111,"end":1113,"text":" So, just like you have,","temperature":0,"avg_logprob":-0.19093528368794327,"compression_ratio":1.6870503597122302,"no_speech_prob":0.0026721954345703125,"words":[]},{"start":1113,"end":1117,"text":" maybe central adiposity, you have visceral fat.","temperature":0,"avg_logprob":-0.19093528368794327,"compression_ratio":1.6870503597122302,"no_speech_prob":0.0026721954345703125,"words":[]},{"start":1117,"end":1122,"text":" That local fat is going to put a lot of those inflammatory cytokines","temperature":0,"avg_logprob":-0.19093528368794327,"compression_ratio":1.6870503597122302,"no_speech_prob":0.0026721954345703125,"words":[]},{"start":1122,"end":1124,"text":" and those, quote, unquote, bad cells,","temperature":0,"avg_logprob":-0.19093528368794327,"compression_ratio":1.6870503597122302,"no_speech_prob":0.0026721954345703125,"words":[]},{"start":1124,"end":1125,"text":" into the joint directly.","temperature":0,"avg_logprob":-0.19093528368794327,"compression_ratio":1.6870503597122302,"no_speech_prob":0.0026721954345703125,"words":[]},{"start":1125,"end":1127,"text":" And so, that's maybe another reason,","temperature":0,"avg_logprob":-0.137525826446281,"compression_ratio":1.6282527881040891,"no_speech_prob":0.005466461181640625,"words":[]},{"start":1127,"end":1129,"text":" why the knee, in particular,","temperature":0,"avg_logprob":-0.137525826446281,"compression_ratio":1.6282527881040891,"no_speech_prob":0.005466461181640625,"words":[]},{"start":1129,"end":1134,"text":" is subject to this metabolic ill-health system,","temperature":0,"avg_logprob":-0.137525826446281,"compression_ratio":1.6282527881040891,"no_speech_prob":0.005466461181640625,"words":[]},{"start":1134,"end":1136,"text":" and actually these medications tend to work better.","temperature":0,"avg_logprob":-0.137525826446281,"compression_ratio":1.6282527881040891,"no_speech_prob":0.005466461181640625,"words":[]},{"start":1136,"end":1138,"text":" So, that's one thought as well.","temperature":0,"avg_logprob":-0.137525826446281,"compression_ratio":1.6282527881040891,"no_speech_prob":0.005466461181640625,"words":[]},{"start":1138,"end":1142,"text":" The one thing I should say about the glucose piece,","temperature":0,"avg_logprob":-0.137525826446281,"compression_ratio":1.6282527881040891,"no_speech_prob":0.005466461181640625,"words":[]},{"start":1142,"end":1143,"text":" I know we've talked about the antenna knob,","temperature":0,"avg_logprob":-0.137525826446281,"compression_ratio":1.6282527881040891,"no_speech_prob":0.005466461181640625,"words":[]},{"start":1143,"end":1145,"text":" but when I came to,","temperature":0,"avg_logprob":-0.137525826446281,"compression_ratio":1.6282527881040891,"no_speech_prob":0.005466461181640625,"words":[]},{"start":1145,"end":1147,"text":" dig a little bit deeper into this,","temperature":0,"avg_logprob":-0.137525826446281,"compression_ratio":1.6282527881040891,"no_speech_prob":0.005466461181640625,"words":[]},{"start":1147,"end":1150,"text":" that the biology at the bench level is pretty real,","temperature":0,"avg_logprob":-0.137525826446281,"compression_ratio":1.6282527881040891,"no_speech_prob":0.005466461181640625,"words":[]},{"start":1150,"end":1153,"text":" but the human causality contribution,","temperature":0,"avg_logprob":-0.137525826446281,"compression_ratio":1.6282527881040891,"no_speech_prob":0.005466461181640625,"words":[]},{"start":1153,"end":1156,"text":" can't really be separated from body fat.","temperature":0,"avg_logprob":-0.11882267441860465,"compression_ratio":1.6761565836298933,"no_speech_prob":0.005817413330078125,"words":[]},{"start":1156,"end":1158,"text":" And when you look at the RCTs,","temperature":0,"avg_logprob":-0.11882267441860465,"compression_ratio":1.6761565836298933,"no_speech_prob":0.005817413330078125,"words":[]},{"start":1158,"end":1160,"text":" there's one thing you look rather to observational studies,","temperature":0,"avg_logprob":-0.11882267441860465,"compression_ratio":1.6761565836298933,"no_speech_prob":0.005817413330078125,"words":[]},{"start":1160,"end":1161,"text":" that's one thing,","temperature":0,"avg_logprob":-0.11882267441860465,"compression_ratio":1.6761565836298933,"no_speech_prob":0.005817413330078125,"words":[]},{"start":1161,"end":1163,"text":" but the Mendelian randomization studies","temperature":0,"avg_logprob":-0.11882267441860465,"compression_ratio":1.6761565836298933,"no_speech_prob":0.005817413330078125,"words":[]},{"start":1163,"end":1165,"text":" will show that adiposity is the lead actor.","temperature":0,"avg_logprob":-0.11882267441860465,"compression_ratio":1.6761565836298933,"no_speech_prob":0.005817413330078125,"words":[]},{"start":1165,"end":1168,"text":" And because even people who have elevated glucose,","temperature":0,"avg_logprob":-0.11882267441860465,"compression_ratio":1.6761565836298933,"no_speech_prob":0.005817413330078125,"words":[]},{"start":1168,"end":1172,"text":" they've not had an elevated risk osteoarthritis burden.","temperature":0,"avg_logprob":-0.11882267441860465,"compression_ratio":1.6761565836298933,"no_speech_prob":0.005817413330078125,"words":[]},{"start":1172,"end":1174,"text":" Does that make sense right there?","temperature":0,"avg_logprob":-0.11882267441860465,"compression_ratio":1.6761565836298933,"no_speech_prob":0.005817413330078125,"words":[]},{"start":1174,"end":1175,"text":" Cool.","temperature":0,"avg_logprob":-0.11882267441860465,"compression_ratio":1.6761565836298933,"no_speech_prob":0.005817413330078125,"words":[]},{"start":1175,"end":1177,"text":" Anything interesting there,","temperature":0,"avg_logprob":-0.11882267441860465,"compression_ratio":1.6761565836298933,"no_speech_prob":0.005817413330078125,"words":[]},{"start":1177,"end":1179,"text":" anything that you've learned with the mechanism,","temperature":0,"avg_logprob":-0.11882267441860465,"compression_ratio":1.6761565836298933,"no_speech_prob":0.005817413330078125,"words":[]},{"start":1179,"end":1180,"text":" specifically,","temperature":0,"avg_logprob":-0.11882267441860465,"compression_ratio":1.6761565836298933,"no_speech_prob":0.005817413330078125,"words":[]},{"start":1180,"end":1184,"text":" exercise at aposity is problematic for joints?","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1184,"end":1186,"text":" No, I think it makes sense to me.","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1186,"end":1188,"text":" I think even for our listeners,","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1188,"end":1189,"text":" I think as they listen,","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1189,"end":1191,"text":" and they can relate it to themselves or their patients.","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1191,"end":1193,"text":" To me, I don't know if you have more to go,","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1193,"end":1194,"text":" but a lot of this,","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1194,"end":1195,"text":" how does this affect the future?","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1195,"end":1197,"text":" How does this affect practice in the future?","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1197,"end":1199,"text":" But if you have more mechanisms right there,","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1199,"end":1200,"text":" I'd go for it.","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1200,"end":1201,"text":" I'm going to get to that.","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1201,"end":1202,"text":" I promise I will.","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1202,"end":1203,"text":" We want to make it actionable.","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1203,"end":1204,"text":" I think more important than,","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1204,"end":1205,"text":" as sexy as these things are,","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1205,"end":1206,"text":" which, to be honest,","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1206,"end":1207,"text":" the further I get into it,","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1207,"end":1208,"text":" the more patients that treat,","temperature":0,"avg_logprob":-0.15683489304812834,"compression_ratio":1.819277108433735,"no_speech_prob":0.088623046875,"words":[]},{"start":1208,"end":1209,"text":" it's not that sexy.","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1209,"end":1210,"text":" It's fun.","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1210,"end":1211,"text":" It's exciting.","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1211,"end":1212,"text":" And then the question is,","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1212,"end":1213,"text":" one of my college room is used to say,","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1213,"end":1214,"text":" and then what?","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1214,"end":1215,"text":" I have information that's what we do on about this.","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1215,"end":1217,"text":" But one thing I do want to plug in,","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1217,"end":1218,"text":" because my buddy,","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1218,"end":1219,"text":" Amek, I shout out to you if you're listening,","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1219,"end":1220,"text":" he had sent this, right?","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1220,"end":1221,"text":" So this isn't a paper","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1221,"end":1223,"text":" that was published in Selma Tapasam.","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1223,"end":1225,"text":" I think March this year,","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1225,"end":1226,"text":" 2026,","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1226,"end":1230,"text":" and to piggyback off of that step nine trial,","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1230,"end":1231,"text":" looking at semiconductor,","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1231,"end":1233,"text":" they wanted to see,","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1233,"end":1235,"text":" hey, is it actually a weight dependent effect","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1235,"end":1236,"text":" or weight independent effect?","temperature":0,"avg_logprob":-0.2211671270718232,"compression_ratio":1.6587537091988132,"no_speech_prob":0.15771484375,"words":[]},{"start":1237,"end":1238,"text":" So what they did was,","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1238,"end":1240,"text":" they had somewhat elegant mice study,","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1240,"end":1242,"text":" but they took high-fat diet,","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1242,"end":1243,"text":" obese mice, right?","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1243,"end":1245,"text":" And they destabilized the needle miniscus.","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1245,"end":1247,"text":" So the meat miniscus is the cartilage between the knee,","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1247,"end":1250,"text":" it provides cushioning and stabilization of the knee,","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1250,"end":1251,"text":" and resectated it,","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1251,"end":1252,"text":" injured it,","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1252,"end":1255,"text":" and the one side on the mice got weekly stomach lose hide,","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1255,"end":1256,"text":" versus a control,","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1256,"end":1258,"text":" and they were a pair-fat group.","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1258,"end":1261,"text":" And so both of them had restricted food","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1261,"end":1264,"text":" to try to get them to lose the same exact amount of weight,","temperature":0,"avg_logprob":-0.22951858108108109,"compression_ratio":1.7421602787456445,"no_speech_prob":0.316162109375,"words":[]},{"start":1264,"end":1265,"text":" which they did.","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1265,"end":1268,"text":" Now, what they noted was the mice","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1268,"end":1270,"text":" with the semi-glutide versus the mice","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1270,"end":1272,"text":" who did not get them medication,","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1272,"end":1273,"text":" but still lost the same amount of weight,","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1273,"end":1275,"text":" they had no meaningful cartilage protection.","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1275,"end":1278,"text":" The semi-glutide mice did have that.","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1278,"end":1279,"text":" So now,","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1279,"end":1280,"text":" you've taken the weight out of the picture","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1280,"end":1281,"text":" because both of them lost weight, right?","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1281,"end":1283,"text":" So there's something happening here,","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1283,"end":1285,"text":" where semi-glutide is causing,","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1285,"end":1287,"text":" or offering some type of protection is what they think.","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1287,"end":1289,"text":" How did they measure that, right?","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1289,"end":1291,"text":" So they measured the cartilage loss","temperature":0,"avg_logprob":-0.11636513157894737,"compression_ratio":1.8996415770609318,"no_speech_prob":0.01186370849609375,"words":[]},{"start":1291,"end":1293,"text":" and protection with micro CT,","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1293,"end":1294,"text":" histology,","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1294,"end":1296,"text":" and pain behavior testing as well.","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1296,"end":1297,"text":" They went in a step further.","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1297,"end":1299,"text":" Then they knocked out,","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1299,"end":1302,"text":" so they knocked out the GLP-1 receptor gene,","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1302,"end":1304,"text":" and what they noted was the effect was gone.","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1304,"end":1306,"text":" So that's cool.","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1306,"end":1308,"text":" Again, this is not human studies,","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1308,"end":1310,"text":" but what it is able to show","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1310,"end":1313,"text":" is that maybe that this medication,","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1313,"end":1314,"text":" this medication,","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1314,"end":1316,"text":" enough familiar if metformat has done something like that,","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1316,"end":1318,"text":" but in observation of large trials,","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1318,"end":1320,"text":" they've been able to pick up a similar signal.","temperature":0,"avg_logprob":-0.14689700704225353,"compression_ratio":1.6723549488054608,"no_speech_prob":0.01047515869140625,"words":[]},{"start":1320,"end":1322,"text":" I think that kind of is really exciting,","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1322,"end":1324,"text":" and that's the type of stuff that you need","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1324,"end":1326,"text":" to get this pushing forward.","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1326,"end":1328,"text":" Now, I know,","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1328,"end":1329,"text":" no minor risk,","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1329,"end":1330,"text":" and I think Eli Lilly has a register","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1330,"end":1331,"text":" to try to call stop,","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1331,"end":1332,"text":" Neostruth,","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1332,"end":1333,"text":" and Neostruth, right?","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1333,"end":1334,"text":" As well,","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1334,"end":1336,"text":" that the register to try to really get indication,","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1336,"end":1338,"text":" because right now,","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1338,"end":1340,"text":" these medications are not FDA-approved","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1340,"end":1341,"text":" for osteoarthritis.","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1341,"end":1343,"text":" So it's not the medication","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1343,"end":1344,"text":" that you're going in,","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1344,"end":1345,"text":" because of osteoarthritis","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1345,"end":1347,"text":" that should be on this medication,","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1347,"end":1349,"text":" because they might be better medications out there.","temperature":0,"avg_logprob":-0.2053840361445783,"compression_ratio":1.8501742160278745,"no_speech_prob":0.00817108154296875,"words":[]},{"start":1349,"end":1351,"text":" If you're going to use this medication,","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1351,"end":1352,"text":" you want to think about,","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1352,"end":1353,"text":" look, why are we doing it?","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1353,"end":1355,"text":" And I guess maybe the question","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1355,"end":1356,"text":" that maybe you're getting at is,","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1356,"end":1358,"text":" who is the right person","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1358,"end":1360,"text":" who we can identify that,","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1360,"end":1361,"text":" hey, we got to look at that.","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1361,"end":1364,"text":" So given everything that I've presented to you at this point,","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1364,"end":1366,"text":" one, do you have any questions about this study?","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1366,"end":1367,"text":" And then two,","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1367,"end":1369,"text":" how would this change your practice?","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1369,"end":1371,"text":" And how would you use this information","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1371,"end":1372,"text":" to try to identify","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1372,"end":1373,"text":" or profile that person,","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1373,"end":1374,"text":" if I can use that word,","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1374,"end":1377,"text":" who maybe this is a conversation for?","temperature":0,"avg_logprob":-0.09291470125786164,"compression_ratio":1.8305084745762712,"no_speech_prob":0.0171661376953125,"words":[]},{"start":1378,"end":1379,"text":" Yeah, I guess,","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1379,"end":1381,"text":" I think the questions the listeners might have is,","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1381,"end":1384,"text":" do we know if osteoarthritis is reversible?","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1384,"end":1385,"text":" So these medications are helping,","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1385,"end":1387,"text":" and there's an inflammatory process","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1387,"end":1388,"text":" that is disease-modifying.","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1388,"end":1390,"text":" Are we able to then go back","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1390,"end":1391,"text":" on the class patients?","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1391,"end":1392,"text":" Can we go from the severe osteoarthritic","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1392,"end":1394,"text":" knee joint to now moderate?","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1394,"end":1395,"text":" Yeah.","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1395,"end":1396,"text":" That's an unanswered question.","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1396,"end":1398,"text":" We don't know that yet, right?","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1398,"end":1400,"text":" So that would be the whole disease","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1400,"end":1401,"text":" and structural modifying thing","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1401,"end":1402,"text":" that we have to look at,","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1402,"end":1403,"text":" because like we talked about is,","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1403,"end":1404,"text":" yeah, you would have to look at this for long enough.","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1404,"end":1406,"text":" We know that osteoarthritis","temperature":0,"avg_logprob":-0.13325140449438203,"compression_ratio":1.7804154302670623,"no_speech_prob":0.062744140625,"words":[]},{"start":1406,"end":1408,"text":" is a progressive disease at this point.","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1408,"end":1410,"text":" I tell people when they come in with osteoarthritis,","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1410,"end":1411,"text":" and they're like,","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1411,"end":1412,"text":" man, I got really bad away,","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1412,"end":1413,"text":" and I say, hey, congratulations,","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1413,"end":1414,"text":" they look at me.","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1414,"end":1415,"text":" Really weird, I'm like,","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1415,"end":1417,"text":" that means you've lived long enough to accumulate them.","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1417,"end":1418,"text":" So there is an accumulation.","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1418,"end":1421,"text":" It might not necessarily be wear and tear.","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1421,"end":1423,"text":" There is some level wear and tear,","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1423,"end":1424,"text":" but it might necessarily be all wear and tear,","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1424,"end":1426,"text":" but it is a progressive, right?","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1426,"end":1428,"text":" Processed, probably,","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1428,"end":1431,"text":" as what we say about heart disease and hypertension,","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1431,"end":1433,"text":" the number one risk factor is age.","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1433,"end":1434,"text":" People in their 70s","temperature":0,"avg_logprob":-0.13685661764705884,"compression_ratio":1.804953560371517,"no_speech_prob":0.009857177734375,"words":[]},{"start":1434,"end":1436,"text":" are more likely to have it in their 20s.","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1436,"end":1438,"text":" But disease modifying is the interesting question","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1438,"end":1439,"text":" which we have to ask.","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1439,"end":1440,"text":" And I think this cell study,","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1440,"end":1441,"text":" this mice study,","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1441,"end":1442,"text":" is one piece of the puzzle.","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1442,"end":1443,"text":" Metformin is similar.","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1443,"end":1446,"text":" I think the one thing I didn't mention is,","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1446,"end":1449,"text":" both of them are converging on the similar mechanism.","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1449,"end":1452,"text":" And that mechanism is looking at AMPK,","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1452,"end":1454,"text":" which is the AMP protein kinase.","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1454,"end":1455,"text":" People have heard that,","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1455,"end":1456,"text":" the MTOR pathway as well,","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1456,"end":1458,"text":" and that's really how Metform is working.","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1458,"end":1461,"text":" That part of the list sells.","temperature":0,"avg_logprob":-0.1397804054054054,"compression_ratio":1.6938775510204083,"no_speech_prob":0.007114410400390625,"words":[]},{"start":1461,"end":1464,"text":" And GLP1 also is going mediated","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1464,"end":1466,"text":" through the AMPK pathway as well.","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1466,"end":1469,"text":" I think there is a conversation about the gut joint pathway,","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1469,"end":1470,"text":" everything,","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1470,"end":1472,"text":" as other people have said starts with the gut, right?","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1472,"end":1473,"text":" As you would know.","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1473,"end":1475,"text":" But really, its AMPK modulation is what's happening.","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1475,"end":1476,"text":" You have some GLP,","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1476,"end":1478,"text":" one receptors into the joint.","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1478,"end":1479,"text":" So these questions,","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1479,"end":1481,"text":" these studies, as recent as two months ago,","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1481,"end":1483,"text":" are starting to put some information out there","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1483,"end":1485,"text":" that we have to test a little bit more","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1485,"end":1486,"text":" to see what's going on.","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1486,"end":1487,"text":" Cool.","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1487,"end":1488,"text":" This.","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1488,"end":1489,"text":" So,","temperature":0,"avg_logprob":-0.18482730263157895,"compression_ratio":1.6384364820846906,"no_speech_prob":0.1910400390625,"words":[]},{"start":1489,"end":1490,"text":" go back there,","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1490,"end":1492,"text":" try to figure out who the right patient is.","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1492,"end":1493,"text":" That's the question now.","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1493,"end":1494,"text":" For you.","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1494,"end":1495,"text":" Given this information I give you,","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1495,"end":1497,"text":" how would you think about,","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1497,"end":1498,"text":" hey, should I consider this,","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1498,"end":1500,"text":" where you would open the conversation?","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1500,"end":1501,"text":" Yeah.","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1501,"end":1503,"text":" So I think what's interesting again,","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1503,"end":1506,"text":" is the first headline is,","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1506,"end":1507,"text":" OA Metabolic Disease.","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1507,"end":1510,"text":" So regardless of who has the OA,","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1510,"end":1512,"text":" let's say they're elderly,","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1512,"end":1514,"text":" sure we might think it's more age related,","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1514,"end":1515,"text":" like you said.","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1515,"end":1516,"text":" If they're younger,","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1516,"end":1518,"text":" we put up a little bit more top of mind","temperature":0,"avg_logprob":-0.18596813725490197,"compression_ratio":1.6366666666666667,"no_speech_prob":0.04730224609375,"words":[]},{"start":1518,"end":1519,"text":" to make it okay.","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1519,"end":1521,"text":" Especially if they have a higher BMI,","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1521,"end":1523,"text":" they have an ASCVD risk,","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1523,"end":1525,"text":" they've got things like fatty liver,","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1525,"end":1527,"text":" they do show the side of the symptoms","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1527,"end":1529,"text":" of metabolic syndrome.","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1529,"end":1531,"text":" Is that something that we go and look for, right?","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1531,"end":1532,"text":" That's also the question.","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1532,"end":1536,"text":" So we're trained that you don't necessarily order something","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1536,"end":1537,"text":" unless you're going to do something about it.","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1537,"end":1539,"text":" And even when you do order something,","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1539,"end":1540,"text":" sometimes you don't,","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1540,"end":1541,"text":" because it can put you in trouble,","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1541,"end":1542,"text":" because now you're responsible","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1542,"end":1544,"text":" for kind of treating that, right?","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1544,"end":1546,"text":" And I don't think a lot of patients understand that,","temperature":0,"avg_logprob":-0.15711805555555555,"compression_ratio":1.784375,"no_speech_prob":0.048797607421875,"words":[]},{"start":1546,"end":1547,"text":" but it's always a tough discussion.","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1547,"end":1548,"text":" It's okay.","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1548,"end":1551,"text":" The best way I explain it is getting a full body MRI, right?","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1551,"end":1553,"text":" The reason why you don't do it is sometimes is","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1553,"end":1554,"text":" you see something,","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1554,"end":1555,"text":" you want to treat it,","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1555,"end":1556,"text":" but in the end it's actually benign.","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1556,"end":1558,"text":" And so that can go for all sorts of imaging","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1558,"end":1559,"text":" from the back to the knee,","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1559,"end":1560,"text":" and et cetera.","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1560,"end":1562,"text":" That being said,","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1562,"end":1564,"text":" does the astute physician now say,","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1564,"end":1566,"text":" okay, you have knee OA?","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1566,"end":1568,"text":" Should we go out and also look for things like","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1568,"end":1569,"text":" fatty liver syndrome?","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1569,"end":1572,"text":" Should we go out and get a lipid panel again","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1572,"end":1573,"text":" if you haven't done it?","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1573,"end":1574,"text":" Check your A1C.","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1574,"end":1575,"text":" Do all these things that seem pretty standard,","temperature":0,"avg_logprob":-0.12567567567567567,"compression_ratio":1.6666666666666667,"no_speech_prob":0.006191253662109375,"words":[]},{"start":1575,"end":1578,"text":" but actually do more of a little bit of a deep dive on it","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1578,"end":1580,"text":" to see if metabolic syndrome","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1580,"end":1582,"text":" in its totality kind of exists?","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1582,"end":1584,"text":" Probably, yes.","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1584,"end":1585,"text":" Like I would say,","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1585,"end":1589,"text":" I think that I've changed up my documentation a little bit.","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1589,"end":1591,"text":" And so there are certain people","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1591,"end":1592,"text":" what I think that,","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1592,"end":1594,"text":" like the idea of precision medicine,","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1594,"end":1596,"text":" then subclassifying osteoarthritis","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1596,"end":1598,"text":" is the big takeaway for me on this.","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1598,"end":1600,"text":" And so certain people,","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1600,"end":1601,"text":" which I can tell you,","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1601,"end":1603,"text":" who I think I'm going to start labeling this for,","temperature":0,"avg_logprob":-0.1322992700729927,"compression_ratio":1.6666666666666667,"no_speech_prob":0.0140533447265625,"words":[]},{"start":1604,"end":1605,"text":" is where I would say,","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1605,"end":1608,"text":" oh, this patient probably has the METS dash away.","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1608,"end":1610,"text":" It's a metabolic syndrome away.","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1610,"end":1612,"text":" And either we already know","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1612,"end":1615,"text":" that they have fatty liver disease, right?","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1615,"end":1617,"text":" Or we know that they are prediabetic.","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1617,"end":1619,"text":" We can see,","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1619,"end":1621,"text":" and we know that they're dealing with","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1621,"end":1622,"text":" exoscientiposity right there,","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1622,"end":1623,"text":" and that could be waste,","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1623,"end":1625,"text":" waste to height circumference.","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1625,"end":1627,"text":" And those races we can look at,","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1627,"end":1629,"text":" maybe they already have hypertension,","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1629,"end":1631,"text":" those other metabolic symptoms that I talked about.","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1631,"end":1632,"text":" And now we're diagnosing with osteoarthritis,","temperature":0,"avg_logprob":-0.21895833333333334,"compression_ratio":1.739864864864865,"no_speech_prob":0.0240325927734375,"words":[]},{"start":1632,"end":1633,"text":" which is either later,","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1633,"end":1635,"text":" or we're seeing,","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1635,"end":1638,"text":" actually, now that we're talking about it,","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1638,"end":1642,"text":" I'm not sure that you can diagnose osteoarthritis","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1642,"end":1643,"text":" and then go the other way,","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1643,"end":1645,"text":" unless you have these other signals.","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1645,"end":1649,"text":" Like somebody just comes in with osteoarthritis in isolation.","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1649,"end":1651,"text":" And I think there would be one hint","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1651,"end":1652,"text":" that would give that, right?","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1652,"end":1653,"text":" And that would be,","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1653,"end":1656,"text":" if somebody has osteoarthritis in multiple joints.","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1656,"end":1658,"text":" Typically, when you hear somebody","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1658,"end":1659,"text":" has osteoarthritis in multiple joints,","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1659,"end":1660,"text":" what did medical students teach us?","temperature":0,"avg_logprob":-0.10722931338028169,"compression_ratio":1.8661710037174721,"no_speech_prob":0.0032215118408203125,"words":[]},{"start":1661,"end":1662,"text":" That's going to be the,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1662,"end":1665,"text":" what type of pattern that we talked about, the phenotypes.","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1665,"end":1667,"text":" I know you love when I put you on the side.","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1667,"end":1668,"text":" Yeah, I know, I'm like,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1668,"end":1669,"text":" we don't like it here, man.","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1669,"end":1670,"text":" I don't think I'm dull with this.","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1670,"end":1672,"text":" Well, you talk about bilateral,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1672,"end":1673,"text":" or just, you know,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1673,"end":1674,"text":" wrist bilateral.","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1674,"end":1675,"text":" Okay, then, yeah,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1675,"end":1676,"text":" we're thinking to play a tutorial,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1676,"end":1677,"text":" right?","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1677,"end":1678,"text":" Yeah, we're thinking to say,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1678,"end":1679,"text":" I think, yeah.","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1679,"end":1680,"text":" What was interesting is,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1680,"end":1681,"text":" when, for our step one,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1681,"end":1682,"text":" and stuff like, oh,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1682,"end":1683,"text":" is, you know,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1683,"end":1684,"text":" if somebody comes in the morning","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1684,"end":1686,"text":" and they're knee pain worsens throughout the day,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1686,"end":1687,"text":" it's more osteoarthritis.","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1687,"end":1688,"text":" Somebody comes up,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1688,"end":1689,"text":" they have bilateral wrist,","temperature":0,"avg_logprob":-0.2931547619047619,"compression_ratio":1.8402366863905326,"no_speech_prob":0.0151824951171875,"words":[]},{"start":1689,"end":1690,"text":" and like, that's,","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1690,"end":1691,"text":" it's in temperature.","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1691,"end":1692,"text":" So it's like, those are the two buckets.","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1692,"end":1693,"text":" It's a fork in the road.","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1693,"end":1694,"text":" And that's actually not the case here.","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1694,"end":1696,"text":" The reason I say that is,","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1696,"end":1699,"text":" if somebody just comes in with a unilateral knee away,","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1699,"end":1701,"text":" then why would a metabolic component","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1701,"end":1702,"text":" be only affecting them?","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1702,"end":1705,"text":" But if somebody comes in with a little bit more of a,","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1705,"end":1707,"text":" oh, man, my hands are a little bit achy,","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1707,"end":1708,"text":" and both knees are aching,","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1708,"end":1709,"text":" and two knees,","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1709,"end":1710,"text":" and a hip and stuff like that.","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1710,"end":1711,"text":" Okay.","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1711,"end":1712,"text":" Yes, you could think about an inflammatory component,","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1712,"end":1714,"text":" but there could be a metabolic component too,","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1714,"end":1716,"text":" which we know is causing a little bit of inflammation,","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1716,"end":1717,"text":" but different type of an inflammation,","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1717,"end":1718,"text":" right?","temperature":0,"avg_logprob":-0.16370558375634517,"compression_ratio":1.8857142857142857,"no_speech_prob":0.002887725830078125,"words":[]},{"start":1718,"end":1720,"text":" So within the inflammatory pathway,","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1720,"end":1723,"text":" I suppose you could have another fork in the road.","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1723,"end":1724,"text":" But now, especially,","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1724,"end":1725,"text":" especially if all those,","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1725,"end":1728,"text":" especially if a lot of the autoimmune stuff is negative,","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1728,"end":1729,"text":" right?","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1729,"end":1731,"text":" Which we see all the time.","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1731,"end":1732,"text":" That's a brilliant thing.","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1732,"end":1733,"text":" This is one of those things where,","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1733,"end":1734,"text":" yeah, patients come up to,","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1734,"end":1735,"text":" like, everything hurts,","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1735,"end":1736,"text":" and I have,","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1736,"end":1737,"text":" I'm guilty of this,","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1737,"end":1738,"text":" right?","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1738,"end":1739,"text":" Because I won't do this anymore.","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1739,"end":1740,"text":" Well, I just try not to,","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1740,"end":1741,"text":" is they'll come in,","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1741,"end":1742,"text":" everything hurts.","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1742,"end":1743,"text":" I'm like, you got to go see rheumatology.","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1743,"end":1744,"text":" They go to rheumatology,","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1744,"end":1746,"text":" and they get the full rheumatological workout.","temperature":0,"avg_logprob":-0.1573304521276596,"compression_ratio":1.8080495356037152,"no_speech_prob":0.00638580322265625,"words":[]},{"start":1747,"end":1749,"text":" And what's interesting is a lot of times people","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1749,"end":1750,"text":" will come back with a diagnosis,","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1750,"end":1752,"text":" you have RA negative.","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1752,"end":1753,"text":" Seronegative.","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1753,"end":1754,"text":" Seronegative.","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1754,"end":1755,"text":" Yeah.","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1755,"end":1756,"text":" Seronegative rheumatology arthritis,","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1756,"end":1757,"text":" or seronegative.","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1757,"end":1758,"text":" Maybe they don't have rheumatology arthritis.","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1758,"end":1759,"text":" How about that?","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1759,"end":1760,"text":" There's nothing.","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1760,"end":1761,"text":" Right.","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1761,"end":1762,"text":" It's very interesting.","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1762,"end":1763,"text":" Any, like, 60 to 70% of people,","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1763,"end":1764,"text":" sorry, I think, like,","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1764,"end":1766,"text":" 30% of people have seronegative RA.","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1766,"end":1768,"text":" I believe that's, yeah, 30% or so.","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1768,"end":1769,"text":" Good amount of people that are...","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1769,"end":1770,"text":" Maybe for the listener,","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1770,"end":1771,"text":" who doesn't know what that means?","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1771,"end":1772,"text":" Tell them what seronegative means.","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1772,"end":1773,"text":" Seronegative.","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1773,"end":1774,"text":" So essentially,","temperature":0,"avg_logprob":-0.20281559405940594,"compression_ratio":1.8863636363636365,"no_speech_prob":0.11737060546875,"words":[]},{"start":1774,"end":1776,"text":" you have these types of complaints and you go,","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1776,"end":1778,"text":" and if you do have autoimmune disease,","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1778,"end":1780,"text":" you get an A&A, a rheumatoid factor.","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1780,"end":1781,"text":" These are all different markers.","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1781,"end":1784,"text":" Now, typically, one of those would be positive,","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1784,"end":1785,"text":" which, if one of them are positive,","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1785,"end":1787,"text":" then you can go down the rabbit hole","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1787,"end":1789,"text":" to check out which markers are super sensitive,","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1789,"end":1791,"text":" or super specific, for certain diseases.","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1791,"end":1793,"text":" In about 30% of these patients,","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1793,"end":1795,"text":" nothing comes up with an answer.","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1795,"end":1797,"text":" You might have an A&A, let's say,","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1797,"end":1798,"text":" that's positive,","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1798,"end":1799,"text":" but that still is just...","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1799,"end":1802,"text":" It's so general that it doesn't really point to inflammation.","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1802,"end":1803,"text":" Yeah.","temperature":0,"avg_logprob":-0.11534926470588236,"compression_ratio":1.6911764705882353,"no_speech_prob":0.0335693359375,"words":[]},{"start":1803,"end":1804,"text":" It just says you have information.","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1804,"end":1805,"text":" So a lot of these patients,","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1805,"end":1807,"text":" they actually can't find a marker","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1807,"end":1809,"text":" that is specific for their complaint,","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1809,"end":1811,"text":" that can be generalized with population.","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1811,"end":1813,"text":" So even though it seems like they have rheumatoid arthritis,","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1813,"end":1815,"text":" and that's exactly the type of pattern they're showing,","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1815,"end":1817,"text":" they don't have the marker to show for it,","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1817,"end":1819,"text":" so they automatically are classified","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1819,"end":1821,"text":" as seronegative rheumatoid arthritis.","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1821,"end":1822,"text":" And oftentimes,","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1822,"end":1824,"text":" they get started on those demards,","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1824,"end":1826,"text":" disease-modifying drugs.","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1826,"end":1827,"text":" Yeah.","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1827,"end":1828,"text":" And those are not medications","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1828,"end":1829,"text":" to be messing around with.","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1829,"end":1830,"text":" Right?","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1830,"end":1831,"text":" Those are some really intense medications","temperature":0,"avg_logprob":-0.13119283536585366,"compression_ratio":1.7850746268656716,"no_speech_prob":0.0130157470703125,"words":[]},{"start":1831,"end":1832,"text":" with an intense side effect.","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1832,"end":1834,"text":" So common ones people might have heard of","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1834,"end":1835,"text":" methotrexate,","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1835,"end":1837,"text":" plaquanal, things like that.","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1837,"end":1839,"text":" Here is something that we need to start looking into.","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1839,"end":1840,"text":" Right?","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1840,"end":1843,"text":" Because I can think of 20 patients on top of my head","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1843,"end":1844,"text":" where they've had some type of,","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1844,"end":1845,"text":" which are maybe not 20,","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1845,"end":1847,"text":" but I can definitely think of five or six right now,","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1847,"end":1848,"text":" that I've had something like this.","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1848,"end":1851,"text":" And let's explore this area a little bit more.","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1851,"end":1852,"text":" These are difficult conversations to have, though.","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1852,"end":1855,"text":" So here are some key messages that I would say","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1855,"end":1858,"text":" for the clinicians listening that we need to start communicating with their patients","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1858,"end":1860,"text":" when you have this type of disease burden.","temperature":0,"avg_logprob":-0.18605491329479767,"compression_ratio":1.7358490566037736,"no_speech_prob":0.017974853515625,"words":[]},{"start":1861,"end":1863,"text":" So one is identifying the person, right?","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1863,"end":1864,"text":" If you have suspicion,","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1864,"end":1866,"text":" they've got something like that going on,","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1866,"end":1867,"text":" and you're not thinking,","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1867,"end":1868,"text":" it's a rheumatoid condition,","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1868,"end":1870,"text":" maybe there are some labs that we start getting.","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1870,"end":1873,"text":" So certainly checking their blood pressure.","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1873,"end":1875,"text":" That's going to be part of the process.","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1875,"end":1877,"text":" I think we talked about getting their waist","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1877,"end":1878,"text":" and waist to height,","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1878,"end":1880,"text":" waist circumference to height ratio.","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1880,"end":1881,"text":" It's probably better,","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1881,"end":1884,"text":" because I think it's probably a better indicator of central out of hostility.","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1884,"end":1886,"text":" That's going to be a big one.","temperature":0,"avg_logprob":-0.18976293103448275,"compression_ratio":1.78839590443686,"no_speech_prob":0.01241302490234375,"words":[]},{"start":1886,"end":1889,"text":" Checking their high sensitivity CRP,","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1889,"end":1892,"text":" but HSCRP is going to be really good for inflammation.","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1892,"end":1894,"text":" Fasting glucose, home IR,","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1894,"end":1896,"text":" we've talked about that at the length,","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1896,"end":1897,"text":" so people can check home IR as well,","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1897,"end":1899,"text":" because I think it's a better indicator than just A1C.","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1899,"end":1900,"text":" I would probably still get A1C,","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1900,"end":1902,"text":" but I think home IR is going to be better.","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1902,"end":1903,"text":" Anything else that I'm missing","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1903,"end":1905,"text":" that you would put in your metabolic pattern?","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1905,"end":1906,"text":" This lipid profile, A1C,","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1906,"end":1907,"text":" I think we're going to question those.","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1907,"end":1908,"text":" Just, yeah.","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1908,"end":1909,"text":" I think that's pretty much it.","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1909,"end":1911,"text":" I think I would start doing that.","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1911,"end":1912,"text":" And if these are things flagging,","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1912,"end":1914,"text":" now we can start having conversations with people","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1914,"end":1915,"text":" that are really meaningful.","temperature":0,"avg_logprob":-0.18147786458333334,"compression_ratio":1.7506702412868633,"no_speech_prob":0.06640625,"words":[]},{"start":1915,"end":1916,"text":" Because you know what's interesting.","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1916,"end":1917,"text":" We talk about this.","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1917,"end":1918,"text":" If somebody comes in with elevated LDL,","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1918,"end":1921,"text":" like that sometimes,","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1921,"end":1925,"text":" and oftentimes is not enough for people to make a change.","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1925,"end":1928,"text":" Because high LDL is not symptomatic.","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1928,"end":1929,"text":" When it becomes symptomatic,","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1929,"end":1931,"text":" it's a heart attack and it's a problem.","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1931,"end":1933,"text":" So people are less likely to be proactive.","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1933,"end":1935,"text":" What is symptomatic is knee arthritis.","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1935,"end":1937,"text":" Pain is a really strong motivator.","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1937,"end":1939,"text":" But now we can use this, right?","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1939,"end":1941,"text":" So I think conversations that have with patients say,","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1941,"end":1944,"text":" hey, your fat tissue is actually talking to your joints.","temperature":0,"avg_logprob":-0.16474412751677853,"compression_ratio":1.6801242236024845,"no_speech_prob":0.012420654296875,"words":[]},{"start":1944,"end":1945,"text":" Right?","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1945,"end":1946,"text":" Because your fat tissue is releasing.","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1946,"end":1949,"text":" These things like leptin and other inflammatory molecules","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1949,"end":1951,"text":" that are causing destruction to the joint.","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1951,"end":1955,"text":" So you want to help improve this and reverse some of this","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1955,"end":1956,"text":" than you're talking about?","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1956,"end":1958,"text":" We know that there is a signal here.","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1958,"end":1959,"text":" We don't know how strong it is,","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1959,"end":1961,"text":" but we know there's something going on.","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1961,"end":1964,"text":" And this metabolic environment that's driving high blood sugar","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1964,"end":1966,"text":" is also affecting a cartilage.","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1966,"end":1969,"text":" And again, it's having some type of effect.","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1969,"end":1971,"text":" Maybe it's not super, super strong,","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1971,"end":1972,"text":" but it is having effect.","temperature":0,"avg_logprob":-0.1257543103448276,"compression_ratio":1.718849840255591,"no_speech_prob":0.00830841064453125,"words":[]},{"start":1972,"end":1976,"text":" And weight loss is going to treat the disease,","temperature":0,"avg_logprob":-0.11848021582733813,"compression_ratio":1.8064516129032258,"no_speech_prob":0.0007205009460449219,"words":[]},{"start":1976,"end":1977,"text":" not just the symptom.","temperature":0,"avg_logprob":-0.11848021582733813,"compression_ratio":1.8064516129032258,"no_speech_prob":0.0007205009460449219,"words":[]},{"start":1977,"end":1978,"text":" So like we talked about,","temperature":0,"avg_logprob":-0.11848021582733813,"compression_ratio":1.8064516129032258,"no_speech_prob":0.0007205009460449219,"words":[]},{"start":1978,"end":1981,"text":" the step nine trial showed that it's going to treat the symptom for sure.","temperature":0,"avg_logprob":-0.11848021582733813,"compression_ratio":1.8064516129032258,"no_speech_prob":0.0007205009460449219,"words":[]},{"start":1981,"end":1985,"text":" So every pound that you lose is about four pounds of loss,","temperature":0,"avg_logprob":-0.11848021582733813,"compression_ratio":1.8064516129032258,"no_speech_prob":0.0007205009460449219,"words":[]},{"start":1985,"end":1986,"text":" four pounds of force less,","temperature":0,"avg_logprob":-0.11848021582733813,"compression_ratio":1.8064516129032258,"no_speech_prob":0.0007205009460449219,"words":[]},{"start":1986,"end":1989,"text":" onto your knee joint per step.","temperature":0,"avg_logprob":-0.11848021582733813,"compression_ratio":1.8064516129032258,"no_speech_prob":0.0007205009460449219,"words":[]},{"start":1989,"end":1991,"text":" And it's helping with the inflammatory burden,","temperature":0,"avg_logprob":-0.11848021582733813,"compression_ratio":1.8064516129032258,"no_speech_prob":0.0007205009460449219,"words":[]},{"start":1991,"end":1992,"text":" like we talked about, right?","temperature":0,"avg_logprob":-0.11848021582733813,"compression_ratio":1.8064516129032258,"no_speech_prob":0.0007205009460449219,"words":[]},{"start":1992,"end":1994,"text":" So there is meaningful pain improvement.","temperature":0,"avg_logprob":-0.11848021582733813,"compression_ratio":1.8064516129032258,"no_speech_prob":0.0007205009460449219,"words":[]},{"start":1994,"end":1997,"text":" And these new medications that we're looking at,","temperature":0,"avg_logprob":-0.11848021582733813,"compression_ratio":1.8064516129032258,"no_speech_prob":0.0007205009460449219,"words":[]},{"start":1997,"end":1998,"text":" these could help.","temperature":0,"avg_logprob":-0.11848021582733813,"compression_ratio":1.8064516129032258,"no_speech_prob":0.0007205009460449219,"words":[]},{"start":1998,"end":2000,"text":" It could be a two-pronged approach.","temperature":0,"avg_logprob":-0.11848021582733813,"compression_ratio":1.8064516129032258,"no_speech_prob":0.0007205009460449219,"words":[]},{"start":2000,"end":2001,"text":" At the very least,","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2001,"end":2003,"text":" it's going to know that it's going to solve the tried and true problem","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2003,"end":2004,"text":" that we have.","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2004,"end":2006,"text":" It's going to take care of the quote-unquote backpack.","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2006,"end":2008,"text":" That's going to be amazing.","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2008,"end":2010,"text":" And hopefully,","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2010,"end":2011,"text":" if what we think is true,","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2011,"end":2013,"text":" it's going to affect it independently as well.","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2013,"end":2015,"text":" And that's not only going to affect your joints","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2015,"end":2018,"text":" and make your overall disease burden from an osteoarthritis better","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2018,"end":2020,"text":" and your quality of life better,","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2020,"end":2022,"text":" but it's going to help your LDL get better,","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2022,"end":2023,"text":" which is going to be less heart attacks","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2023,"end":2024,"text":" and less kidney disease","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2024,"end":2027,"text":" and the blood pressure and less strokes and all.","temperature":0,"avg_logprob":-0.09360532407407407,"compression_ratio":1.9108910891089108,"no_speech_prob":0.0292816162109375,"words":[]},{"start":2027,"end":2030,"text":" So that's kind of how I would approach it, I think.","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2030,"end":2032,"text":" What do you tell the patient who,","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2032,"end":2034,"text":" and again, I see there's a lot of health care","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2034,"end":2036,"text":" and people who want to do it the natural way,","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2036,"end":2039,"text":" who are afraid of the GLP ones don't think it's the natural way","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2039,"end":2040,"text":" of doing things.","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2040,"end":2042,"text":" They are obese,","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2042,"end":2043,"text":" and they want to stick","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2043,"end":2044,"text":" to the Korgoceroid injections,","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2044,"end":2045,"text":" the hyaluronic acid,","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2045,"end":2048,"text":" just oral medication that they can do,","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2048,"end":2050,"text":" which we've been doing for years.","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2050,"end":2052,"text":" What's the conversation like with that?","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2052,"end":2053,"text":" How do you kind of think about that?","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2053,"end":2055,"text":" I'm all about, right?","temperature":0,"avg_logprob":-0.1808449074074074,"compression_ratio":1.7308970099667773,"no_speech_prob":0.01690673828125,"words":[]},{"start":2055,"end":2057,"text":" I think that if you are,","temperature":0,"avg_logprob":-0.08763177710843373,"compression_ratio":1.896103896103896,"no_speech_prob":0.004535675048828125,"words":[]},{"start":2057,"end":2059,"text":" I don't want to say necessarily anti-pharmacology,","temperature":0,"avg_logprob":-0.08763177710843373,"compression_ratio":1.896103896103896,"no_speech_prob":0.004535675048828125,"words":[]},{"start":2059,"end":2062,"text":" I think that if you're anti this specific medication","temperature":0,"avg_logprob":-0.08763177710843373,"compression_ratio":1.896103896103896,"no_speech_prob":0.004535675048828125,"words":[]},{"start":2062,"end":2064,"text":" for whatever reason that you have, great.","temperature":0,"avg_logprob":-0.08763177710843373,"compression_ratio":1.896103896103896,"no_speech_prob":0.004535675048828125,"words":[]},{"start":2064,"end":2066,"text":" We can try to solve this problem,","temperature":0,"avg_logprob":-0.08763177710843373,"compression_ratio":1.896103896103896,"no_speech_prob":0.004535675048828125,"words":[]},{"start":2066,"end":2068,"text":" just recognize it's going to be harder.","temperature":0,"avg_logprob":-0.08763177710843373,"compression_ratio":1.896103896103896,"no_speech_prob":0.004535675048828125,"words":[]},{"start":2068,"end":2070,"text":" I don't get to make the decision that you do.","temperature":0,"avg_logprob":-0.08763177710843373,"compression_ratio":1.896103896103896,"no_speech_prob":0.004535675048828125,"words":[]},{"start":2070,"end":2073,"text":" I think that if we want to do it whichever way we do it,","temperature":0,"avg_logprob":-0.08763177710843373,"compression_ratio":1.896103896103896,"no_speech_prob":0.004535675048828125,"words":[]},{"start":2073,"end":2077,"text":" if the end goal is that the person can have less body fat,","temperature":0,"avg_logprob":-0.08763177710843373,"compression_ratio":1.896103896103896,"no_speech_prob":0.004535675048828125,"words":[]},{"start":2077,"end":2078,"text":" their blood pressure is better managed,","temperature":0,"avg_logprob":-0.08763177710843373,"compression_ratio":1.896103896103896,"no_speech_prob":0.004535675048828125,"words":[]},{"start":2078,"end":2080,"text":" all those things that we're trying to get to,","temperature":0,"avg_logprob":-0.08763177710843373,"compression_ratio":1.896103896103896,"no_speech_prob":0.004535675048828125,"words":[]},{"start":2080,"end":2081,"text":" they're going to do better.","temperature":0,"avg_logprob":-0.08763177710843373,"compression_ratio":1.896103896103896,"no_speech_prob":0.004535675048828125,"words":[]},{"start":2081,"end":2084,"text":" Because what we're trying to do here is we're trying to reduce,","temperature":0,"avg_logprob":-0.08763177710843373,"compression_ratio":1.896103896103896,"no_speech_prob":0.004535675048828125,"words":[]},{"start":2084,"end":2087,"text":" if we talked about that you have less of a pack,","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2087,"end":2088,"text":" that's one method that's going to improve,","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2088,"end":2090,"text":" but if it's also an endocrine immune organ,","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2090,"end":2091,"text":" we reduce that,","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2091,"end":2093,"text":" and it has less of an inflammatory burn,","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2093,"end":2094,"text":" they're still going to help.","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2094,"end":2095,"text":" Now, that's why,","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2095,"end":2098,"text":" if the signal was stronger that these medications","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2098,"end":2101,"text":" were certainly causing disease protection","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2101,"end":2103,"text":" from a disease modifying agent,","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2103,"end":2104,"text":" that would be a different conversation,","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2104,"end":2106,"text":" but we're not there yet at all.","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2106,"end":2111,"text":" But what we do know is that being metabolically unhealthy","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2111,"end":2113,"text":" is causing problems, right?","temperature":0,"avg_logprob":-0.1131161971830986,"compression_ratio":1.7105263157894737,"no_speech_prob":0.0009694099426269531,"words":[]},{"start":2113,"end":2116,"text":" From again, a double wami approach.","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2116,"end":2118,"text":" So whatever way that it is they get there.","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2118,"end":2120,"text":" So I guess maybe the analogy,","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2120,"end":2123,"text":" something that I'll start refining, people don't,","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2123,"end":2124,"text":" with this one medication,","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2124,"end":2126,"text":" people don't say they want to do the natural way, by the way,","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2126,"end":2128,"text":" with other medications they will say.","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2128,"end":2130,"text":" This is the one that the insurance won't pay for.","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2130,"end":2131,"text":" I don't know, have you had this?","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2131,"end":2132,"text":" Has the insurance paying for this,","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2132,"end":2133,"text":" and they don't want to be on it?","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2133,"end":2134,"text":" I've had a few patients that are just,","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2134,"end":2135,"text":" I don't want to touch it.","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2135,"end":2136,"text":" I don't want to be near it.","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2136,"end":2137,"text":" They've had bad experiences with it.","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2137,"end":2138,"text":" Too much rapid weight loss.","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2138,"end":2140,"text":" So I've had patients who have too rapid weight loss,","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2140,"end":2142,"text":" and they're just like, they got sick from it.","temperature":0,"avg_logprob":-0.14903846153846154,"compression_ratio":1.938375350140056,"no_speech_prob":0.00870513916015625,"words":[]},{"start":2143,"end":2144,"text":" I don't know, I've also just had patients","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2144,"end":2145,"text":" where I think they hear horror stories,","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2145,"end":2147,"text":" or they have here about the risks.","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2147,"end":2148,"text":" There's not enough long-term data.","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2148,"end":2149,"text":" And so they could stay away.","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2149,"end":2151,"text":" They think, I don't know, I think it's just that story","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2151,"end":2153,"text":" that's been told about, hey, here's another drug","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2153,"end":2155,"text":" that can just cure all in a way, right?","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2155,"end":2156,"text":" Because think about what we're talking about.","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2156,"end":2158,"text":" We're talking about all this different metabolic stuff","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2158,"end":2160,"text":" and to some people, that's too good to be true.","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2160,"end":2161,"text":" Exactly.","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2161,"end":2163,"text":" Yeah, no, listen, there are downsides with it.","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2163,"end":2166,"text":" Maybe actually, yeah, I'd be remiss","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2166,"end":2167,"text":" if I didn't talk about this important one,","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2167,"end":2169,"text":" but I want to come back to natural way.","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2169,"end":2170,"text":" Yeah, I would tell them, hey, listen,","temperature":0,"avg_logprob":-0.13572303921568626,"compression_ratio":1.7772020725388602,"no_speech_prob":0.032562255859375,"words":[]},{"start":2171,"end":2172,"text":" like if you tell me I got to go down here,","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2172,"end":2174,"text":" and we have to go to, I'm a jersey,","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2174,"end":2175,"text":" and we got to go to the shore,","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2175,"end":2177,"text":" like we could ride the bike there,","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2177,"end":2178,"text":" or we could take the car there,","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2178,"end":2180,"text":" and the bike's going to be a lot longer,","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2180,"end":2181,"text":" and it's going to be a lot harder,","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2181,"end":2182,"text":" but it'll get you there.","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2182,"end":2184,"text":" Or you could walk there, that's a very natural.","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2184,"end":2185,"text":" The car isn't, right?","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2185,"end":2186,"text":" It's just going to be difficult,","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2186,"end":2187,"text":" but understand that it's doable,","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2187,"end":2190,"text":" and you get the decide at the end of the day.","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2190,"end":2192,"text":" Now, I think the one important thing","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2192,"end":2194,"text":" that we need to talk about, though,","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2194,"end":2195,"text":" the rapid weight loss that you brought up,","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2195,"end":2196,"text":" I'm glad that you brought up.","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2196,"end":2199,"text":" Because interesting conversations happening on social media,","temperature":0,"avg_logprob":-0.1394704433497537,"compression_ratio":1.936046511627907,"no_speech_prob":0.015899658203125,"words":[]},{"start":2199,"end":2200,"text":" I don't know if you see this,","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2200,"end":2203,"text":" where a lot of my clinician colleagues,","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2203,"end":2205,"text":" and I'm going to caveat this by saying,","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2205,"end":2207,"text":" I have been on record saying that I think","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2207,"end":2209,"text":" this is one of the most revolutionary drugs,","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2209,"end":2210,"text":" certainly in my time practicing.","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2210,"end":2212,"text":" I've said that multiple times, a big fan of it.","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2212,"end":2215,"text":" I do see a lot of clinician colleagues jumping on","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2215,"end":2217,"text":" and saying, oh no, this is like,","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2217,"end":2219,"text":" even that excess lean body mass,","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2219,"end":2221,"text":" that the studies have reported 25% to 40%,","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2221,"end":2223,"text":" that's not really actual muscle.","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2223,"end":2225,"text":" I agree, that's probably true.","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2225,"end":2228,"text":" Because Dexas is not great at teasing out","temperature":0,"avg_logprob":-0.13471554487179488,"compression_ratio":1.7097791798107256,"no_speech_prob":0.015411376953125,"words":[]},{"start":2228,"end":2230,"text":" what's actual muscle loss,","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2230,"end":2232,"text":" versus just water weight and bone content, et cetera.","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2232,"end":2236,"text":" But I do know that lean body mass is better than fat mass,","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2236,"end":2238,"text":" and I'd rather hold on lean body mass,","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2238,"end":2239,"text":" so whatever it is.","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2239,"end":2240,"text":" Here's the challenge.","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2240,"end":2241,"text":" What they're saying is,","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2241,"end":2242,"text":" when you compare it to people","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2242,"end":2244,"text":" who are just on dietary restriction,","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2244,"end":2245,"text":" it's about the same.","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2245,"end":2247,"text":" That may be true,","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2247,"end":2249,"text":" but the reality is people on dietary restriction","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2249,"end":2251,"text":" don't lose it at first.","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2251,"end":2252,"text":" It's not as accessible.","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2252,"end":2254,"text":" People who are typically doing dietary restriction","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2254,"end":2255,"text":" and can lose that much weight,","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2255,"end":2257,"text":" where you have 25% to 40%,","temperature":0,"avg_logprob":-0.09267578125,"compression_ratio":1.750788643533123,"no_speech_prob":0.002979278564453125,"words":[]},{"start":2257,"end":2259,"text":" they're also going crazy","temperature":0,"avg_logprob":-0.07231747787610619,"compression_ratio":1.7026022304832713,"no_speech_prob":0.0015726089477539062,"words":[]},{"start":2259,"end":2261,"text":" with their exercise and resistance training.","temperature":0,"avg_logprob":-0.07231747787610619,"compression_ratio":1.7026022304832713,"no_speech_prob":0.0015726089477539062,"words":[]},{"start":2261,"end":2263,"text":" They're doing everything possible.","temperature":0,"avg_logprob":-0.07231747787610619,"compression_ratio":1.7026022304832713,"no_speech_prob":0.0015726089477539062,"words":[]},{"start":2263,"end":2265,"text":" The people who can lose that much weight,","temperature":0,"avg_logprob":-0.07231747787610619,"compression_ratio":1.7026022304832713,"no_speech_prob":0.0015726089477539062,"words":[]},{"start":2265,"end":2267,"text":" where they have the luxury","temperature":0,"avg_logprob":-0.07231747787610619,"compression_ratio":1.7026022304832713,"no_speech_prob":0.0015726089477539062,"words":[]},{"start":2267,"end":2269,"text":" of losing 25% lean body mass,","temperature":0,"avg_logprob":-0.07231747787610619,"compression_ratio":1.7026022304832713,"no_speech_prob":0.0015726089477539062,"words":[]},{"start":2269,"end":2273,"text":" those are some really competitive people who are committed.","temperature":0,"avg_logprob":-0.07231747787610619,"compression_ratio":1.7026022304832713,"no_speech_prob":0.0015726089477539062,"words":[]},{"start":2273,"end":2275,"text":" Whereas now it is so accessible","temperature":0,"avg_logprob":-0.07231747787610619,"compression_ratio":1.7026022304832713,"no_speech_prob":0.0015726089477539062,"words":[]},{"start":2275,"end":2278,"text":" that the person who does not have high intrinsic motivation","temperature":0,"avg_logprob":-0.07231747787610619,"compression_ratio":1.7026022304832713,"no_speech_prob":0.0015726089477539062,"words":[]},{"start":2278,"end":2280,"text":" to do this is now getting those results.","temperature":0,"avg_logprob":-0.07231747787610619,"compression_ratio":1.7026022304832713,"no_speech_prob":0.0015726089477539062,"words":[]},{"start":2280,"end":2283,"text":" So you are getting the weight loss","temperature":0,"avg_logprob":-0.07231747787610619,"compression_ratio":1.7026022304832713,"no_speech_prob":0.0015726089477539062,"words":[]},{"start":2283,"end":2286,"text":" without having the type of","temperature":0,"avg_logprob":-0.07231747787610619,"compression_ratio":1.7026022304832713,"no_speech_prob":0.0015726089477539062,"words":[]},{"start":2286,"end":2288,"text":" profile as a person","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2288,"end":2290,"text":" who is going to continue training and exercising hard.","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2290,"end":2292,"text":" And so that's why you're losing","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2292,"end":2294,"text":" the good quality muscle.","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2294,"end":2295,"text":" Why is that important","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2295,"end":2297,"text":" with the relevant to what we're talking about?","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2297,"end":2299,"text":" One of the best things that you can do","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2299,"end":2302,"text":" to reduce the progression of the disease","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2302,"end":2304,"text":" of osteoarthritis","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2304,"end":2307,"text":" is to strengthen the periarticular structures.","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2307,"end":2308,"text":" So I tell people,","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2308,"end":2310,"text":" the reason we have works,","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2310,"end":2312,"text":" the reason it works is because","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2312,"end":2314,"text":" it's glorified strength training","temperature":0,"avg_logprob":-0.1240625,"compression_ratio":1.6777777777777778,"no_speech_prob":0.005992889404296875,"words":[]},{"start":2314,"end":2315,"text":" and joints,","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2315,"end":2316,"text":" despite what we think,","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2316,"end":2318,"text":" they're not great at tolerating stress.","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2318,"end":2319,"text":" You know what it is","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2319,"end":2320,"text":" greater at tolerating stress?","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2320,"end":2321,"text":" Your muscles,","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2321,"end":2322,"text":" your tendons,","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2322,"end":2323,"text":" and you look at this,","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2323,"end":2324,"text":" that surround those structures.","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2324,"end":2325,"text":" So the more resilient","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2325,"end":2327,"text":" and robust those structures are,","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2327,"end":2329,"text":" the better people end up doing,","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2329,"end":2330,"text":" the less pain that they have,","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2330,"end":2332,"text":" because that force gets dispersed","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2332,"end":2333,"text":" onto those structures.","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2333,"end":2335,"text":" Now, if you have rapid weight loss","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2335,"end":2337,"text":" and you lose those structures,","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2337,"end":2339,"text":" you've taken your first defense mechanism","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2339,"end":2342,"text":" and the most amazing defense mechanism","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2342,"end":2343,"text":" for the osteoarthritis","temperature":0,"avg_logprob":-0.11576704545454546,"compression_ratio":1.8900343642611683,"no_speech_prob":0.0034275054931640625,"words":[]},{"start":2343,"end":2344,"text":" and you've taken it out","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2344,"end":2345,"text":" or you made it weaker.","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2345,"end":2346,"text":" Now, you got bigger problem.","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2346,"end":2348,"text":" So that's a very real concern","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2348,"end":2350,"text":" with this that we need to keep in mind as well.","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2350,"end":2351,"text":" Yeah.","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2351,"end":2352,"text":" It's interesting.","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2352,"end":2353,"text":" I think about,","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2353,"end":2355,"text":" we talk about how we're going to use this in practice","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2355,"end":2356,"text":" and for both of us,","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2356,"end":2357,"text":" we're in different settings, right?","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2357,"end":2358,"text":" And for me,","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2358,"end":2360,"text":" this is an educational piece","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2360,"end":2361,"text":" that comes to my patients","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2361,"end":2362,"text":" and I say, hey, after this rehab,","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2362,"end":2363,"text":" after we try to build that muscle,","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2363,"end":2365,"text":" after we try to do all these things,","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2365,"end":2366,"text":" go talk to your entrepreneurs,","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2366,"end":2368,"text":" or go talk to your sportsman,","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2368,"end":2369,"text":" doctor, your PCP,","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2369,"end":2370,"text":" and kind of these discussions","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2370,"end":2371,"text":" with them.","temperature":0,"avg_logprob":-0.12194113756613757,"compression_ratio":1.7603550295857988,"no_speech_prob":0.0215911865234375,"words":[]},{"start":2371,"end":2372,"text":" When you look at,","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2372,"end":2374,"text":" after you get out of intense rehab,","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2374,"end":2375,"text":" and you still have that pain,","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2375,"end":2376,"text":" obviously for you,","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2376,"end":2377,"text":" you're doing it,","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2377,"end":2378,"text":" doing the injections","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2378,"end":2379,"text":" and really having the discussion","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2379,"end":2380,"text":" and thinking about initiating","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2380,"end":2381,"text":" these patients on it.","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2381,"end":2382,"text":" Yeah.","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2382,"end":2383,"text":" I think these types of papers","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2383,"end":2384,"text":" are, it's going to change the game","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2384,"end":2385,"text":" of medicine.","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2385,"end":2386,"text":" I put into chat,","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2386,"end":2387,"text":" UBT, just get a summary and all","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2387,"end":2388,"text":" and it says,","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2388,"end":2389,"text":" are we now entering an era","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2389,"end":2390,"text":" where like orthopedics","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2390,"end":2391,"text":" and endocrine actually talk more","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2391,"end":2392,"text":" and do more,","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2392,"end":2394,"text":" more referrals and more back and forth","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2394,"end":2395,"text":" and before we kind of look,","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2395,"end":2396,"text":" I still think we do.","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2396,"end":2398,"text":" We see medicine being very siloed.","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2398,"end":2399,"text":" Now we're starting to see more","temperature":0,"avg_logprob":-0.18028846153846154,"compression_ratio":1.7742857142857142,"no_speech_prob":0.0166473388671875,"words":[]},{"start":2399,"end":2401,"text":" across talk and more of referrals","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2401,"end":2402,"text":" to the specialists","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2402,"end":2403,"text":" who need to be involved.","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2403,"end":2404,"text":" Yeah.","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2404,"end":2405,"text":" This is exactly what PHS","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2405,"end":2406,"text":" and Ghani talked about,","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2406,"end":2408,"text":" how she is doing lectures,","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2408,"end":2409,"text":" she's collaborating","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2409,"end":2410,"text":" with the sports medicine department.","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2410,"end":2411,"text":" I love it.","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2411,"end":2412,"text":" In fact, did you see this","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2412,"end":2414,"text":" that PCOS got renamed?","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2414,"end":2415,"text":" No.","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2415,"end":2416,"text":" Oh, maybe.","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2416,"end":2418,"text":" That's something metabolic.","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2418,"end":2419,"text":" Yeah.","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2419,"end":2420,"text":" It's PMOS,","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2420,"end":2422,"text":" polyendocrine metabolic","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2422,"end":2424,"text":" ingredients to PMS.","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2424,"end":2425,"text":" Yeah.","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2425,"end":2427,"text":" Polyendocrine metabolic","temperature":0,"avg_logprob":-0.2595301418439716,"compression_ratio":1.5708812260536398,"no_speech_prob":0.0340576171875,"words":[]},{"start":2427,"end":2428,"text":" ac or something.","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2428,"end":2429,"text":" Cause she has a strong point","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2429,"end":2430,"text":" is people who get","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2430,"end":2431,"text":" at ease of capsulitis,","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2431,"end":2432,"text":" frozen shoulder for those","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2432,"end":2433,"text":" who don't know.","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2433,"end":2434,"text":" You've got these","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2434,"end":2435,"text":" hormonal irregularities,","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2435,"end":2436,"text":" a lot of times,","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2436,"end":2437,"text":" there are going to be people","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2437,"end":2438,"text":" who have some type of strong","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2438,"end":2440,"text":" insulin-resistant diabetes,","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2440,"end":2441,"text":" interesting correlation","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2441,"end":2442,"text":" with epilepsy as well.","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2442,"end":2443,"text":" But yeah.","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2443,"end":2444,"text":" Yeah.","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2444,"end":2445,"text":" There is a ton of cross-stop.","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2445,"end":2446,"text":" Again,","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2446,"end":2447,"text":" bodies don't repeat","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2447,"end":2448,"text":" and they don't repeat","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2448,"end":2449,"text":" and they don't repeat","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2449,"end":2450,"text":" and they don't repeat","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2450,"end":2451,"text":" and they don't repeat","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2451,"end":2452,"text":" and they don't repeat","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2452,"end":2453,"text":" and they don't repeat","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2453,"end":2454,"text":" and they don't repeat","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2454,"end":2455,"text":" and they don't repeat","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2455,"end":2456,"text":" and they don't repeat","temperature":0,"avg_logprob":-0.24593098958333334,"compression_ratio":2.277992277992278,"no_speech_prob":0.042022705078125,"words":[]},{"start":2457,"end":2458,"text":" bodies don't repeat text","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2458,"end":2459,"text":" and they certainly don't","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2459,"end":2460,"text":" do residency","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2460,"end":2462,"text":" training in certain","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2462,"end":2463,"text":" specialities.","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2463,"end":2464,"text":" I say that much.","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2464,"end":2465,"text":" Yeah, this wasn't the","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2465,"end":2466,"text":" fun one. For me,","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2466,"end":2467,"text":" hopefully the audience","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2467,"end":2468,"text":" got something fun out of it","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2468,"end":2470,"text":" and hopefully we answered","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2470,"end":2471,"text":" them questions. So, we'll","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2471,"end":2473,"text":" be sure to link all","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2473,"end":2474,"text":" the show notes and the studies","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2474,"end":2475,"text":" in here. I don't know if","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2475,"end":2476,"text":" people are going to go","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2476,"end":2477,"text":" deep dive. But, hopefully","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2477,"end":2484,"text":" this answers all the","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2484,"end":2485,"text":" questions. I think this is","temperature":1,"avg_logprob":-0.5507755985966435,"compression_ratio":1.7188755020080322,"no_speech_prob":0.0185089111328125,"words":[]},{"start":2485,"end":2489.88,"text":" share with whoever you know needs to listen to this so that they can initiate that conversation.","temperature":0,"avg_logprob":-0.25537909836065575,"compression_ratio":1.6531986531986531,"no_speech_prob":0.42138671875,"words":[]},{"start":2489.88,"end":2493.24,"text":" I think that's the biggest takeaway is like this is so relevant today.","temperature":0,"avg_logprob":-0.25537909836065575,"compression_ratio":1.6531986531986531,"no_speech_prob":0.42138671875,"words":[]},{"start":2493.24,"end":2496.36,"text":" It's such a common disease like you were saying and so I just encourage people","temperature":0,"avg_logprob":-0.25537909836065575,"compression_ratio":1.6531986531986531,"no_speech_prob":0.42138671875,"words":[]},{"start":2497.16,"end":2500.6,"text":" be sure to whoever you think it will help. And if you're a clinician,","temperature":0,"avg_logprob":-0.25537909836065575,"compression_ratio":1.6531986531986531,"no_speech_prob":0.42138671875,"words":[]},{"start":2500.6,"end":2502.52,"text":" start looking into these things. I have those discussions.","temperature":0,"avg_logprob":-0.25537909836065575,"compression_ratio":1.6531986531986531,"no_speech_prob":0.42138671875,"words":[]},{"start":2503.16,"end":2504.44,"text":" I love it. Awesome.","temperature":0,"avg_logprob":-0.25537909836065575,"compression_ratio":1.6531986531986531,"no_speech_prob":0.42138671875,"words":[]},{"start":2505.8,"end":2507.16,"text":" All right, man. Until next time.","temperature":0,"avg_logprob":-0.25537909836065575,"compression_ratio":1.6531986531986531,"no_speech_prob":0.42138671875,"words":[]},{"start":2509.72,"end":2512.6,"text":" Thanks for listening to another episode of Medicine Redefined.","temperature":0,"avg_logprob":-0.25537909836065575,"compression_ratio":1.6531986531986531,"no_speech_prob":0.42138671875,"words":[]},{"start":2512.6,"end":2515.88,"text":" If you enjoyed this episode, please be sure to check out some of the additional resources","temperature":0,"avg_logprob":-0.19990458015267176,"compression_ratio":1.6187683284457477,"no_speech_prob":0.0296630859375,"words":[]},{"start":2515.88,"end":2521.08,"text":" in the show notes. Please also check out our social media platforms where you can find more content","temperature":0,"avg_logprob":-0.19990458015267176,"compression_ratio":1.6187683284457477,"no_speech_prob":0.0296630859375,"words":[]},{"start":2521.08,"end":2526.36,"text":" like this. You can follow us on Instagram, Twitter, and TikTok at Med Redefined.","temperature":0,"avg_logprob":-0.19990458015267176,"compression_ratio":1.6187683284457477,"no_speech_prob":0.0296630859375,"words":[]},{"start":2527.08,"end":2531.16,"text":" We also want to thank our team for the production of this podcast, specifically Ethan Jewel","temperature":0,"avg_logprob":-0.19990458015267176,"compression_ratio":1.6187683284457477,"no_speech_prob":0.0296630859375,"words":[]},{"start":2531.16,"end":2536.52,"text":" video, Harita Yeporian social media, Zana Blugmani on research and Sarah Hahn for newsletter.","temperature":0,"avg_logprob":-0.19990458015267176,"compression_ratio":1.6187683284457477,"no_speech_prob":0.0296630859375,"words":[]},{"start":2536.52,"end":2541.4,"text":" Oh, and if you want to get similar bite-sized information delivered to your inbox every Sunday,","temperature":0,"avg_logprob":-0.19990458015267176,"compression_ratio":1.6187683284457477,"no_speech_prob":0.0296630859375,"words":[]},{"start":2541.4,"end":2545.2400000000002,"text":" please be sure to sign up for our newsletter. Also, if you enjoyed the show,","temperature":0,"avg_logprob":-0.111375,"compression_ratio":1.694189602446483,"no_speech_prob":0.00376129150390625,"words":[]},{"start":2545.2400000000002,"end":2549,"text":" please be sure to subscribe, review, and share with anyone who you think will gain value from this","temperature":0,"avg_logprob":-0.111375,"compression_ratio":1.694189602446483,"no_speech_prob":0.00376129150390625,"words":[]},{"start":2549,"end":2556.04,"text":" as well. Now, time for the ever-so-important disclaimer. This podcast is intended for general","temperature":0,"avg_logprob":-0.111375,"compression_ratio":1.694189602446483,"no_speech_prob":0.00376129150390625,"words":[]},{"start":2556.04,"end":2560.6,"text":" public use and is for educational purposes only. It does not constitute the practice of medicine,","temperature":0,"avg_logprob":-0.111375,"compression_ratio":1.694189602446483,"no_speech_prob":0.00376129150390625,"words":[]},{"start":2560.6,"end":2564.52,"text":" nor should be construed as medical advice. No physician-patient relationship is formed,","temperature":0,"avg_logprob":-0.111375,"compression_ratio":1.694189602446483,"no_speech_prob":0.00376129150390625,"words":[]},{"start":2564.52,"end":2569.48,"text":" and anything discussed in this podcast does not represent the views of our employers. We recommend","temperature":0,"avg_logprob":-0.111375,"compression_ratio":1.694189602446483,"no_speech_prob":0.00376129150390625,"words":[]},{"start":2569.48,"end":2574.52,"text":" that you seek the guidance of your personal physician regarding any specific health-related issues.","temperature":0,"avg_logprob":-0.14208984375,"compression_ratio":1.1647058823529413,"no_speech_prob":0.107177734375,"words":[]}],"vtt":"WEBVTT\n\n1\n00:00:00.000 --> 00:00:06.000\n Welcome to Medicine Redefined. I'm Dr. Altama Sharaja, and I'm Dr. Darsh Show.\n\n2\n00:00:06.000 --> 00:00:09.000\n Let's put the help back in the healthcare.\n\n3\n00:00:11.000 --> 00:00:17.000\n If you're a high performer who wants a clear plan for longevity, performance, and staying active with fewer setbacks,\n\n4\n00:00:17.000 --> 00:00:21.000\n I'm now seeing patients through my telemedicine practice refining health and performance.\n\n5\n00:00:21.000 --> 00:00:26.000\n I'm opening a limited number of founding member spots at refininghealthrx.com.\n\n6\n00:00:26.000 --> 00:00:28.000\n All right, let's jump in.\n\n7\n00:00:28.000 --> 00:00:33.000\n Is osteoarthritis a metabolic disease? What do you think?\n\n8\n00:00:33.000 --> 00:00:36.000\n Now, I feel like we've touched on this in a previous episode, haven't we?\n\n9\n00:00:36.000 --> 00:00:37.000\n Kind of, right away.\n\n10\n00:00:37.000 --> 00:00:40.000\n Preferably. Yeah, we kind of said yes, but yes.\n\n11\n00:00:40.000 --> 00:00:41.000\n Why do we say yes?\n\n12\n00:00:41.000 --> 00:00:42.000\n Tell me this.\n\n13\n00:00:42.000 --> 00:00:45.000\n Well, try to think of why it's metabolic disease at this current time.\n\n14\n00:00:45.000 --> 00:00:50.000\n Yeah, so I think like, so we're trained on, let's say, in the medical institution primarily,\n\n15\n00:00:50.000 --> 00:00:52.000\n is that OA is a structural disease, right?\n\n16\n00:00:52.000 --> 00:00:54.000\n We think about the cartilage being lost.\n\n17\n00:00:54.000 --> 00:00:56.000\n We think about the mechanics of it.\n\n18\n00:00:56.000 --> 00:00:59.000\n We look at the x-ray findings and there's things to actual see, right?\n\n19\n00:00:59.000 --> 00:01:03.000\n When we think metabolic disease, we don't always see structural disease, right?\n\n20\n00:01:03.000 --> 00:01:06.000\n Those are always complications of it, but with metabolic disease,\n\n21\n00:01:06.000 --> 00:01:10.000\n we look at the connection between maybe two organ systems, right?\n\n22\n00:01:10.000 --> 00:01:14.000\n So in this case, maybe hormones from an endocrinology standpoint and osteoarthritis.\n\n23\n00:01:14.000 --> 00:01:21.000\n And I think what, at least, what probably what we'll go down is the rabbit hole of how OA now is being seen\n\n24\n00:01:21.000 --> 00:01:25.000\n also primarily as metabolic disease because of the hormonal changes.\n\n25\n00:01:25.000 --> 00:01:30.000\n Of course, the papers we're going to be talking about include GLP1s and the effective weight loss on OA.\n\n26\n00:01:30.000 --> 00:01:33.000\n And again, not necessarily from just the weight reduction standpoint,\n\n27\n00:01:33.000 --> 00:01:35.000\n but also just from a metabolic standpoint.\n\n28\n00:01:35.000 --> 00:01:39.000\n But that's, at least, if I can tell the audience, our understanding of how we get trained\n\n29\n00:01:39.000 --> 00:01:43.000\n when we look at OA, even as physiatrist, but I think this is a new frontier\n\n30\n00:01:43.000 --> 00:01:45.000\n and way of thinking about how to treat the disease.\n\n31\n00:01:45.000 --> 00:01:53.000\n Yeah, I think that our biases looking at the whole system were both osteopaths by nature.\n\n32\n00:01:53.000 --> 00:01:58.000\n We've talked about that before, as well as fitness oriented health first, right?\n\n33\n00:01:58.000 --> 00:02:00.000\n Talk about health not being the absence of disease.\n\n34\n00:02:00.000 --> 00:02:05.000\n We recognize that the system doesn't work in isolation.\n\n35\n00:02:05.000 --> 00:02:09.000\n I didn't know these discussions, these murmurings, if you will,\n\n36\n00:02:09.000 --> 00:02:11.000\n there was actually some evidence behind it.\n\n37\n00:02:11.000 --> 00:02:15.000\n And had these conversations have been actually reported in literature for a long time.\n\n38\n00:02:15.000 --> 00:02:17.000\n And so maybe I'll just set the stage.\n\n39\n00:02:17.000 --> 00:02:20.000\n The precedent was set back in 2012.\n\n40\n00:02:20.000 --> 00:02:24.000\n So there was this paper in Nature Reviews Germanology in 2012, Zowadael.\n\n41\n00:02:24.000 --> 00:02:26.000\n They talked about metabolic syndrome.\n\n42\n00:02:26.000 --> 00:02:30.000\n The title of paper actually is metabolic syndrome meets osteoarthritis.\n\n43\n00:02:30.000 --> 00:02:36.000\n And what they proposed was that metabolic osteoarthritis is the fifth component of metabolic syndrome.\n\n44\n00:02:37.000 --> 00:02:41.000\n So those who remember or don't remember metabolic syndrome.\n\n45\n00:02:41.000 --> 00:02:44.000\n So you have central obesity, insulin resistant, dyslipidemia, hypertension.\n\n46\n00:02:44.000 --> 00:02:47.000\n Those are like the four main arms.\n\n47\n00:02:47.000 --> 00:02:51.000\n And so they said, hey, there's a component of arthritis as well in these people.\n\n48\n00:02:51.000 --> 00:02:53.000\n And it's this quartet.\n\n49\n00:02:53.000 --> 00:02:57.000\n And each quartet member has its own joint damaging right?\n\n50\n00:02:57.000 --> 00:03:02.000\n And so we'll link this for people to read, but hypertension causes subcontract ischemia.\n\n51\n00:03:02.000 --> 00:03:06.000\n So that's the bone underneath the cartilage.\n\n52\n00:03:06.000 --> 00:03:07.000\n And we'll look at the knee.\n\n53\n00:03:07.000 --> 00:03:10.000\n I think a lot of this literature is looking at the knee.\n\n54\n00:03:10.000 --> 00:03:18.000\n When you start looking at other joints with the load bearing combined with the inflammatory metabolic component doesn't really pan out.\n\n55\n00:03:18.000 --> 00:03:21.000\n And so we can talk about some of the limitations of this.\n\n56\n00:03:21.000 --> 00:03:24.000\n But hypertension coming back to it causes subcontract ischemia.\n\n57\n00:03:24.000 --> 00:03:27.000\n So that's a blood flow in that area.\n\n58\n00:03:27.000 --> 00:03:29.000\n We've talked about how blood flow historically is a good thing.\n\n59\n00:03:29.000 --> 00:03:32.000\n And so when you have, that's going to be damaging to the tissue.\n\n60\n00:03:32.000 --> 00:03:40.000\n And dyslipidemia causes these ectopic lipid causes formation of ectopic lipid incontrocytes, which is problematic.\n\n61\n00:03:40.000 --> 00:03:43.000\n Hyperglycemia, high blood glucose causes glycation.\n\n62\n00:03:43.000 --> 00:03:48.000\n We've talked about advanced or glycation end products that cause problematic problem.\n\n63\n00:03:48.000 --> 00:03:49.000\n Excuse me.\n\n64\n00:03:49.000 --> 00:03:52.000\n And the obesity releases these cytokines in inflammatory cytokines.\n\n65\n00:03:52.000 --> 00:03:54.000\n And so it's not just one mechanism they talked about.\n\n66\n00:03:55.000 --> 00:04:03.000\n It's a convergence of all these mechanisms for metabolic syndrome that actually progress the disease burden and cause some structural issues too.\n\n67\n00:04:03.000 --> 00:04:11.000\n So this idea that metabolism drive the subset of OA is 13 plus years old.\n\n68\n00:04:11.000 --> 00:04:20.000\n What's new that in the last two to three years in 2024 to 26 is that we can now intervene from ecologically and watch how the job responds.\n\n69\n00:04:20.000 --> 00:04:23.000\n And that's what I think has been more exciting.\n\n70\n00:04:23.000 --> 00:04:32.000\n And actually, when I was even doing this literature, I think that in the literature review rather, people are even describing multiple phenotypes of osteoarthritis.\n\n71\n00:04:32.000 --> 00:04:36.000\n So you listed a couple, but here's a little quiz moment for you.\n\n72\n00:04:36.000 --> 00:04:41.000\n What would be some of the main phenotypes of osteoarthritis if you could describe for the listener?\n\n73\n00:04:41.000 --> 00:04:43.000\n Maybe my phenotype.\n\n74\n00:04:43.000 --> 00:04:45.000\n Because I'm like mild, mild, severe.\n\n75\n00:04:45.000 --> 00:04:48.000\n Are you talking about what type of people present with?\n\n76\n00:04:48.000 --> 00:04:51.000\n No, so when we think about it, it's got a sports room, right?\n\n77\n00:04:51.000 --> 00:04:57.000\n So there is the classic, when you think wear and tear, what does that mean to you?\n\n78\n00:04:57.000 --> 00:04:59.000\n That's more of an age-related process, right?\n\n79\n00:04:59.000 --> 00:05:00.000\n Sure.\n\n80\n00:05:00.000 --> 00:05:01.000\n It almost seems inevitable.\n\n81\n00:05:01.000 --> 00:05:11.000\n Do you remember learning about the fact that when somebody has trauma, like a fracture or an ACL tear, a meniscus tear, accelerates arthritis.\n\n82\n00:05:11.000 --> 00:05:12.000\n Sure.\n\n83\n00:05:12.000 --> 00:05:14.000\n So we'll bucket that into post-traumatic arthritis.\n\n84\n00:05:14.000 --> 00:05:18.000\n So if you've got the age-related senescence, you've got the post-traumatic arthritis.\n\n85\n00:05:18.000 --> 00:05:21.000\n The other one, the one that you might center rheumatologist would be which one?\n\n86\n00:05:21.000 --> 00:05:24.000\n Intoid arthritis or inflammatory.\n\n87\n00:05:24.000 --> 00:05:25.000\n Yeah, inflammatory.\n\n88\n00:05:25.000 --> 00:05:28.000\n Yeah, so we would put that into the inflammatory bucket.\n\n89\n00:05:28.000 --> 00:05:31.000\n The other one is called the mechanical malalignment model.\n\n90\n00:05:31.000 --> 00:05:34.000\n So we talked a little bit about this, Dr. Alison Grimalti, right?\n\n91\n00:05:34.000 --> 00:05:36.000\n When somebody's got, maybe let's say they have a really wide pelvis.\n\n92\n00:05:37.000 --> 00:05:40.000\n And they've got more knock knee presentation versus a bone-legged presentation.\n\n93\n00:05:40.000 --> 00:05:42.000\n So that would be a malalignment.\n\n94\n00:05:42.000 --> 00:05:49.000\n Those types of burnt stresses onto the knee joint is going to cause some more structural degradation in certain parts of the joint.\n\n95\n00:05:49.000 --> 00:05:55.000\n There's this pain-central desensitization pathway, pain-sensitization dominant, either they say, where you don't,\n\n96\n00:05:55.000 --> 00:06:00.000\n might necessarily have a lot of structural issues, but you might have a lot of a heavy symptom.\n\n97\n00:06:01.000 --> 00:06:03.000\n And so this last phenotype is what we're going to talk about.\n\n98\n00:06:03.000 --> 00:06:06.000\n It's called the, so I'm sort of the metabolic syndrome.\n\n99\n00:06:06.000 --> 00:06:10.000\n Now, here's where the smoking gum gun came up for all this, right?\n\n100\n00:06:10.000 --> 00:06:18.000\n So the clue that started breaking this whole purely mechanical idea is that we've noted over the last 15 years,\n\n101\n00:06:18.000 --> 00:06:24.000\n maybe two decades, that obesity is modest, just strongly associated with hand-ostered arthritis.\n\n102\n00:06:25.000 --> 00:06:30.000\n And not many people, so maybe some, are walking around their hands, right?\n\n103\n00:06:30.000 --> 00:06:32.000\n So there's not a lot of load being dispersed with the hands.\n\n104\n00:06:32.000 --> 00:06:38.000\n And so there's no way, why is there an excess or why is there an increased correlation with osteoarthritis?\n\n105\n00:06:38.000 --> 00:06:44.000\n Because that backpack analogy, damaging the joint through load alone, it should have zero effect.\n\n106\n00:06:44.000 --> 00:06:49.000\n Again, caveat, because initially when it started learning and reading about this,\n\n107\n00:06:49.000 --> 00:06:52.000\n it was like, oh, maybe there's two to three times more likely to happen.\n\n108\n00:06:52.000 --> 00:06:56.000\n And that's really not the case, because when you look at the observational studies,\n\n109\n00:06:56.000 --> 00:07:03.000\n when you look at the Mendelian randomization studies, it's really an odds ratio of 1.21 versus 1.91,\n\n110\n00:07:03.000 --> 00:07:06.000\n which is, okay, the odds are going to be 1.91 greater, right?\n\n111\n00:07:06.000 --> 00:07:08.000\n And then I mean, for hip is a little bit less.\n\n112\n00:07:08.000 --> 00:07:13.000\n And so some of this, I think, is even though it's modest, it's still debated.\n\n113\n00:07:13.000 --> 00:07:18.000\n Got us thinking, okay, there must be something, because it's too weak to be a mechanical load only,\n\n114\n00:07:18.000 --> 00:07:20.000\n but it's too real to be nothing.\n\n115\n00:07:20.000 --> 00:07:26.000\n And there has to be somewhat of a systemic signal reaching a joint that carries no weight, like your hands.\n\n116\n00:07:26.000 --> 00:07:28.000\n And that's what we're trying to fish out.\n\n117\n00:07:28.000 --> 00:07:31.000\n Maybe now, I think, do you have anything to add to that?\n\n118\n00:07:31.000 --> 00:07:35.000\n Or should I just get into the studies that actually incited this whole discussion here?\n\n119\n00:07:35.000 --> 00:07:38.000\n Yeah, let's also get into it. I think that was a good preview of kind of what.\n\n120\n00:07:38.000 --> 00:07:40.000\n Now to think about it away, yeah.\n\n121\n00:07:40.000 --> 00:07:43.000\n And I'll talk a little bit more about mechanisms.\n\n122\n00:07:43.000 --> 00:07:45.000\n If that's interesting to you, interesting to the audience.\n\n123\n00:07:45.000 --> 00:07:49.000\n But I think that the two main studies for the drug evidence, so you talked about GLP1.\n\n124\n00:07:49.000 --> 00:07:54.000\n So semi-glutide in particular, that's a govi ozemic, how people recognize it.\n\n125\n00:07:54.000 --> 00:07:56.000\n This is the step nine trial.\n\n126\n00:07:56.000 --> 00:08:01.000\n So this was published in the New England Journal Medicine in 2024.\n\n127\n00:08:01.000 --> 00:08:06.000\n And what they looked at is the max dose of semi-glutide, 2.4 milligrams weekly,\n\n128\n00:08:06.000 --> 00:08:11.000\n and given at 107 people, randomized control trial, lasted 68 weeks,\n\n129\n00:08:11.000 --> 00:08:13.000\n so a little over a year.\n\n130\n00:08:13.000 --> 00:08:19.000\n And the BMI cut off was 30, 81% female population, and the KL score.\n\n131\n00:08:19.000 --> 00:08:22.000\n So that's the killer again, Lawrence school.\n\n132\n00:08:22.000 --> 00:08:24.000\n I think I'm gonna get that right, KL.\n\n133\n00:08:24.000 --> 00:08:25.000\n That stands for again.\n\n134\n00:08:25.000 --> 00:08:28.000\n By the way, it's rating severity of osteoarthritis.\n\n135\n00:08:28.000 --> 00:08:29.000\n So that's two to three.\n\n136\n00:08:29.000 --> 00:08:32.000\n So moderate to somewhat severe arthritis.\n\n137\n00:08:32.000 --> 00:08:35.000\n And what they wanted to look for is what's the percent weight change?\n\n138\n00:08:35.000 --> 00:08:37.000\n And the Womac pain scores.\n\n139\n00:08:37.000 --> 00:08:41.000\n So Womac is the Western Rantart O something arthritis.\n\n140\n00:08:41.000 --> 00:08:42.000\n No, Western.\n\n141\n00:08:42.000 --> 00:08:43.000\n I forget what it is.\n\n142\n00:08:43.000 --> 00:08:44.000\n Look up Womac real quick.\n\n143\n00:08:44.000 --> 00:08:48.000\n Womac pain scale.\n\n144\n00:08:48.000 --> 00:08:52.000\n Yes, Western, Ontario, and McMastery universities.\n\n145\n00:08:52.000 --> 00:08:55.000\n So serving you is that evaluate severity of hip and knee away,\n\n146\n00:08:55.000 --> 00:08:59.000\n and ask specific question by your daily life, including pain stiffness, physical functioning.\n\n147\n00:09:00.000 --> 00:09:04.000\n Essentially, it is checking what the disease burden is for osteoarthritis.\n\n148\n00:09:04.000 --> 00:09:07.000\n What they found was between the treatment group,\n\n149\n00:09:07.000 --> 00:09:09.000\n semi-glutide versus the placebo group,\n\n150\n00:09:09.000 --> 00:09:14.000\n that was a 14.1 greater improvement in the treatment group.\n\n151\n00:09:14.000 --> 00:09:18.000\n I think the treatment group has a school improvement of 41 points, something,\n\n152\n00:09:18.000 --> 00:09:20.000\n versus I forget what the other one was.\n\n153\n00:09:20.000 --> 00:09:21.000\n So 27 point, right?\n\n154\n00:09:21.000 --> 00:09:24.000\n And so that exceeded the threshold of what they thought with them,\n\n155\n00:09:24.000 --> 00:09:26.000\n minimally clinically important difference would be.\n\n156\n00:09:26.000 --> 00:09:28.000\n And that's a pretty large clinical effect, right?\n\n157\n00:09:28.000 --> 00:09:31.000\n The way change in the treatment group was 13.7%.\n\n158\n00:09:31.000 --> 00:09:35.000\n And the placebo group was 3.2% less.\n\n159\n00:09:35.000 --> 00:09:39.000\n And so, yeah, you had a meaningful weight reduction.\n\n160\n00:09:39.000 --> 00:09:43.000\n And you had a meaningful improvement in your symptoms, right?\n\n161\n00:09:43.000 --> 00:09:44.000\n The Womac scores as well.\n\n162\n00:09:44.000 --> 00:09:45.000\n They had some secondary outcomes as well.\n\n163\n00:09:45.000 --> 00:09:47.000\n They had something called the SF-36,\n\n164\n00:09:47.000 --> 00:09:51.000\n which had also improved in favor of the treatment group.\n\n165\n00:09:51.000 --> 00:09:55.000\n No, a couple of biases with this one, or caveats pointing.\n\n166\n00:09:55.000 --> 00:09:56.000\n It was industry funded.\n\n167\n00:09:56.000 --> 00:09:59.000\n So, Novan Ordersk, which is the company, had funded this,\n\n168\n00:09:59.000 --> 00:10:00.000\n whatever that means to you, right?\n\n169\n00:10:00.000 --> 00:10:03.000\n We always want to make sure that we're looking at that stuff.\n\n170\n00:10:03.000 --> 00:10:09.000\n And you had this improvement, but I did point out the fact that there was substantial weight change, right?\n\n171\n00:10:09.000 --> 00:10:17.000\n So it doesn't necessarily prove that the effect was because of some magical component of GLP1s,\n\n172\n00:10:17.000 --> 00:10:19.000\n because, again, you could just say, hey, listen,\n\n173\n00:10:19.000 --> 00:10:22.000\n you had a significant weight loss, and that's why these people did better, right?\n\n174\n00:10:22.000 --> 00:10:23.000\n 13.7 versus 3.2%.\n\n175\n00:10:24.000 --> 00:10:27.000\n So, this metabolic intervention, we know had a big clinical improvement,\n\n176\n00:10:27.000 --> 00:10:29.000\n but why did it happen?\n\n177\n00:10:29.000 --> 00:10:31.000\n Is it the drug, or is it, again, the backpack?\n\n178\n00:10:31.000 --> 00:10:32.000\n All right.\n\n179\n00:10:32.000 --> 00:10:33.000\n So, let's fast forward.\n\n180\n00:10:33.000 --> 00:10:34.000\n So, that's the GLP1, right?\n\n181\n00:10:34.000 --> 00:10:37.000\n The other study that I think is worth mentioning here,\n\n182\n00:10:37.000 --> 00:10:40.000\n is the Pan et al. paper that was published in JAMA 2025.\n\n183\n00:10:40.000 --> 00:10:43.000\n So, in this study, they looked at different drugs.\n\n184\n00:10:43.000 --> 00:10:46.000\n Metformin, good old diabetes drug, right?\n\n185\n00:10:46.000 --> 00:10:48.000\n Penies on the dollar at this point.\n\n186\n00:10:48.000 --> 00:10:50.000\n So, they took a little smaller study.\n\n187\n00:10:50.000 --> 00:10:53.000\n They took 107 people, randomized control trial, six months long.\n\n188\n00:10:53.000 --> 00:10:55.000\n Here, they had the overweight population.\n\n189\n00:10:55.000 --> 00:10:57.000\n So, the BMI cut up was 25 or greater,\n\n190\n00:10:57.000 --> 00:10:59.000\n and you had to have symptomatic knee, okay?\n\n191\n00:10:59.000 --> 00:11:03.000\n And they gave them 2,000 milligrams of metformin every single day.\n\n192\n00:11:03.000 --> 00:11:06.000\n What they looked at is these things called the VS knee pain score.\n\n193\n00:11:06.000 --> 00:11:09.000\n So, this is just your classic visual analog scale,\n\n194\n00:11:09.000 --> 00:11:11.000\n your pain score, how much your pain improved.\n\n195\n00:11:11.000 --> 00:11:16.000\n And what they noted was that there was an 11.4 millimeter difference.\n\n196\n00:11:17.000 --> 00:11:18.000\n What's important, worth noting,\n\n197\n00:11:18.000 --> 00:11:20.000\n what they thought to the MCID prior to the study\n\n198\n00:11:20.000 --> 00:11:23.000\n with the mean clinically important difference would be 15 millimeters.\n\n199\n00:11:23.000 --> 00:11:25.000\n And that didn't actually achieve that,\n\n200\n00:11:25.000 --> 00:11:27.000\n but there was an improvement.\n\n201\n00:11:27.000 --> 00:11:29.000\n Weight change, this is the important.\n\n202\n00:11:29.000 --> 00:11:34.000\n Treatment group was negative 1.2 kilograms versus 1.2 kilograms.\n\n203\n00:11:34.000 --> 00:11:36.000\n Really not much of a difference at all.\n\n204\n00:11:36.000 --> 00:11:39.000\n So, the interesting thing here is that the treatment group\n\n205\n00:11:39.000 --> 00:11:44.000\n had benefit despite no excess weight loss, right?\n\n206\n00:11:44.000 --> 00:11:46.000\n So, no significant changes in weight loss.\n\n207\n00:11:46.000 --> 00:11:48.000\n They also looked at the Wormack pain stiffness,\n\n208\n00:11:48.000 --> 00:11:51.000\n function, quality of life, all these were unchanged\n\n209\n00:11:51.000 --> 00:11:52.000\n and nothing got three months,\n\n210\n00:11:52.000 --> 00:11:54.000\n but at six months, they did have a little bit of improvement.\n\n211\n00:11:54.000 --> 00:11:55.000\n Have the outs here?\n\n212\n00:11:55.000 --> 00:11:57.000\n This was a small study, right?\n\n213\n00:11:57.000 --> 00:11:59.000\n A hundred and seven total people.\n\n214\n00:11:59.000 --> 00:12:02.000\n A lot of that was via telemedicine, self-reporting,\n\n215\n00:12:02.000 --> 00:12:04.000\n barely any significant secondary effect.\n\n216\n00:12:04.000 --> 00:12:08.000\n So, I think big takeaway from this was that got a lot of people excited,\n\n217\n00:12:08.000 --> 00:12:10.000\n was, hey, you can actually see some changes happen\n\n218\n00:12:10.000 --> 00:12:12.000\n even though they're modest,\n\n219\n00:12:12.000 --> 00:12:15.000\n but it can happen despite no changes in weight.\n\n220\n00:12:15.000 --> 00:12:18.000\n So, there must be something with these prediabetes drugs,\n\n221\n00:12:18.000 --> 00:12:21.000\n these diabetes drugs, these metabolic drugs, if you will,\n\n222\n00:12:21.000 --> 00:12:25.000\n that are affecting the joint health, the joint milieu,\n\n223\n00:12:25.000 --> 00:12:29.000\n in favor of improving disease burden.\n\n224\n00:12:29.000 --> 00:12:33.000\n I will pause there to see what your takeaway is.\n\n225\n00:12:33.000 --> 00:12:35.000\n And did you come across this?\n\n226\n00:12:35.000 --> 00:12:37.000\n Because they definitely caused some headlines\n\n227\n00:12:37.000 --> 00:12:39.000\n and a lot of my colleagues were sending it to me.\n\n228\n00:12:40.000 --> 00:12:42.000\n So, I think one of them had pointed out that, hey,\n\n229\n00:12:42.000 --> 00:12:44.000\n they're, she's seeing some of our colleagues\n\n230\n00:12:44.000 --> 00:12:46.000\n or maybe patients talking about this.\n\n231\n00:12:46.000 --> 00:12:48.000\n Is this something that's been your on your radar?\n\n232\n00:12:48.000 --> 00:12:51.000\n No, this is, the first time I've heard of this is when you sent it to me.\n\n233\n00:12:51.000 --> 00:12:53.000\n The only thing that I recently saw,\n\n234\n00:12:53.000 --> 00:12:55.000\n it was on Instagram, it was funny, on Polymarket,\n\n235\n00:12:55.000 --> 00:12:59.000\n the page about GLP1's and both mineral density loss,\n\n236\n00:12:59.000 --> 00:13:01.000\n and how rapid weight loss is causing that.\n\n237\n00:13:01.000 --> 00:13:03.000\n So, that was something that was going back by my mind\n\n238\n00:13:03.000 --> 00:13:04.000\n as I was looking at these papers.\n\n239\n00:13:04.000 --> 00:13:06.000\n As much as the GLP1 standpoint is,\n\n240\n00:13:06.000 --> 00:13:07.000\n while we look at OA,\n\n241\n00:13:07.000 --> 00:13:11.000\n and then we look at other phenotype when you talk about rapid bone loss and osteoporosis,\n\n242\n00:13:11.000 --> 00:13:14.000\n again, we could talk about this coming up in terms of\n\n243\n00:13:14.000 --> 00:13:16.000\n who are the best candidates when you look at these papers\n\n244\n00:13:16.000 --> 00:13:18.000\n to really ask your doctor and say,\n\n245\n00:13:18.000 --> 00:13:20.000\n is it beneficial for me to be able to do the GLP1\n\n246\n00:13:20.000 --> 00:13:23.000\n because, again, if you're a frail, elderly individual,\n\n247\n00:13:23.000 --> 00:13:26.000\n then these papers may not exactly have the right idea\n\n248\n00:13:26.000 --> 00:13:28.000\n from weight loss perspective,\n\n249\n00:13:28.000 --> 00:13:30.000\n but for a minute again,\n\n250\n00:13:30.000 --> 00:13:32.000\n it depends on kind of the goals.\n\n251\n00:13:32.000 --> 00:13:34.000\n But for me, really, as I'm reading this,\n\n252\n00:13:34.000 --> 00:13:37.000\n I've had people that have been talking to where colleagues, friends,\n\n253\n00:13:37.000 --> 00:13:41.000\n who are in this position where they could make a benefit from a GLP1.\n\n254\n00:13:41.000 --> 00:13:43.000\n They have arthritis, and they're asking me questions,\n\n255\n00:13:43.000 --> 00:13:46.000\n and oftentimes we're looking at standard treatment,\n\n256\n00:13:46.000 --> 00:13:49.000\n which is, I'd be profan, Tylenol, Abraise, Therapy,\n\n257\n00:13:49.000 --> 00:13:51.000\n Corticosteroid injections, maybe PRP.\n\n258\n00:13:51.000 --> 00:13:53.000\n So, these are the things that kind of get brought up to me,\n\n259\n00:13:53.000 --> 00:13:55.000\n but to think about it from this standpoint,\n\n260\n00:13:55.000 --> 00:13:57.000\n I think is really fascinating.\n\n261\n00:13:57.000 --> 00:13:59.000\n Yeah, all those are amazing options, right?\n\n262\n00:13:59.000 --> 00:14:01.000\n For somebody, I think I treat osteoarthritis probably more\n\n263\n00:14:01.000 --> 00:14:03.000\n so than any other thing I treat in my practice.\n\n264\n00:14:03.000 --> 00:14:05.000\n Everything that you're talking, I think,\n\n265\n00:14:05.000 --> 00:14:08.000\n is looking at the symptom burden of the disease.\n\n266\n00:14:08.000 --> 00:14:10.000\n I think this is still true,\n\n267\n00:14:10.000 --> 00:14:13.000\n that knee osteoarthritis is the leading cause of disability worldwide,\n\n268\n00:14:13.000 --> 00:14:16.000\n at this point, at least from a musculoskeletal standpoint.\n\n269\n00:14:16.000 --> 00:14:18.000\n That might not, maybe not overall,\n\n270\n00:14:18.000 --> 00:14:21.000\n but from a musculoskeletal standpoint, that's the number one.\n\n271\n00:14:21.000 --> 00:14:23.000\n When somebody is filing for disability,\n\n272\n00:14:23.000 --> 00:14:26.000\n symptoms is really the main thing for play they're going to have.\n\n273\n00:14:26.000 --> 00:14:28.000\n And so, if you can modulate those symptoms\n\n274\n00:14:28.000 --> 00:14:30.000\n with everything that you mentioned,\n\n275\n00:14:30.000 --> 00:14:32.000\n and other options that we haven't covered,\n\n276\n00:14:32.000 --> 00:14:34.000\n you're going to potentially improve their quality of light,\n\n277\n00:14:34.000 --> 00:14:36.000\n which is the main thing that you and I care about,\n\n278\n00:14:36.000 --> 00:14:38.000\n certainly in our practice, right?\n\n279\n00:14:38.000 --> 00:14:40.000\n But then there is another way to look at something.\n\n280\n00:14:40.000 --> 00:14:42.000\n Something could be disease modifying as well,\n\n281\n00:14:42.000 --> 00:14:44.000\n something could be structurally modifying as well.\n\n282\n00:14:44.000 --> 00:14:46.000\n So, disease modifying is what we're looking at here.\n\n283\n00:14:46.000 --> 00:14:49.000\n Because certainly, step nine trial showed that symptoms\n\n284\n00:14:49.000 --> 00:14:51.000\n has significantly improved, right?\n\n285\n00:14:51.000 --> 00:14:54.000\n We've got a clear signal here that's happening.\n\n286\n00:14:54.000 --> 00:14:56.000\n The question is if disease modifying,\n\n287\n00:14:56.000 --> 00:14:58.000\n and if so, how is that happening?\n\n288\n00:14:58.000 --> 00:15:01.000\n So, I think at this point, maybe we take a step back, right?\n\n289\n00:15:01.000 --> 00:15:03.000\n And try to understand some of the ways\n\n290\n00:15:03.000 --> 00:15:10.000\n how excess adiposity can be toxic to the joint.\n\n291\n00:15:10.000 --> 00:15:12.000\n And why some of the arguments are being made.\n\n292\n00:15:12.000 --> 00:15:14.000\n And why we should actually, I think,\n\n293\n00:15:14.000 --> 00:15:16.000\n that really pay attention to this.\n\n294\n00:15:16.000 --> 00:15:20.000\n So, the reality is that that is,\n\n295\n00:15:20.000 --> 00:15:23.000\n adipose, particularly, is an endocrine and immune organ.\n\n296\n00:15:23.000 --> 00:15:25.000\n We know this. We've talked about this, right?\n\n297\n00:15:25.000 --> 00:15:26.000\n How it's communicating.\n\n298\n00:15:26.000 --> 00:15:28.000\n And this way, it's just touching so many different things.\n\n299\n00:15:28.000 --> 00:15:30.000\n So, the GLP ones, like not only do they have indication\n\n300\n00:15:30.000 --> 00:15:33.000\n for diabetes and weight loss,\n\n301\n00:15:33.000 --> 00:15:36.000\n but trizipotite is FDA approved for sleep apnea.\n\n302\n00:15:36.000 --> 00:15:40.000\n And you, I think, one of them has level one data\n\n303\n00:15:40.000 --> 00:15:42.000\n and FDA approval for a mash, right?\n\n304\n00:15:42.000 --> 00:15:45.000\n Another one has cardio metabolic as well, heart failure.\n\n305\n00:15:45.000 --> 00:15:48.000\n So, you're getting all these things because it turns out\n\n306\n00:15:48.000 --> 00:15:51.000\n that metabolism seems to touch on multiple systems of the body.\n\n307\n00:15:51.000 --> 00:15:54.000\n So, it's an endocrine and an immune organ.\n\n308\n00:15:55.000 --> 00:15:57.000\n So, you have these things called adipocines,\n\n309\n00:15:57.000 --> 00:15:59.000\n leptin, resistant, visfat, and in particular,\n\n310\n00:15:59.000 --> 00:16:02.000\n they cause a lot of this condrocyte inflammation.\n\n311\n00:16:02.000 --> 00:16:05.000\n Condrocytes are the cells of the cartilage.\n\n312\n00:16:05.000 --> 00:16:09.000\n And they're going to increase this majorce-metalloprotinase\n\n313\n00:16:09.000 --> 00:16:12.000\n activity, which is going to ultimately lead to degrading the cartilage.\n\n314\n00:16:12.000 --> 00:16:15.000\n Insulin resistance, the other canary in the guanma.\n\n315\n00:16:15.000 --> 00:16:18.000\n It's going to impair cartilage homeostasis, right?\n\n316\n00:16:18.000 --> 00:16:20.000\n So, those advanced glycation end products\n\n317\n00:16:20.000 --> 00:16:21.000\n that we talked about intended up,\n\n318\n00:16:21.000 --> 00:16:23.000\n but they're either implicated as well.\n\n319\n00:16:23.000 --> 00:16:27.000\n They tend to accumulate and are problematic for the joint\n\n320\n00:16:27.000 --> 00:16:30.000\n because instead of going through oxidative phosphorylation,\n\n321\n00:16:30.000 --> 00:16:34.000\n which is a more efficient mechanism energy production,\n\n322\n00:16:34.000 --> 00:16:36.000\n we're going more through glycolysis,\n\n323\n00:16:36.000 --> 00:16:39.000\n and that's more inefficient for your cartilage\n\n324\n00:16:39.000 --> 00:16:40.000\n and your joint health.\n\n325\n00:16:40.000 --> 00:16:44.000\n And then you have synovium, which is what the joints are bathing.\n\n326\n00:16:44.000 --> 00:16:47.000\n So, you have the synovium through all of your joints\n\n327\n00:16:47.000 --> 00:16:48.000\n and circulating.\n\n328\n00:16:48.000 --> 00:16:51.000\n You'll have a lot of these M1 macrophage infiltration,\n\n329\n00:16:51.000 --> 00:16:53.000\n which is going to cause IL-6.\n\n330\n00:16:53.000 --> 00:16:55.000\n These are inflammatory cytokines, TNF alpha,\n\n331\n00:16:55.000 --> 00:16:57.000\n MMP, matrix degradation, all that's going to happen.\n\n332\n00:16:57.000 --> 00:16:59.000\n So, it's not just an autoimmune thing,\n\n333\n00:16:59.000 --> 00:17:01.000\n like rheumatoid arthritis is,\n\n334\n00:17:01.000 --> 00:17:04.000\n but it's also not inflammation-free.\n\n335\n00:17:04.000 --> 00:17:07.000\n So, maybe this is one of the reasons why we'll say,\n\n336\n00:17:07.000 --> 00:17:11.000\n oh, take NSAIDs for 10 days, let's kill the inflammation,\n\n337\n00:17:11.000 --> 00:17:14.000\n when maybe there's a small component to that,\n\n338\n00:17:14.000 --> 00:17:17.000\n but there's also the component that those are really good analgesics.\n\n339\n00:17:17.000 --> 00:17:18.000\n But when somebody injures their knee,\n\n340\n00:17:18.000 --> 00:17:20.000\n they might have some local swelling and stuff.\n\n341\n00:17:20.000 --> 00:17:22.000\n So, you know, there is some inflammation happening.\n\n342\n00:17:22.000 --> 00:17:24.000\n Now, NSAIDs, you brought it up,\n\n343\n00:17:24.000 --> 00:17:25.000\n and I just brought it up again.\n\n344\n00:17:25.000 --> 00:17:27.000\n There is a little bit of an interesting paradox,\n\n345\n00:17:27.000 --> 00:17:30.000\n because if we say that always not in inflammatory,\n\n346\n00:17:30.000 --> 00:17:32.000\n or we are saying if always in inflammatory,\n\n347\n00:17:32.000 --> 00:17:34.000\n then why are NSAIDs not working better?\n\n348\n00:17:34.000 --> 00:17:36.000\n Because it's the type of the local inflammation.\n\n349\n00:17:36.000 --> 00:17:38.000\n So, it's not necessarily the way NSAIDs work with\n\n350\n00:17:38.000 --> 00:17:40.000\n on your prostate gland in system.\n\n351\n00:17:40.000 --> 00:17:42.000\n I'm not going to get too deep into the immune pathway here.\n\n352\n00:17:42.000 --> 00:17:45.000\n But this is a different type of inflammation.\n\n353\n00:17:45.000 --> 00:17:47.000\n So, this is coming from those adipocines,\n\n354\n00:17:47.000 --> 00:17:48.000\n like I talked about, right?\n\n355\n00:17:48.000 --> 00:17:50.000\n It's coming from the insulin resistance.\n\n356\n00:17:50.000 --> 00:17:52.000\n What other interesting thing that I learned\n\n357\n00:17:52.000 --> 00:17:54.000\n during this research here is half-as-fat fat.\n\n358\n00:17:54.000 --> 00:17:56.000\n You familiar with this one?\n\n359\n00:17:56.000 --> 00:17:57.000\n No, I've told you about it.\n\n360\n00:17:57.000 --> 00:17:59.000\n I know half-as-fat fat, at least.\n\n361\n00:17:59.000 --> 00:18:00.000\n Yeah.\n\n362\n00:18:00.000 --> 00:18:02.000\n So, everybody, underneath your kneecap,\n\n363\n00:18:02.000 --> 00:18:04.000\n that's the patella.\n\n364\n00:18:04.000 --> 00:18:06.000\n It's called the infra-patella fat pad.\n\n365\n00:18:06.000 --> 00:18:08.000\n So, you have the little tendon, if you're listening,\n\n366\n00:18:08.000 --> 00:18:10.000\n and you're driving or something like that,\n\n367\n00:18:10.000 --> 00:18:12.000\n you can feel underneath your kneecap.\n\n368\n00:18:12.000 --> 00:18:14.000\n It's going to be this roby little structure.\n\n369\n00:18:14.000 --> 00:18:16.000\n That's called your patella tendon.\n\n370\n00:18:16.000 --> 00:18:18.000\n That's going to get hurt.\n\n371\n00:18:18.000 --> 00:18:20.000\n Right underneath that, deeper to that layer,\n\n372\n00:18:20.000 --> 00:18:22.000\n is a big fat, everybody has this,\n\n373\n00:18:22.000 --> 00:18:24.000\n called half-as-fat pad or infra-patella fat pad.\n\n374\n00:18:24.000 --> 00:18:27.000\n So, this is directly overlying your joint.\n\n375\n00:18:27.000 --> 00:18:29.000\n And this actually turns out,\n\n376\n00:18:29.000 --> 00:18:31.000\n is a local inflammatory source as well.\n\n377\n00:18:31.000 --> 00:18:33.000\n So, just like you have,\n\n378\n00:18:33.000 --> 00:18:37.000\n maybe central adiposity, you have visceral fat.\n\n379\n00:18:37.000 --> 00:18:42.000\n That local fat is going to put a lot of those inflammatory cytokines\n\n380\n00:18:42.000 --> 00:18:44.000\n and those, quote, unquote, bad cells,\n\n381\n00:18:44.000 --> 00:18:45.000\n into the joint directly.\n\n382\n00:18:45.000 --> 00:18:47.000\n And so, that's maybe another reason,\n\n383\n00:18:47.000 --> 00:18:49.000\n why the knee, in particular,\n\n384\n00:18:49.000 --> 00:18:54.000\n is subject to this metabolic ill-health system,\n\n385\n00:18:54.000 --> 00:18:56.000\n and actually these medications tend to work better.\n\n386\n00:18:56.000 --> 00:18:58.000\n So, that's one thought as well.\n\n387\n00:18:58.000 --> 00:19:02.000\n The one thing I should say about the glucose piece,\n\n388\n00:19:02.000 --> 00:19:03.000\n I know we've talked about the antenna knob,\n\n389\n00:19:03.000 --> 00:19:05.000\n but when I came to,\n\n390\n00:19:05.000 --> 00:19:07.000\n dig a little bit deeper into this,\n\n391\n00:19:07.000 --> 00:19:10.000\n that the biology at the bench level is pretty real,\n\n392\n00:19:10.000 --> 00:19:13.000\n but the human causality contribution,\n\n393\n00:19:13.000 --> 00:19:16.000\n can't really be separated from body fat.\n\n394\n00:19:16.000 --> 00:19:18.000\n And when you look at the RCTs,\n\n395\n00:19:18.000 --> 00:19:20.000\n there's one thing you look rather to observational studies,\n\n396\n00:19:20.000 --> 00:19:21.000\n that's one thing,\n\n397\n00:19:21.000 --> 00:19:23.000\n but the Mendelian randomization studies\n\n398\n00:19:23.000 --> 00:19:25.000\n will show that adiposity is the lead actor.\n\n399\n00:19:25.000 --> 00:19:28.000\n And because even people who have elevated glucose,\n\n400\n00:19:28.000 --> 00:19:32.000\n they've not had an elevated risk osteoarthritis burden.\n\n401\n00:19:32.000 --> 00:19:34.000\n Does that make sense right there?\n\n402\n00:19:34.000 --> 00:19:35.000\n Cool.\n\n403\n00:19:35.000 --> 00:19:37.000\n Anything interesting there,\n\n404\n00:19:37.000 --> 00:19:39.000\n anything that you've learned with the mechanism,\n\n405\n00:19:39.000 --> 00:19:40.000\n specifically,\n\n406\n00:19:40.000 --> 00:19:44.000\n exercise at aposity is problematic for joints?\n\n407\n00:19:44.000 --> 00:19:46.000\n No, I think it makes sense to me.\n\n408\n00:19:46.000 --> 00:19:48.000\n I think even for our listeners,\n\n409\n00:19:48.000 --> 00:19:49.000\n I think as they listen,\n\n410\n00:19:49.000 --> 00:19:51.000\n and they can relate it to themselves or their patients.\n\n411\n00:19:51.000 --> 00:19:53.000\n To me, I don't know if you have more to go,\n\n412\n00:19:53.000 --> 00:19:54.000\n but a lot of this,\n\n413\n00:19:54.000 --> 00:19:55.000\n how does this affect the future?\n\n414\n00:19:55.000 --> 00:19:57.000\n How does this affect practice in the future?\n\n415\n00:19:57.000 --> 00:19:59.000\n But if you have more mechanisms right there,\n\n416\n00:19:59.000 --> 00:20:00.000\n I'd go for it.\n\n417\n00:20:00.000 --> 00:20:01.000\n I'm going to get to that.\n\n418\n00:20:01.000 --> 00:20:02.000\n I promise I will.\n\n419\n00:20:02.000 --> 00:20:03.000\n We want to make it actionable.\n\n420\n00:20:03.000 --> 00:20:04.000\n I think more important than,\n\n421\n00:20:04.000 --> 00:20:05.000\n as sexy as these things are,\n\n422\n00:20:05.000 --> 00:20:06.000\n which, to be honest,\n\n423\n00:20:06.000 --> 00:20:07.000\n the further I get into it,\n\n424\n00:20:07.000 --> 00:20:08.000\n the more patients that treat,\n\n425\n00:20:08.000 --> 00:20:09.000\n it's not that sexy.\n\n426\n00:20:09.000 --> 00:20:10.000\n It's fun.\n\n427\n00:20:10.000 --> 00:20:11.000\n It's exciting.\n\n428\n00:20:11.000 --> 00:20:12.000\n And then the question is,\n\n429\n00:20:12.000 --> 00:20:13.000\n one of my college room is used to say,\n\n430\n00:20:13.000 --> 00:20:14.000\n and then what?\n\n431\n00:20:14.000 --> 00:20:15.000\n I have information that's what we do on about this.\n\n432\n00:20:15.000 --> 00:20:17.000\n But one thing I do want to plug in,\n\n433\n00:20:17.000 --> 00:20:18.000\n because my buddy,\n\n434\n00:20:18.000 --> 00:20:19.000\n Amek, I shout out to you if you're listening,\n\n435\n00:20:19.000 --> 00:20:20.000\n he had sent this, right?\n\n436\n00:20:20.000 --> 00:20:21.000\n So this isn't a paper\n\n437\n00:20:21.000 --> 00:20:23.000\n that was published in Selma Tapasam.\n\n438\n00:20:23.000 --> 00:20:25.000\n I think March this year,\n\n439\n00:20:25.000 --> 00:20:26.000\n 2026,\n\n440\n00:20:26.000 --> 00:20:30.000\n and to piggyback off of that step nine trial,\n\n441\n00:20:30.000 --> 00:20:31.000\n looking at semiconductor,\n\n442\n00:20:31.000 --> 00:20:33.000\n they wanted to see,\n\n443\n00:20:33.000 --> 00:20:35.000\n hey, is it actually a weight dependent effect\n\n444\n00:20:35.000 --> 00:20:36.000\n or weight independent effect?\n\n445\n00:20:37.000 --> 00:20:38.000\n So what they did was,\n\n446\n00:20:38.000 --> 00:20:40.000\n they had somewhat elegant mice study,\n\n447\n00:20:40.000 --> 00:20:42.000\n but they took high-fat diet,\n\n448\n00:20:42.000 --> 00:20:43.000\n obese mice, right?\n\n449\n00:20:43.000 --> 00:20:45.000\n And they destabilized the needle miniscus.\n\n450\n00:20:45.000 --> 00:20:47.000\n So the meat miniscus is the cartilage between the knee,\n\n451\n00:20:47.000 --> 00:20:50.000\n it provides cushioning and stabilization of the knee,\n\n452\n00:20:50.000 --> 00:20:51.000\n and resectated it,\n\n453\n00:20:51.000 --> 00:20:52.000\n injured it,\n\n454\n00:20:52.000 --> 00:20:55.000\n and the one side on the mice got weekly stomach lose hide,\n\n455\n00:20:55.000 --> 00:20:56.000\n versus a control,\n\n456\n00:20:56.000 --> 00:20:58.000\n and they were a pair-fat group.\n\n457\n00:20:58.000 --> 00:21:01.000\n And so both of them had restricted food\n\n458\n00:21:01.000 --> 00:21:04.000\n to try to get them to lose the same exact amount of weight,\n\n459\n00:21:04.000 --> 00:21:05.000\n which they did.\n\n460\n00:21:05.000 --> 00:21:08.000\n Now, what they noted was the mice\n\n461\n00:21:08.000 --> 00:21:10.000\n with the semi-glutide versus the mice\n\n462\n00:21:10.000 --> 00:21:12.000\n who did not get them medication,\n\n463\n00:21:12.000 --> 00:21:13.000\n but still lost the same amount of weight,\n\n464\n00:21:13.000 --> 00:21:15.000\n they had no meaningful cartilage protection.\n\n465\n00:21:15.000 --> 00:21:18.000\n The semi-glutide mice did have that.\n\n466\n00:21:18.000 --> 00:21:19.000\n So now,\n\n467\n00:21:19.000 --> 00:21:20.000\n you've taken the weight out of the picture\n\n468\n00:21:20.000 --> 00:21:21.000\n because both of them lost weight, right?\n\n469\n00:21:21.000 --> 00:21:23.000\n So there's something happening here,\n\n470\n00:21:23.000 --> 00:21:25.000\n where semi-glutide is causing,\n\n471\n00:21:25.000 --> 00:21:27.000\n or offering some type of protection is what they think.\n\n472\n00:21:27.000 --> 00:21:29.000\n How did they measure that, right?\n\n473\n00:21:29.000 --> 00:21:31.000\n So they measured the cartilage loss\n\n474\n00:21:31.000 --> 00:21:33.000\n and protection with micro CT,\n\n475\n00:21:33.000 --> 00:21:34.000\n histology,\n\n476\n00:21:34.000 --> 00:21:36.000\n and pain behavior testing as well.\n\n477\n00:21:36.000 --> 00:21:37.000\n They went in a step further.\n\n478\n00:21:37.000 --> 00:21:39.000\n Then they knocked out,\n\n479\n00:21:39.000 --> 00:21:42.000\n so they knocked out the GLP-1 receptor gene,\n\n480\n00:21:42.000 --> 00:21:44.000\n and what they noted was the effect was gone.\n\n481\n00:21:44.000 --> 00:21:46.000\n So that's cool.\n\n482\n00:21:46.000 --> 00:21:48.000\n Again, this is not human studies,\n\n483\n00:21:48.000 --> 00:21:50.000\n but what it is able to show\n\n484\n00:21:50.000 --> 00:21:53.000\n is that maybe that this medication,\n\n485\n00:21:53.000 --> 00:21:54.000\n this medication,\n\n486\n00:21:54.000 --> 00:21:56.000\n enough familiar if metformat has done something like that,\n\n487\n00:21:56.000 --> 00:21:58.000\n but in observation of large trials,\n\n488\n00:21:58.000 --> 00:22:00.000\n they've been able to pick up a similar signal.\n\n489\n00:22:00.000 --> 00:22:02.000\n I think that kind of is really exciting,\n\n490\n00:22:02.000 --> 00:22:04.000\n and that's the type of stuff that you need\n\n491\n00:22:04.000 --> 00:22:06.000\n to get this pushing forward.\n\n492\n00:22:06.000 --> 00:22:08.000\n Now, I know,\n\n493\n00:22:08.000 --> 00:22:09.000\n no minor risk,\n\n494\n00:22:09.000 --> 00:22:10.000\n and I think Eli Lilly has a register\n\n495\n00:22:10.000 --> 00:22:11.000\n to try to call stop,\n\n496\n00:22:11.000 --> 00:22:12.000\n Neostruth,\n\n497\n00:22:12.000 --> 00:22:13.000\n and Neostruth, right?\n\n498\n00:22:13.000 --> 00:22:14.000\n As well,\n\n499\n00:22:14.000 --> 00:22:16.000\n that the register to try to really get indication,\n\n500\n00:22:16.000 --> 00:22:18.000\n because right now,\n\n501\n00:22:18.000 --> 00:22:20.000\n these medications are not FDA-approved\n\n502\n00:22:20.000 --> 00:22:21.000\n for osteoarthritis.\n\n503\n00:22:21.000 --> 00:22:23.000\n So it's not the medication\n\n504\n00:22:23.000 --> 00:22:24.000\n that you're going in,\n\n505\n00:22:24.000 --> 00:22:25.000\n because of osteoarthritis\n\n506\n00:22:25.000 --> 00:22:27.000\n that should be on this medication,\n\n507\n00:22:27.000 --> 00:22:29.000\n because they might be better medications out there.\n\n508\n00:22:29.000 --> 00:22:31.000\n If you're going to use this medication,\n\n509\n00:22:31.000 --> 00:22:32.000\n you want to think about,\n\n510\n00:22:32.000 --> 00:22:33.000\n look, why are we doing it?\n\n511\n00:22:33.000 --> 00:22:35.000\n And I guess maybe the question\n\n512\n00:22:35.000 --> 00:22:36.000\n that maybe you're getting at is,\n\n513\n00:22:36.000 --> 00:22:38.000\n who is the right person\n\n514\n00:22:38.000 --> 00:22:40.000\n who we can identify that,\n\n515\n00:22:40.000 --> 00:22:41.000\n hey, we got to look at that.\n\n516\n00:22:41.000 --> 00:22:44.000\n So given everything that I've presented to you at this point,\n\n517\n00:22:44.000 --> 00:22:46.000\n one, do you have any questions about this study?\n\n518\n00:22:46.000 --> 00:22:47.000\n And then two,\n\n519\n00:22:47.000 --> 00:22:49.000\n how would this change your practice?\n\n520\n00:22:49.000 --> 00:22:51.000\n And how would you use this information\n\n521\n00:22:51.000 --> 00:22:52.000\n to try to identify\n\n522\n00:22:52.000 --> 00:22:53.000\n or profile that person,\n\n523\n00:22:53.000 --> 00:22:54.000\n if I can use that word,\n\n524\n00:22:54.000 --> 00:22:57.000\n who maybe this is a conversation for?\n\n525\n00:22:58.000 --> 00:22:59.000\n Yeah, I guess,\n\n526\n00:22:59.000 --> 00:23:01.000\n I think the questions the listeners might have is,\n\n527\n00:23:01.000 --> 00:23:04.000\n do we know if osteoarthritis is reversible?\n\n528\n00:23:04.000 --> 00:23:05.000\n So these medications are helping,\n\n529\n00:23:05.000 --> 00:23:07.000\n and there's an inflammatory process\n\n530\n00:23:07.000 --> 00:23:08.000\n that is disease-modifying.\n\n531\n00:23:08.000 --> 00:23:10.000\n Are we able to then go back\n\n532\n00:23:10.000 --> 00:23:11.000\n on the class patients?\n\n533\n00:23:11.000 --> 00:23:12.000\n Can we go from the severe osteoarthritic\n\n534\n00:23:12.000 --> 00:23:14.000\n knee joint to now moderate?\n\n535\n00:23:14.000 --> 00:23:15.000\n Yeah.\n\n536\n00:23:15.000 --> 00:23:16.000\n That's an unanswered question.\n\n537\n00:23:16.000 --> 00:23:18.000\n We don't know that yet, right?\n\n538\n00:23:18.000 --> 00:23:20.000\n So that would be the whole disease\n\n539\n00:23:20.000 --> 00:23:21.000\n and structural modifying thing\n\n540\n00:23:21.000 --> 00:23:22.000\n that we have to look at,\n\n541\n00:23:22.000 --> 00:23:23.000\n because like we talked about is,\n\n542\n00:23:23.000 --> 00:23:24.000\n yeah, you would have to look at this for long enough.\n\n543\n00:23:24.000 --> 00:23:26.000\n We know that osteoarthritis\n\n544\n00:23:26.000 --> 00:23:28.000\n is a progressive disease at this point.\n\n545\n00:23:28.000 --> 00:23:30.000\n I tell people when they come in with osteoarthritis,\n\n546\n00:23:30.000 --> 00:23:31.000\n and they're like,\n\n547\n00:23:31.000 --> 00:23:32.000\n man, I got really bad away,\n\n548\n00:23:32.000 --> 00:23:33.000\n and I say, hey, congratulations,\n\n549\n00:23:33.000 --> 00:23:34.000\n they look at me.\n\n550\n00:23:34.000 --> 00:23:35.000\n Really weird, I'm like,\n\n551\n00:23:35.000 --> 00:23:37.000\n that means you've lived long enough to accumulate them.\n\n552\n00:23:37.000 --> 00:23:38.000\n So there is an accumulation.\n\n553\n00:23:38.000 --> 00:23:41.000\n It might not necessarily be wear and tear.\n\n554\n00:23:41.000 --> 00:23:43.000\n There is some level wear and tear,\n\n555\n00:23:43.000 --> 00:23:44.000\n but it might necessarily be all wear and tear,\n\n556\n00:23:44.000 --> 00:23:46.000\n but it is a progressive, right?\n\n557\n00:23:46.000 --> 00:23:48.000\n Processed, probably,\n\n558\n00:23:48.000 --> 00:23:51.000\n as what we say about heart disease and hypertension,\n\n559\n00:23:51.000 --> 00:23:53.000\n the number one risk factor is age.\n\n560\n00:23:53.000 --> 00:23:54.000\n People in their 70s\n\n561\n00:23:54.000 --> 00:23:56.000\n are more likely to have it in their 20s.\n\n562\n00:23:56.000 --> 00:23:58.000\n But disease modifying is the interesting question\n\n563\n00:23:58.000 --> 00:23:59.000\n which we have to ask.\n\n564\n00:23:59.000 --> 00:24:00.000\n And I think this cell study,\n\n565\n00:24:00.000 --> 00:24:01.000\n this mice study,\n\n566\n00:24:01.000 --> 00:24:02.000\n is one piece of the puzzle.\n\n567\n00:24:02.000 --> 00:24:03.000\n Metformin is similar.\n\n568\n00:24:03.000 --> 00:24:06.000\n I think the one thing I didn't mention is,\n\n569\n00:24:06.000 --> 00:24:09.000\n both of them are converging on the similar mechanism.\n\n570\n00:24:09.000 --> 00:24:12.000\n And that mechanism is looking at AMPK,\n\n571\n00:24:12.000 --> 00:24:14.000\n which is the AMP protein kinase.\n\n572\n00:24:14.000 --> 00:24:15.000\n People have heard that,\n\n573\n00:24:15.000 --> 00:24:16.000\n the MTOR pathway as well,\n\n574\n00:24:16.000 --> 00:24:18.000\n and that's really how Metform is working.\n\n575\n00:24:18.000 --> 00:24:21.000\n That part of the list sells.\n\n576\n00:24:21.000 --> 00:24:24.000\n And GLP1 also is going mediated\n\n577\n00:24:24.000 --> 00:24:26.000\n through the AMPK pathway as well.\n\n578\n00:24:26.000 --> 00:24:29.000\n I think there is a conversation about the gut joint pathway,\n\n579\n00:24:29.000 --> 00:24:30.000\n everything,\n\n580\n00:24:30.000 --> 00:24:32.000\n as other people have said starts with the gut, right?\n\n581\n00:24:32.000 --> 00:24:33.000\n As you would know.\n\n582\n00:24:33.000 --> 00:24:35.000\n But really, its AMPK modulation is what's happening.\n\n583\n00:24:35.000 --> 00:24:36.000\n You have some GLP,\n\n584\n00:24:36.000 --> 00:24:38.000\n one receptors into the joint.\n\n585\n00:24:38.000 --> 00:24:39.000\n So these questions,\n\n586\n00:24:39.000 --> 00:24:41.000\n these studies, as recent as two months ago,\n\n587\n00:24:41.000 --> 00:24:43.000\n are starting to put some information out there\n\n588\n00:24:43.000 --> 00:24:45.000\n that we have to test a little bit more\n\n589\n00:24:45.000 --> 00:24:46.000\n to see what's going on.\n\n590\n00:24:46.000 --> 00:24:47.000\n Cool.\n\n591\n00:24:47.000 --> 00:24:48.000\n This.\n\n592\n00:24:48.000 --> 00:24:49.000\n So,\n\n593\n00:24:49.000 --> 00:24:50.000\n go back there,\n\n594\n00:24:50.000 --> 00:24:52.000\n try to figure out who the right patient is.\n\n595\n00:24:52.000 --> 00:24:53.000\n That's the question now.\n\n596\n00:24:53.000 --> 00:24:54.000\n For you.\n\n597\n00:24:54.000 --> 00:24:55.000\n Given this information I give you,\n\n598\n00:24:55.000 --> 00:24:57.000\n how would you think about,\n\n599\n00:24:57.000 --> 00:24:58.000\n hey, should I consider this,\n\n600\n00:24:58.000 --> 00:25:00.000\n where you would open the conversation?\n\n601\n00:25:00.000 --> 00:25:01.000\n Yeah.\n\n602\n00:25:01.000 --> 00:25:03.000\n So I think what's interesting again,\n\n603\n00:25:03.000 --> 00:25:06.000\n is the first headline is,\n\n604\n00:25:06.000 --> 00:25:07.000\n OA Metabolic Disease.\n\n605\n00:25:07.000 --> 00:25:10.000\n So regardless of who has the OA,\n\n606\n00:25:10.000 --> 00:25:12.000\n let's say they're elderly,\n\n607\n00:25:12.000 --> 00:25:14.000\n sure we might think it's more age related,\n\n608\n00:25:14.000 --> 00:25:15.000\n like you said.\n\n609\n00:25:15.000 --> 00:25:16.000\n If they're younger,\n\n610\n00:25:16.000 --> 00:25:18.000\n we put up a little bit more top of mind\n\n611\n00:25:18.000 --> 00:25:19.000\n to make it okay.\n\n612\n00:25:19.000 --> 00:25:21.000\n Especially if they have a higher BMI,\n\n613\n00:25:21.000 --> 00:25:23.000\n they have an ASCVD risk,\n\n614\n00:25:23.000 --> 00:25:25.000\n they've got things like fatty liver,\n\n615\n00:25:25.000 --> 00:25:27.000\n they do show the side of the symptoms\n\n616\n00:25:27.000 --> 00:25:29.000\n of metabolic syndrome.\n\n617\n00:25:29.000 --> 00:25:31.000\n Is that something that we go and look for, right?\n\n618\n00:25:31.000 --> 00:25:32.000\n That's also the question.\n\n619\n00:25:32.000 --> 00:25:36.000\n So we're trained that you don't necessarily order something\n\n620\n00:25:36.000 --> 00:25:37.000\n unless you're going to do something about it.\n\n621\n00:25:37.000 --> 00:25:39.000\n And even when you do order something,\n\n622\n00:25:39.000 --> 00:25:40.000\n sometimes you don't,\n\n623\n00:25:40.000 --> 00:25:41.000\n because it can put you in trouble,\n\n624\n00:25:41.000 --> 00:25:42.000\n because now you're responsible\n\n625\n00:25:42.000 --> 00:25:44.000\n for kind of treating that, right?\n\n626\n00:25:44.000 --> 00:25:46.000\n And I don't think a lot of patients understand that,\n\n627\n00:25:46.000 --> 00:25:47.000\n but it's always a tough discussion.\n\n628\n00:25:47.000 --> 00:25:48.000\n It's okay.\n\n629\n00:25:48.000 --> 00:25:51.000\n The best way I explain it is getting a full body MRI, right?\n\n630\n00:25:51.000 --> 00:25:53.000\n The reason why you don't do it is sometimes is\n\n631\n00:25:53.000 --> 00:25:54.000\n you see something,\n\n632\n00:25:54.000 --> 00:25:55.000\n you want to treat it,\n\n633\n00:25:55.000 --> 00:25:56.000\n but in the end it's actually benign.\n\n634\n00:25:56.000 --> 00:25:58.000\n And so that can go for all sorts of imaging\n\n635\n00:25:58.000 --> 00:25:59.000\n from the back to the knee,\n\n636\n00:25:59.000 --> 00:26:00.000\n and et cetera.\n\n637\n00:26:00.000 --> 00:26:02.000\n That being said,\n\n638\n00:26:02.000 --> 00:26:04.000\n does the astute physician now say,\n\n639\n00:26:04.000 --> 00:26:06.000\n okay, you have knee OA?\n\n640\n00:26:06.000 --> 00:26:08.000\n Should we go out and also look for things like\n\n641\n00:26:08.000 --> 00:26:09.000\n fatty liver syndrome?\n\n642\n00:26:09.000 --> 00:26:12.000\n Should we go out and get a lipid panel again\n\n643\n00:26:12.000 --> 00:26:13.000\n if you haven't done it?\n\n644\n00:26:13.000 --> 00:26:14.000\n Check your A1C.\n\n645\n00:26:14.000 --> 00:26:15.000\n Do all these things that seem pretty standard,\n\n646\n00:26:15.000 --> 00:26:18.000\n but actually do more of a little bit of a deep dive on it\n\n647\n00:26:18.000 --> 00:26:20.000\n to see if metabolic syndrome\n\n648\n00:26:20.000 --> 00:26:22.000\n in its totality kind of exists?\n\n649\n00:26:22.000 --> 00:26:24.000\n Probably, yes.\n\n650\n00:26:24.000 --> 00:26:25.000\n Like I would say,\n\n651\n00:26:25.000 --> 00:26:29.000\n I think that I've changed up my documentation a little bit.\n\n652\n00:26:29.000 --> 00:26:31.000\n And so there are certain people\n\n653\n00:26:31.000 --> 00:26:32.000\n what I think that,\n\n654\n00:26:32.000 --> 00:26:34.000\n like the idea of precision medicine,\n\n655\n00:26:34.000 --> 00:26:36.000\n then subclassifying osteoarthritis\n\n656\n00:26:36.000 --> 00:26:38.000\n is the big takeaway for me on this.\n\n657\n00:26:38.000 --> 00:26:40.000\n And so certain people,\n\n658\n00:26:40.000 --> 00:26:41.000\n which I can tell you,\n\n659\n00:26:41.000 --> 00:26:43.000\n who I think I'm going to start labeling this for,\n\n660\n00:26:44.000 --> 00:26:45.000\n is where I would say,\n\n661\n00:26:45.000 --> 00:26:48.000\n oh, this patient probably has the METS dash away.\n\n662\n00:26:48.000 --> 00:26:50.000\n It's a metabolic syndrome away.\n\n663\n00:26:50.000 --> 00:26:52.000\n And either we already know\n\n664\n00:26:52.000 --> 00:26:55.000\n that they have fatty liver disease, right?\n\n665\n00:26:55.000 --> 00:26:57.000\n Or we know that they are prediabetic.\n\n666\n00:26:57.000 --> 00:26:59.000\n We can see,\n\n667\n00:26:59.000 --> 00:27:01.000\n and we know that they're dealing with\n\n668\n00:27:01.000 --> 00:27:02.000\n exoscientiposity right there,\n\n669\n00:27:02.000 --> 00:27:03.000\n and that could be waste,\n\n670\n00:27:03.000 --> 00:27:05.000\n waste to height circumference.\n\n671\n00:27:05.000 --> 00:27:07.000\n And those races we can look at,\n\n672\n00:27:07.000 --> 00:27:09.000\n maybe they already have hypertension,\n\n673\n00:27:09.000 --> 00:27:11.000\n those other metabolic symptoms that I talked about.\n\n674\n00:27:11.000 --> 00:27:12.000\n And now we're diagnosing with osteoarthritis,\n\n675\n00:27:12.000 --> 00:27:13.000\n which is either later,\n\n676\n00:27:13.000 --> 00:27:15.000\n or we're seeing,\n\n677\n00:27:15.000 --> 00:27:18.000\n actually, now that we're talking about it,\n\n678\n00:27:18.000 --> 00:27:22.000\n I'm not sure that you can diagnose osteoarthritis\n\n679\n00:27:22.000 --> 00:27:23.000\n and then go the other way,\n\n680\n00:27:23.000 --> 00:27:25.000\n unless you have these other signals.\n\n681\n00:27:25.000 --> 00:27:29.000\n Like somebody just comes in with osteoarthritis in isolation.\n\n682\n00:27:29.000 --> 00:27:31.000\n And I think there would be one hint\n\n683\n00:27:31.000 --> 00:27:32.000\n that would give that, right?\n\n684\n00:27:32.000 --> 00:27:33.000\n And that would be,\n\n685\n00:27:33.000 --> 00:27:36.000\n if somebody has osteoarthritis in multiple joints.\n\n686\n00:27:36.000 --> 00:27:38.000\n Typically, when you hear somebody\n\n687\n00:27:38.000 --> 00:27:39.000\n has osteoarthritis in multiple joints,\n\n688\n00:27:39.000 --> 00:27:40.000\n what did medical students teach us?\n\n689\n00:27:41.000 --> 00:27:42.000\n That's going to be the,\n\n690\n00:27:42.000 --> 00:27:45.000\n what type of pattern that we talked about, the phenotypes.\n\n691\n00:27:45.000 --> 00:27:47.000\n I know you love when I put you on the side.\n\n692\n00:27:47.000 --> 00:27:48.000\n Yeah, I know, I'm like,\n\n693\n00:27:48.000 --> 00:27:49.000\n we don't like it here, man.\n\n694\n00:27:49.000 --> 00:27:50.000\n I don't think I'm dull with this.\n\n695\n00:27:50.000 --> 00:27:52.000\n Well, you talk about bilateral,\n\n696\n00:27:52.000 --> 00:27:53.000\n or just, you know,\n\n697\n00:27:53.000 --> 00:27:54.000\n wrist bilateral.\n\n698\n00:27:54.000 --> 00:27:55.000\n Okay, then, yeah,\n\n699\n00:27:55.000 --> 00:27:56.000\n we're thinking to play a tutorial,\n\n700\n00:27:56.000 --> 00:27:57.000\n right?\n\n701\n00:27:57.000 --> 00:27:58.000\n Yeah, we're thinking to say,\n\n702\n00:27:58.000 --> 00:27:59.000\n I think, yeah.\n\n703\n00:27:59.000 --> 00:28:00.000\n What was interesting is,\n\n704\n00:28:00.000 --> 00:28:01.000\n when, for our step one,\n\n705\n00:28:01.000 --> 00:28:02.000\n and stuff like, oh,\n\n706\n00:28:02.000 --> 00:28:03.000\n is, you know,\n\n707\n00:28:03.000 --> 00:28:04.000\n if somebody comes in the morning\n\n708\n00:28:04.000 --> 00:28:06.000\n and they're knee pain worsens throughout the day,\n\n709\n00:28:06.000 --> 00:28:07.000\n it's more osteoarthritis.\n\n710\n00:28:07.000 --> 00:28:08.000\n Somebody comes up,\n\n711\n00:28:08.000 --> 00:28:09.000\n they have bilateral wrist,\n\n712\n00:28:09.000 --> 00:28:10.000\n and like, that's,\n\n713\n00:28:10.000 --> 00:28:11.000\n it's in temperature.\n\n714\n00:28:11.000 --> 00:28:12.000\n So it's like, those are the two buckets.\n\n715\n00:28:12.000 --> 00:28:13.000\n It's a fork in the road.\n\n716\n00:28:13.000 --> 00:28:14.000\n And that's actually not the case here.\n\n717\n00:28:14.000 --> 00:28:16.000\n The reason I say that is,\n\n718\n00:28:16.000 --> 00:28:19.000\n if somebody just comes in with a unilateral knee away,\n\n719\n00:28:19.000 --> 00:28:21.000\n then why would a metabolic component\n\n720\n00:28:21.000 --> 00:28:22.000\n be only affecting them?\n\n721\n00:28:22.000 --> 00:28:25.000\n But if somebody comes in with a little bit more of a,\n\n722\n00:28:25.000 --> 00:28:27.000\n oh, man, my hands are a little bit achy,\n\n723\n00:28:27.000 --> 00:28:28.000\n and both knees are aching,\n\n724\n00:28:28.000 --> 00:28:29.000\n and two knees,\n\n725\n00:28:29.000 --> 00:28:30.000\n and a hip and stuff like that.\n\n726\n00:28:30.000 --> 00:28:31.000\n Okay.\n\n727\n00:28:31.000 --> 00:28:32.000\n Yes, you could think about an inflammatory component,\n\n728\n00:28:32.000 --> 00:28:34.000\n but there could be a metabolic component too,\n\n729\n00:28:34.000 --> 00:28:36.000\n which we know is causing a little bit of inflammation,\n\n730\n00:28:36.000 --> 00:28:37.000\n but different type of an inflammation,\n\n731\n00:28:37.000 --> 00:28:38.000\n right?\n\n732\n00:28:38.000 --> 00:28:40.000\n So within the inflammatory pathway,\n\n733\n00:28:40.000 --> 00:28:43.000\n I suppose you could have another fork in the road.\n\n734\n00:28:43.000 --> 00:28:44.000\n But now, especially,\n\n735\n00:28:44.000 --> 00:28:45.000\n especially if all those,\n\n736\n00:28:45.000 --> 00:28:48.000\n especially if a lot of the autoimmune stuff is negative,\n\n737\n00:28:48.000 --> 00:28:49.000\n right?\n\n738\n00:28:49.000 --> 00:28:51.000\n Which we see all the time.\n\n739\n00:28:51.000 --> 00:28:52.000\n That's a brilliant thing.\n\n740\n00:28:52.000 --> 00:28:53.000\n This is one of those things where,\n\n741\n00:28:53.000 --> 00:28:54.000\n yeah, patients come up to,\n\n742\n00:28:54.000 --> 00:28:55.000\n like, everything hurts,\n\n743\n00:28:55.000 --> 00:28:56.000\n and I have,\n\n744\n00:28:56.000 --> 00:28:57.000\n I'm guilty of this,\n\n745\n00:28:57.000 --> 00:28:58.000\n right?\n\n746\n00:28:58.000 --> 00:28:59.000\n Because I won't do this anymore.\n\n747\n00:28:59.000 --> 00:29:00.000\n Well, I just try not to,\n\n748\n00:29:00.000 --> 00:29:01.000\n is they'll come in,\n\n749\n00:29:01.000 --> 00:29:02.000\n everything hurts.\n\n750\n00:29:02.000 --> 00:29:03.000\n I'm like, you got to go see rheumatology.\n\n751\n00:29:03.000 --> 00:29:04.000\n They go to rheumatology,\n\n752\n00:29:04.000 --> 00:29:06.000\n and they get the full rheumatological workout.\n\n753\n00:29:07.000 --> 00:29:09.000\n And what's interesting is a lot of times people\n\n754\n00:29:09.000 --> 00:29:10.000\n will come back with a diagnosis,\n\n755\n00:29:10.000 --> 00:29:12.000\n you have RA negative.\n\n756\n00:29:12.000 --> 00:29:13.000\n Seronegative.\n\n757\n00:29:13.000 --> 00:29:14.000\n Seronegative.\n\n758\n00:29:14.000 --> 00:29:15.000\n Yeah.\n\n759\n00:29:15.000 --> 00:29:16.000\n Seronegative rheumatology arthritis,\n\n760\n00:29:16.000 --> 00:29:17.000\n or seronegative.\n\n761\n00:29:17.000 --> 00:29:18.000\n Maybe they don't have rheumatology arthritis.\n\n762\n00:29:18.000 --> 00:29:19.000\n How about that?\n\n763\n00:29:19.000 --> 00:29:20.000\n There's nothing.\n\n764\n00:29:20.000 --> 00:29:21.000\n Right.\n\n765\n00:29:21.000 --> 00:29:22.000\n It's very interesting.\n\n766\n00:29:22.000 --> 00:29:23.000\n Any, like, 60 to 70% of people,\n\n767\n00:29:23.000 --> 00:29:24.000\n sorry, I think, like,\n\n768\n00:29:24.000 --> 00:29:26.000\n 30% of people have seronegative RA.\n\n769\n00:29:26.000 --> 00:29:28.000\n I believe that's, yeah, 30% or so.\n\n770\n00:29:28.000 --> 00:29:29.000\n Good amount of people that are...\n\n771\n00:29:29.000 --> 00:29:30.000\n Maybe for the listener,\n\n772\n00:29:30.000 --> 00:29:31.000\n who doesn't know what that means?\n\n773\n00:29:31.000 --> 00:29:32.000\n Tell them what seronegative means.\n\n774\n00:29:32.000 --> 00:29:33.000\n Seronegative.\n\n775\n00:29:33.000 --> 00:29:34.000\n So essentially,\n\n776\n00:29:34.000 --> 00:29:36.000\n you have these types of complaints and you go,\n\n777\n00:29:36.000 --> 00:29:38.000\n and if you do have autoimmune disease,\n\n778\n00:29:38.000 --> 00:29:40.000\n you get an A&A, a rheumatoid factor.\n\n779\n00:29:40.000 --> 00:29:41.000\n These are all different markers.\n\n780\n00:29:41.000 --> 00:29:44.000\n Now, typically, one of those would be positive,\n\n781\n00:29:44.000 --> 00:29:45.000\n which, if one of them are positive,\n\n782\n00:29:45.000 --> 00:29:47.000\n then you can go down the rabbit hole\n\n783\n00:29:47.000 --> 00:29:49.000\n to check out which markers are super sensitive,\n\n784\n00:29:49.000 --> 00:29:51.000\n or super specific, for certain diseases.\n\n785\n00:29:51.000 --> 00:29:53.000\n In about 30% of these patients,\n\n786\n00:29:53.000 --> 00:29:55.000\n nothing comes up with an answer.\n\n787\n00:29:55.000 --> 00:29:57.000\n You might have an A&A, let's say,\n\n788\n00:29:57.000 --> 00:29:58.000\n that's positive,\n\n789\n00:29:58.000 --> 00:29:59.000\n but that still is just...\n\n790\n00:29:59.000 --> 00:30:02.000\n It's so general that it doesn't really point to inflammation.\n\n791\n00:30:02.000 --> 00:30:03.000\n Yeah.\n\n792\n00:30:03.000 --> 00:30:04.000\n It just says you have information.\n\n793\n00:30:04.000 --> 00:30:05.000\n So a lot of these patients,\n\n794\n00:30:05.000 --> 00:30:07.000\n they actually can't find a marker\n\n795\n00:30:07.000 --> 00:30:09.000\n that is specific for their complaint,\n\n796\n00:30:09.000 --> 00:30:11.000\n that can be generalized with population.\n\n797\n00:30:11.000 --> 00:30:13.000\n So even though it seems like they have rheumatoid arthritis,\n\n798\n00:30:13.000 --> 00:30:15.000\n and that's exactly the type of pattern they're showing,\n\n799\n00:30:15.000 --> 00:30:17.000\n they don't have the marker to show for it,\n\n800\n00:30:17.000 --> 00:30:19.000\n so they automatically are classified\n\n801\n00:30:19.000 --> 00:30:21.000\n as seronegative rheumatoid arthritis.\n\n802\n00:30:21.000 --> 00:30:22.000\n And oftentimes,\n\n803\n00:30:22.000 --> 00:30:24.000\n they get started on those demards,\n\n804\n00:30:24.000 --> 00:30:26.000\n disease-modifying drugs.\n\n805\n00:30:26.000 --> 00:30:27.000\n Yeah.\n\n806\n00:30:27.000 --> 00:30:28.000\n And those are not medications\n\n807\n00:30:28.000 --> 00:30:29.000\n to be messing around with.\n\n808\n00:30:29.000 --> 00:30:30.000\n Right?\n\n809\n00:30:30.000 --> 00:30:31.000\n Those are some really intense medications\n\n810\n00:30:31.000 --> 00:30:32.000\n with an intense side effect.\n\n811\n00:30:32.000 --> 00:30:34.000\n So common ones people might have heard of\n\n812\n00:30:34.000 --> 00:30:35.000\n methotrexate,\n\n813\n00:30:35.000 --> 00:30:37.000\n plaquanal, things like that.\n\n814\n00:30:37.000 --> 00:30:39.000\n Here is something that we need to start looking into.\n\n815\n00:30:39.000 --> 00:30:40.000\n Right?\n\n816\n00:30:40.000 --> 00:30:43.000\n Because I can think of 20 patients on top of my head\n\n817\n00:30:43.000 --> 00:30:44.000\n where they've had some type of,\n\n818\n00:30:44.000 --> 00:30:45.000\n which are maybe not 20,\n\n819\n00:30:45.000 --> 00:30:47.000\n but I can definitely think of five or six right now,\n\n820\n00:30:47.000 --> 00:30:48.000\n that I've had something like this.\n\n821\n00:30:48.000 --> 00:30:51.000\n And let's explore this area a little bit more.\n\n822\n00:30:51.000 --> 00:30:52.000\n These are difficult conversations to have, though.\n\n823\n00:30:52.000 --> 00:30:55.000\n So here are some key messages that I would say\n\n824\n00:30:55.000 --> 00:30:58.000\n for the clinicians listening that we need to start communicating with their patients\n\n825\n00:30:58.000 --> 00:31:00.000\n when you have this type of disease burden.\n\n826\n00:31:01.000 --> 00:31:03.000\n So one is identifying the person, right?\n\n827\n00:31:03.000 --> 00:31:04.000\n If you have suspicion,\n\n828\n00:31:04.000 --> 00:31:06.000\n they've got something like that going on,\n\n829\n00:31:06.000 --> 00:31:07.000\n and you're not thinking,\n\n830\n00:31:07.000 --> 00:31:08.000\n it's a rheumatoid condition,\n\n831\n00:31:08.000 --> 00:31:10.000\n maybe there are some labs that we start getting.\n\n832\n00:31:10.000 --> 00:31:13.000\n So certainly checking their blood pressure.\n\n833\n00:31:13.000 --> 00:31:15.000\n That's going to be part of the process.\n\n834\n00:31:15.000 --> 00:31:17.000\n I think we talked about getting their waist\n\n835\n00:31:17.000 --> 00:31:18.000\n and waist to height,\n\n836\n00:31:18.000 --> 00:31:20.000\n waist circumference to height ratio.\n\n837\n00:31:20.000 --> 00:31:21.000\n It's probably better,\n\n838\n00:31:21.000 --> 00:31:24.000\n because I think it's probably a better indicator of central out of hostility.\n\n839\n00:31:24.000 --> 00:31:26.000\n That's going to be a big one.\n\n840\n00:31:26.000 --> 00:31:29.000\n Checking their high sensitivity CRP,\n\n841\n00:31:29.000 --> 00:31:32.000\n but HSCRP is going to be really good for inflammation.\n\n842\n00:31:32.000 --> 00:31:34.000\n Fasting glucose, home IR,\n\n843\n00:31:34.000 --> 00:31:36.000\n we've talked about that at the length,\n\n844\n00:31:36.000 --> 00:31:37.000\n so people can check home IR as well,\n\n845\n00:31:37.000 --> 00:31:39.000\n because I think it's a better indicator than just A1C.\n\n846\n00:31:39.000 --> 00:31:40.000\n I would probably still get A1C,\n\n847\n00:31:40.000 --> 00:31:42.000\n but I think home IR is going to be better.\n\n848\n00:31:42.000 --> 00:31:43.000\n Anything else that I'm missing\n\n849\n00:31:43.000 --> 00:31:45.000\n that you would put in your metabolic pattern?\n\n850\n00:31:45.000 --> 00:31:46.000\n This lipid profile, A1C,\n\n851\n00:31:46.000 --> 00:31:47.000\n I think we're going to question those.\n\n852\n00:31:47.000 --> 00:31:48.000\n Just, yeah.\n\n853\n00:31:48.000 --> 00:31:49.000\n I think that's pretty much it.\n\n854\n00:31:49.000 --> 00:31:51.000\n I think I would start doing that.\n\n855\n00:31:51.000 --> 00:31:52.000\n And if these are things flagging,\n\n856\n00:31:52.000 --> 00:31:54.000\n now we can start having conversations with people\n\n857\n00:31:54.000 --> 00:31:55.000\n that are really meaningful.\n\n858\n00:31:55.000 --> 00:31:56.000\n Because you know what's interesting.\n\n859\n00:31:56.000 --> 00:31:57.000\n We talk about this.\n\n860\n00:31:57.000 --> 00:31:58.000\n If somebody comes in with elevated LDL,\n\n861\n00:31:58.000 --> 00:32:01.000\n like that sometimes,\n\n862\n00:32:01.000 --> 00:32:05.000\n and oftentimes is not enough for people to make a change.\n\n863\n00:32:05.000 --> 00:32:08.000\n Because high LDL is not symptomatic.\n\n864\n00:32:08.000 --> 00:32:09.000\n When it becomes symptomatic,\n\n865\n00:32:09.000 --> 00:32:11.000\n it's a heart attack and it's a problem.\n\n866\n00:32:11.000 --> 00:32:13.000\n So people are less likely to be proactive.\n\n867\n00:32:13.000 --> 00:32:15.000\n What is symptomatic is knee arthritis.\n\n868\n00:32:15.000 --> 00:32:17.000\n Pain is a really strong motivator.\n\n869\n00:32:17.000 --> 00:32:19.000\n But now we can use this, right?\n\n870\n00:32:19.000 --> 00:32:21.000\n So I think conversations that have with patients say,\n\n871\n00:32:21.000 --> 00:32:24.000\n hey, your fat tissue is actually talking to your joints.\n\n872\n00:32:24.000 --> 00:32:25.000\n Right?\n\n873\n00:32:25.000 --> 00:32:26.000\n Because your fat tissue is releasing.\n\n874\n00:32:26.000 --> 00:32:29.000\n These things like leptin and other inflammatory molecules\n\n875\n00:32:29.000 --> 00:32:31.000\n that are causing destruction to the joint.\n\n876\n00:32:31.000 --> 00:32:35.000\n So you want to help improve this and reverse some of this\n\n877\n00:32:35.000 --> 00:32:36.000\n than you're talking about?\n\n878\n00:32:36.000 --> 00:32:38.000\n We know that there is a signal here.\n\n879\n00:32:38.000 --> 00:32:39.000\n We don't know how strong it is,\n\n880\n00:32:39.000 --> 00:32:41.000\n but we know there's something going on.\n\n881\n00:32:41.000 --> 00:32:44.000\n And this metabolic environment that's driving high blood sugar\n\n882\n00:32:44.000 --> 00:32:46.000\n is also affecting a cartilage.\n\n883\n00:32:46.000 --> 00:32:49.000\n And again, it's having some type of effect.\n\n884\n00:32:49.000 --> 00:32:51.000\n Maybe it's not super, super strong,\n\n885\n00:32:51.000 --> 00:32:52.000\n but it is having effect.\n\n886\n00:32:52.000 --> 00:32:56.000\n And weight loss is going to treat the disease,\n\n887\n00:32:56.000 --> 00:32:57.000\n not just the symptom.\n\n888\n00:32:57.000 --> 00:32:58.000\n So like we talked about,\n\n889\n00:32:58.000 --> 00:33:01.000\n the step nine trial showed that it's going to treat the symptom for sure.\n\n890\n00:33:01.000 --> 00:33:05.000\n So every pound that you lose is about four pounds of loss,\n\n891\n00:33:05.000 --> 00:33:06.000\n four pounds of force less,\n\n892\n00:33:06.000 --> 00:33:09.000\n onto your knee joint per step.\n\n893\n00:33:09.000 --> 00:33:11.000\n And it's helping with the inflammatory burden,\n\n894\n00:33:11.000 --> 00:33:12.000\n like we talked about, right?\n\n895\n00:33:12.000 --> 00:33:14.000\n So there is meaningful pain improvement.\n\n896\n00:33:14.000 --> 00:33:17.000\n And these new medications that we're looking at,\n\n897\n00:33:17.000 --> 00:33:18.000\n these could help.\n\n898\n00:33:18.000 --> 00:33:20.000\n It could be a two-pronged approach.\n\n899\n00:33:20.000 --> 00:33:21.000\n At the very least,\n\n900\n00:33:21.000 --> 00:33:23.000\n it's going to know that it's going to solve the tried and true problem\n\n901\n00:33:23.000 --> 00:33:24.000\n that we have.\n\n902\n00:33:24.000 --> 00:33:26.000\n It's going to take care of the quote-unquote backpack.\n\n903\n00:33:26.000 --> 00:33:28.000\n That's going to be amazing.\n\n904\n00:33:28.000 --> 00:33:30.000\n And hopefully,\n\n905\n00:33:30.000 --> 00:33:31.000\n if what we think is true,\n\n906\n00:33:31.000 --> 00:33:33.000\n it's going to affect it independently as well.\n\n907\n00:33:33.000 --> 00:33:35.000\n And that's not only going to affect your joints\n\n908\n00:33:35.000 --> 00:33:38.000\n and make your overall disease burden from an osteoarthritis better\n\n909\n00:33:38.000 --> 00:33:40.000\n and your quality of life better,\n\n910\n00:33:40.000 --> 00:33:42.000\n but it's going to help your LDL get better,\n\n911\n00:33:42.000 --> 00:33:43.000\n which is going to be less heart attacks\n\n912\n00:33:43.000 --> 00:33:44.000\n and less kidney disease\n\n913\n00:33:44.000 --> 00:33:47.000\n and the blood pressure and less strokes and all.\n\n914\n00:33:47.000 --> 00:33:50.000\n So that's kind of how I would approach it, I think.\n\n915\n00:33:50.000 --> 00:33:52.000\n What do you tell the patient who,\n\n916\n00:33:52.000 --> 00:33:54.000\n and again, I see there's a lot of health care\n\n917\n00:33:54.000 --> 00:33:56.000\n and people who want to do it the natural way,\n\n918\n00:33:56.000 --> 00:33:59.000\n who are afraid of the GLP ones don't think it's the natural way\n\n919\n00:33:59.000 --> 00:34:00.000\n of doing things.\n\n920\n00:34:00.000 --> 00:34:02.000\n They are obese,\n\n921\n00:34:02.000 --> 00:34:03.000\n and they want to stick\n\n922\n00:34:03.000 --> 00:34:04.000\n to the Korgoceroid injections,\n\n923\n00:34:04.000 --> 00:34:05.000\n the hyaluronic acid,\n\n924\n00:34:05.000 --> 00:34:08.000\n just oral medication that they can do,\n\n925\n00:34:08.000 --> 00:34:10.000\n which we've been doing for years.\n\n926\n00:34:10.000 --> 00:34:12.000\n What's the conversation like with that?\n\n927\n00:34:12.000 --> 00:34:13.000\n How do you kind of think about that?\n\n928\n00:34:13.000 --> 00:34:15.000\n I'm all about, right?\n\n929\n00:34:15.000 --> 00:34:17.000\n I think that if you are,\n\n930\n00:34:17.000 --> 00:34:19.000\n I don't want to say necessarily anti-pharmacology,\n\n931\n00:34:19.000 --> 00:34:22.000\n I think that if you're anti this specific medication\n\n932\n00:34:22.000 --> 00:34:24.000\n for whatever reason that you have, great.\n\n933\n00:34:24.000 --> 00:34:26.000\n We can try to solve this problem,\n\n934\n00:34:26.000 --> 00:34:28.000\n just recognize it's going to be harder.\n\n935\n00:34:28.000 --> 00:34:30.000\n I don't get to make the decision that you do.\n\n936\n00:34:30.000 --> 00:34:33.000\n I think that if we want to do it whichever way we do it,\n\n937\n00:34:33.000 --> 00:34:37.000\n if the end goal is that the person can have less body fat,\n\n938\n00:34:37.000 --> 00:34:38.000\n their blood pressure is better managed,\n\n939\n00:34:38.000 --> 00:34:40.000\n all those things that we're trying to get to,\n\n940\n00:34:40.000 --> 00:34:41.000\n they're going to do better.\n\n941\n00:34:41.000 --> 00:34:44.000\n Because what we're trying to do here is we're trying to reduce,\n\n942\n00:34:44.000 --> 00:34:47.000\n if we talked about that you have less of a pack,\n\n943\n00:34:47.000 --> 00:34:48.000\n that's one method that's going to improve,\n\n944\n00:34:48.000 --> 00:34:50.000\n but if it's also an endocrine immune organ,\n\n945\n00:34:50.000 --> 00:34:51.000\n we reduce that,\n\n946\n00:34:51.000 --> 00:34:53.000\n and it has less of an inflammatory burn,\n\n947\n00:34:53.000 --> 00:34:54.000\n they're still going to help.\n\n948\n00:34:54.000 --> 00:34:55.000\n Now, that's why,\n\n949\n00:34:55.000 --> 00:34:58.000\n if the signal was stronger that these medications\n\n950\n00:34:58.000 --> 00:35:01.000\n were certainly causing disease protection\n\n951\n00:35:01.000 --> 00:35:03.000\n from a disease modifying agent,\n\n952\n00:35:03.000 --> 00:35:04.000\n that would be a different conversation,\n\n953\n00:35:04.000 --> 00:35:06.000\n but we're not there yet at all.\n\n954\n00:35:06.000 --> 00:35:11.000\n But what we do know is that being metabolically unhealthy\n\n955\n00:35:11.000 --> 00:35:13.000\n is causing problems, right?\n\n956\n00:35:13.000 --> 00:35:16.000\n From again, a double wami approach.\n\n957\n00:35:16.000 --> 00:35:18.000\n So whatever way that it is they get there.\n\n958\n00:35:18.000 --> 00:35:20.000\n So I guess maybe the analogy,\n\n959\n00:35:20.000 --> 00:35:23.000\n something that I'll start refining, people don't,\n\n960\n00:35:23.000 --> 00:35:24.000\n with this one medication,\n\n961\n00:35:24.000 --> 00:35:26.000\n people don't say they want to do the natural way, by the way,\n\n962\n00:35:26.000 --> 00:35:28.000\n with other medications they will say.\n\n963\n00:35:28.000 --> 00:35:30.000\n This is the one that the insurance won't pay for.\n\n964\n00:35:30.000 --> 00:35:31.000\n I don't know, have you had this?\n\n965\n00:35:31.000 --> 00:35:32.000\n Has the insurance paying for this,\n\n966\n00:35:32.000 --> 00:35:33.000\n and they don't want to be on it?\n\n967\n00:35:33.000 --> 00:35:34.000\n I've had a few patients that are just,\n\n968\n00:35:34.000 --> 00:35:35.000\n I don't want to touch it.\n\n969\n00:35:35.000 --> 00:35:36.000\n I don't want to be near it.\n\n970\n00:35:36.000 --> 00:35:37.000\n They've had bad experiences with it.\n\n971\n00:35:37.000 --> 00:35:38.000\n Too much rapid weight loss.\n\n972\n00:35:38.000 --> 00:35:40.000\n So I've had patients who have too rapid weight loss,\n\n973\n00:35:40.000 --> 00:35:42.000\n and they're just like, they got sick from it.\n\n974\n00:35:43.000 --> 00:35:44.000\n I don't know, I've also just had patients\n\n975\n00:35:44.000 --> 00:35:45.000\n where I think they hear horror stories,\n\n976\n00:35:45.000 --> 00:35:47.000\n or they have here about the risks.\n\n977\n00:35:47.000 --> 00:35:48.000\n There's not enough long-term data.\n\n978\n00:35:48.000 --> 00:35:49.000\n And so they could stay away.\n\n979\n00:35:49.000 --> 00:35:51.000\n They think, I don't know, I think it's just that story\n\n980\n00:35:51.000 --> 00:35:53.000\n that's been told about, hey, here's another drug\n\n981\n00:35:53.000 --> 00:35:55.000\n that can just cure all in a way, right?\n\n982\n00:35:55.000 --> 00:35:56.000\n Because think about what we're talking about.\n\n983\n00:35:56.000 --> 00:35:58.000\n We're talking about all this different metabolic stuff\n\n984\n00:35:58.000 --> 00:36:00.000\n and to some people, that's too good to be true.\n\n985\n00:36:00.000 --> 00:36:01.000\n Exactly.\n\n986\n00:36:01.000 --> 00:36:03.000\n Yeah, no, listen, there are downsides with it.\n\n987\n00:36:03.000 --> 00:36:06.000\n Maybe actually, yeah, I'd be remiss\n\n988\n00:36:06.000 --> 00:36:07.000\n if I didn't talk about this important one,\n\n989\n00:36:07.000 --> 00:36:09.000\n but I want to come back to natural way.\n\n990\n00:36:09.000 --> 00:36:10.000\n Yeah, I would tell them, hey, listen,\n\n991\n00:36:11.000 --> 00:36:12.000\n like if you tell me I got to go down here,\n\n992\n00:36:12.000 --> 00:36:14.000\n and we have to go to, I'm a jersey,\n\n993\n00:36:14.000 --> 00:36:15.000\n and we got to go to the shore,\n\n994\n00:36:15.000 --> 00:36:17.000\n like we could ride the bike there,\n\n995\n00:36:17.000 --> 00:36:18.000\n or we could take the car there,\n\n996\n00:36:18.000 --> 00:36:20.000\n and the bike's going to be a lot longer,\n\n997\n00:36:20.000 --> 00:36:21.000\n and it's going to be a lot harder,\n\n998\n00:36:21.000 --> 00:36:22.000\n but it'll get you there.\n\n999\n00:36:22.000 --> 00:36:24.000\n Or you could walk there, that's a very natural.\n\n1000\n00:36:24.000 --> 00:36:25.000\n The car isn't, right?\n\n1001\n00:36:25.000 --> 00:36:26.000\n It's just going to be difficult,\n\n1002\n00:36:26.000 --> 00:36:27.000\n but understand that it's doable,\n\n1003\n00:36:27.000 --> 00:36:30.000\n and you get the decide at the end of the day.\n\n1004\n00:36:30.000 --> 00:36:32.000\n Now, I think the one important thing\n\n1005\n00:36:32.000 --> 00:36:34.000\n that we need to talk about, though,\n\n1006\n00:36:34.000 --> 00:36:35.000\n the rapid weight loss that you brought up,\n\n1007\n00:36:35.000 --> 00:36:36.000\n I'm glad that you brought up.\n\n1008\n00:36:36.000 --> 00:36:39.000\n Because interesting conversations happening on social media,\n\n1009\n00:36:39.000 --> 00:36:40.000\n I don't know if you see this,\n\n1010\n00:36:40.000 --> 00:36:43.000\n where a lot of my clinician colleagues,\n\n1011\n00:36:43.000 --> 00:36:45.000\n and I'm going to caveat this by saying,\n\n1012\n00:36:45.000 --> 00:36:47.000\n I have been on record saying that I think\n\n1013\n00:36:47.000 --> 00:36:49.000\n this is one of the most revolutionary drugs,\n\n1014\n00:36:49.000 --> 00:36:50.000\n certainly in my time practicing.\n\n1015\n00:36:50.000 --> 00:36:52.000\n I've said that multiple times, a big fan of it.\n\n1016\n00:36:52.000 --> 00:36:55.000\n I do see a lot of clinician colleagues jumping on\n\n1017\n00:36:55.000 --> 00:36:57.000\n and saying, oh no, this is like,\n\n1018\n00:36:57.000 --> 00:36:59.000\n even that excess lean body mass,\n\n1019\n00:36:59.000 --> 00:37:01.000\n that the studies have reported 25% to 40%,\n\n1020\n00:37:01.000 --> 00:37:03.000\n that's not really actual muscle.\n\n1021\n00:37:03.000 --> 00:37:05.000\n I agree, that's probably true.\n\n1022\n00:37:05.000 --> 00:37:08.000\n Because Dexas is not great at teasing out\n\n1023\n00:37:08.000 --> 00:37:10.000\n what's actual muscle loss,\n\n1024\n00:37:10.000 --> 00:37:12.000\n versus just water weight and bone content, et cetera.\n\n1025\n00:37:12.000 --> 00:37:16.000\n But I do know that lean body mass is better than fat mass,\n\n1026\n00:37:16.000 --> 00:37:18.000\n and I'd rather hold on lean body mass,\n\n1027\n00:37:18.000 --> 00:37:19.000\n so whatever it is.\n\n1028\n00:37:19.000 --> 00:37:20.000\n Here's the challenge.\n\n1029\n00:37:20.000 --> 00:37:21.000\n What they're saying is,\n\n1030\n00:37:21.000 --> 00:37:22.000\n when you compare it to people\n\n1031\n00:37:22.000 --> 00:37:24.000\n who are just on dietary restriction,\n\n1032\n00:37:24.000 --> 00:37:25.000\n it's about the same.\n\n1033\n00:37:25.000 --> 00:37:27.000\n That may be true,\n\n1034\n00:37:27.000 --> 00:37:29.000\n but the reality is people on dietary restriction\n\n1035\n00:37:29.000 --> 00:37:31.000\n don't lose it at first.\n\n1036\n00:37:31.000 --> 00:37:32.000\n It's not as accessible.\n\n1037\n00:37:32.000 --> 00:37:34.000\n People who are typically doing dietary restriction\n\n1038\n00:37:34.000 --> 00:37:35.000\n and can lose that much weight,\n\n1039\n00:37:35.000 --> 00:37:37.000\n where you have 25% to 40%,\n\n1040\n00:37:37.000 --> 00:37:39.000\n they're also going crazy\n\n1041\n00:37:39.000 --> 00:37:41.000\n with their exercise and resistance training.\n\n1042\n00:37:41.000 --> 00:37:43.000\n They're doing everything possible.\n\n1043\n00:37:43.000 --> 00:37:45.000\n The people who can lose that much weight,\n\n1044\n00:37:45.000 --> 00:37:47.000\n where they have the luxury\n\n1045\n00:37:47.000 --> 00:37:49.000\n of losing 25% lean body mass,\n\n1046\n00:37:49.000 --> 00:37:53.000\n those are some really competitive people who are committed.\n\n1047\n00:37:53.000 --> 00:37:55.000\n Whereas now it is so accessible\n\n1048\n00:37:55.000 --> 00:37:58.000\n that the person who does not have high intrinsic motivation\n\n1049\n00:37:58.000 --> 00:38:00.000\n to do this is now getting those results.\n\n1050\n00:38:00.000 --> 00:38:03.000\n So you are getting the weight loss\n\n1051\n00:38:03.000 --> 00:38:06.000\n without having the type of\n\n1052\n00:38:06.000 --> 00:38:08.000\n profile as a person\n\n1053\n00:38:08.000 --> 00:38:10.000\n who is going to continue training and exercising hard.\n\n1054\n00:38:10.000 --> 00:38:12.000\n And so that's why you're losing\n\n1055\n00:38:12.000 --> 00:38:14.000\n the good quality muscle.\n\n1056\n00:38:14.000 --> 00:38:15.000\n Why is that important\n\n1057\n00:38:15.000 --> 00:38:17.000\n with the relevant to what we're talking about?\n\n1058\n00:38:17.000 --> 00:38:19.000\n One of the best things that you can do\n\n1059\n00:38:19.000 --> 00:38:22.000\n to reduce the progression of the disease\n\n1060\n00:38:22.000 --> 00:38:24.000\n of osteoarthritis\n\n1061\n00:38:24.000 --> 00:38:27.000\n is to strengthen the periarticular structures.\n\n1062\n00:38:27.000 --> 00:38:28.000\n So I tell people,\n\n1063\n00:38:28.000 --> 00:38:30.000\n the reason we have works,\n\n1064\n00:38:30.000 --> 00:38:32.000\n the reason it works is because\n\n1065\n00:38:32.000 --> 00:38:34.000\n it's glorified strength training\n\n1066\n00:38:34.000 --> 00:38:35.000\n and joints,\n\n1067\n00:38:35.000 --> 00:38:36.000\n despite what we think,\n\n1068\n00:38:36.000 --> 00:38:38.000\n they're not great at tolerating stress.\n\n1069\n00:38:38.000 --> 00:38:39.000\n You know what it is\n\n1070\n00:38:39.000 --> 00:38:40.000\n greater at tolerating stress?\n\n1071\n00:38:40.000 --> 00:38:41.000\n Your muscles,\n\n1072\n00:38:41.000 --> 00:38:42.000\n your tendons,\n\n1073\n00:38:42.000 --> 00:38:43.000\n and you look at this,\n\n1074\n00:38:43.000 --> 00:38:44.000\n that surround those structures.\n\n1075\n00:38:44.000 --> 00:38:45.000\n So the more resilient\n\n1076\n00:38:45.000 --> 00:38:47.000\n and robust those structures are,\n\n1077\n00:38:47.000 --> 00:38:49.000\n the better people end up doing,\n\n1078\n00:38:49.000 --> 00:38:50.000\n the less pain that they have,\n\n1079\n00:38:50.000 --> 00:38:52.000\n because that force gets dispersed\n\n1080\n00:38:52.000 --> 00:38:53.000\n onto those structures.\n\n1081\n00:38:53.000 --> 00:38:55.000\n Now, if you have rapid weight loss\n\n1082\n00:38:55.000 --> 00:38:57.000\n and you lose those structures,\n\n1083\n00:38:57.000 --> 00:38:59.000\n you've taken your first defense mechanism\n\n1084\n00:38:59.000 --> 00:39:02.000\n and the most amazing defense mechanism\n\n1085\n00:39:02.000 --> 00:39:03.000\n for the osteoarthritis\n\n1086\n00:39:03.000 --> 00:39:04.000\n and you've taken it out\n\n1087\n00:39:04.000 --> 00:39:05.000\n or you made it weaker.\n\n1088\n00:39:05.000 --> 00:39:06.000\n Now, you got bigger problem.\n\n1089\n00:39:06.000 --> 00:39:08.000\n So that's a very real concern\n\n1090\n00:39:08.000 --> 00:39:10.000\n with this that we need to keep in mind as well.\n\n1091\n00:39:10.000 --> 00:39:11.000\n Yeah.\n\n1092\n00:39:11.000 --> 00:39:12.000\n It's interesting.\n\n1093\n00:39:12.000 --> 00:39:13.000\n I think about,\n\n1094\n00:39:13.000 --> 00:39:15.000\n we talk about how we're going to use this in practice\n\n1095\n00:39:15.000 --> 00:39:16.000\n and for both of us,\n\n1096\n00:39:16.000 --> 00:39:17.000\n we're in different settings, right?\n\n1097\n00:39:17.000 --> 00:39:18.000\n And for me,\n\n1098\n00:39:18.000 --> 00:39:20.000\n this is an educational piece\n\n1099\n00:39:20.000 --> 00:39:21.000\n that comes to my patients\n\n1100\n00:39:21.000 --> 00:39:22.000\n and I say, hey, after this rehab,\n\n1101\n00:39:22.000 --> 00:39:23.000\n after we try to build that muscle,\n\n1102\n00:39:23.000 --> 00:39:25.000\n after we try to do all these things,\n\n1103\n00:39:25.000 --> 00:39:26.000\n go talk to your entrepreneurs,\n\n1104\n00:39:26.000 --> 00:39:28.000\n or go talk to your sportsman,\n\n1105\n00:39:28.000 --> 00:39:29.000\n doctor, your PCP,\n\n1106\n00:39:29.000 --> 00:39:30.000\n and kind of these discussions\n\n1107\n00:39:30.000 --> 00:39:31.000\n with them.\n\n1108\n00:39:31.000 --> 00:39:32.000\n When you look at,\n\n1109\n00:39:32.000 --> 00:39:34.000\n after you get out of intense rehab,\n\n1110\n00:39:34.000 --> 00:39:35.000\n and you still have that pain,\n\n1111\n00:39:35.000 --> 00:39:36.000\n obviously for you,\n\n1112\n00:39:36.000 --> 00:39:37.000\n you're doing it,\n\n1113\n00:39:37.000 --> 00:39:38.000\n doing the injections\n\n1114\n00:39:38.000 --> 00:39:39.000\n and really having the discussion\n\n1115\n00:39:39.000 --> 00:39:40.000\n and thinking about initiating\n\n1116\n00:39:40.000 --> 00:39:41.000\n these patients on it.\n\n1117\n00:39:41.000 --> 00:39:42.000\n Yeah.\n\n1118\n00:39:42.000 --> 00:39:43.000\n I think these types of papers\n\n1119\n00:39:43.000 --> 00:39:44.000\n are, it's going to change the game\n\n1120\n00:39:44.000 --> 00:39:45.000\n of medicine.\n\n1121\n00:39:45.000 --> 00:39:46.000\n I put into chat,\n\n1122\n00:39:46.000 --> 00:39:47.000\n UBT, just get a summary and all\n\n1123\n00:39:47.000 --> 00:39:48.000\n and it says,\n\n1124\n00:39:48.000 --> 00:39:49.000\n are we now entering an era\n\n1125\n00:39:49.000 --> 00:39:50.000\n where like orthopedics\n\n1126\n00:39:50.000 --> 00:39:51.000\n and endocrine actually talk more\n\n1127\n00:39:51.000 --> 00:39:52.000\n and do more,\n\n1128\n00:39:52.000 --> 00:39:54.000\n more referrals and more back and forth\n\n1129\n00:39:54.000 --> 00:39:55.000\n and before we kind of look,\n\n1130\n00:39:55.000 --> 00:39:56.000\n I still think we do.\n\n1131\n00:39:56.000 --> 00:39:58.000\n We see medicine being very siloed.\n\n1132\n00:39:58.000 --> 00:39:59.000\n Now we're starting to see more\n\n1133\n00:39:59.000 --> 00:40:01.000\n across talk and more of referrals\n\n1134\n00:40:01.000 --> 00:40:02.000\n to the specialists\n\n1135\n00:40:02.000 --> 00:40:03.000\n who need to be involved.\n\n1136\n00:40:03.000 --> 00:40:04.000\n Yeah.\n\n1137\n00:40:04.000 --> 00:40:05.000\n This is exactly what PHS\n\n1138\n00:40:05.000 --> 00:40:06.000\n and Ghani talked about,\n\n1139\n00:40:06.000 --> 00:40:08.000\n how she is doing lectures,\n\n1140\n00:40:08.000 --> 00:40:09.000\n she's collaborating\n\n1141\n00:40:09.000 --> 00:40:10.000\n with the sports medicine department.\n\n1142\n00:40:10.000 --> 00:40:11.000\n I love it.\n\n1143\n00:40:11.000 --> 00:40:12.000\n In fact, did you see this\n\n1144\n00:40:12.000 --> 00:40:14.000\n that PCOS got renamed?\n\n1145\n00:40:14.000 --> 00:40:15.000\n No.\n\n1146\n00:40:15.000 --> 00:40:16.000\n Oh, maybe.\n\n1147\n00:40:16.000 --> 00:40:18.000\n That's something metabolic.\n\n1148\n00:40:18.000 --> 00:40:19.000\n Yeah.\n\n1149\n00:40:19.000 --> 00:40:20.000\n It's PMOS,\n\n1150\n00:40:20.000 --> 00:40:22.000\n polyendocrine metabolic\n\n1151\n00:40:22.000 --> 00:40:24.000\n ingredients to PMS.\n\n1152\n00:40:24.000 --> 00:40:25.000\n Yeah.\n\n1153\n00:40:25.000 --> 00:40:27.000\n Polyendocrine metabolic\n\n1154\n00:40:27.000 --> 00:40:28.000\n ac or something.\n\n1155\n00:40:28.000 --> 00:40:29.000\n Cause she has a strong point\n\n1156\n00:40:29.000 --> 00:40:30.000\n is people who get\n\n1157\n00:40:30.000 --> 00:40:31.000\n at ease of capsulitis,\n\n1158\n00:40:31.000 --> 00:40:32.000\n frozen shoulder for those\n\n1159\n00:40:32.000 --> 00:40:33.000\n who don't know.\n\n1160\n00:40:33.000 --> 00:40:34.000\n You've got these\n\n1161\n00:40:34.000 --> 00:40:35.000\n hormonal irregularities,\n\n1162\n00:40:35.000 --> 00:40:36.000\n a lot of times,\n\n1163\n00:40:36.000 --> 00:40:37.000\n there are going to be people\n\n1164\n00:40:37.000 --> 00:40:38.000\n who have some type of strong\n\n1165\n00:40:38.000 --> 00:40:40.000\n insulin-resistant diabetes,\n\n1166\n00:40:40.000 --> 00:40:41.000\n interesting correlation\n\n1167\n00:40:41.000 --> 00:40:42.000\n with epilepsy as well.\n\n1168\n00:40:42.000 --> 00:40:43.000\n But yeah.\n\n1169\n00:40:43.000 --> 00:40:44.000\n Yeah.\n\n1170\n00:40:44.000 --> 00:40:45.000\n There is a ton of cross-stop.\n\n1171\n00:40:45.000 --> 00:40:46.000\n Again,\n\n1172\n00:40:46.000 --> 00:40:47.000\n bodies don't repeat\n\n1173\n00:40:47.000 --> 00:40:48.000\n and they don't repeat\n\n1174\n00:40:48.000 --> 00:40:49.000\n and they don't repeat\n\n1175\n00:40:49.000 --> 00:40:50.000\n and they don't repeat\n\n1176\n00:40:50.000 --> 00:40:51.000\n and they don't repeat\n\n1177\n00:40:51.000 --> 00:40:52.000\n and they don't repeat\n\n1178\n00:40:52.000 --> 00:40:53.000\n and they don't repeat\n\n1179\n00:40:53.000 --> 00:40:54.000\n and they don't repeat\n\n1180\n00:40:54.000 --> 00:40:55.000\n and they don't repeat\n\n1181\n00:40:55.000 --> 00:40:56.000\n and they don't repeat\n\n1182\n00:40:57.000 --> 00:40:58.000\n bodies don't repeat text\n\n1183\n00:40:58.000 --> 00:40:59.000\n and they certainly don't\n\n1184\n00:40:59.000 --> 00:41:00.000\n do residency\n\n1185\n00:41:00.000 --> 00:41:02.000\n training in certain\n\n1186\n00:41:02.000 --> 00:41:03.000\n specialities.\n\n1187\n00:41:03.000 --> 00:41:04.000\n I say that much.\n\n1188\n00:41:04.000 --> 00:41:05.000\n Yeah, this wasn't the\n\n1189\n00:41:05.000 --> 00:41:06.000\n fun one. For me,\n\n1190\n00:41:06.000 --> 00:41:07.000\n hopefully the audience\n\n1191\n00:41:07.000 --> 00:41:08.000\n got something fun out of it\n\n1192\n00:41:08.000 --> 00:41:10.000\n and hopefully we answered\n\n1193\n00:41:10.000 --> 00:41:11.000\n them questions. So, we'll\n\n1194\n00:41:11.000 --> 00:41:13.000\n be sure to link all\n\n1195\n00:41:13.000 --> 00:41:14.000\n the show notes and the studies\n\n1196\n00:41:14.000 --> 00:41:15.000\n in here. I don't know if\n\n1197\n00:41:15.000 --> 00:41:16.000\n people are going to go\n\n1198\n00:41:16.000 --> 00:41:17.000\n deep dive. But, hopefully\n\n1199\n00:41:17.000 --> 00:41:24.000\n this answers all the\n\n1200\n00:41:24.000 --> 00:41:25.000\n questions. I think this is\n\n1201\n00:41:25.000 --> 00:41:29.880\n share with whoever you know needs to listen to this so that they can initiate that conversation.\n\n1202\n00:41:29.880 --> 00:41:33.239\n I think that's the biggest takeaway is like this is so relevant today.\n\n1203\n00:41:33.239 --> 00:41:36.360\n It's such a common disease like you were saying and so I just encourage people\n\n1204\n00:41:37.159 --> 00:41:40.599\n be sure to whoever you think it will help. And if you're a clinician,\n\n1205\n00:41:40.599 --> 00:41:42.519\n start looking into these things. I have those discussions.\n\n1206\n00:41:43.159 --> 00:41:44.440\n I love it. Awesome.\n\n1207\n00:41:45.800 --> 00:41:47.159\n All right, man. Until next time.\n\n1208\n00:41:49.719 --> 00:41:52.599\n Thanks for listening to another episode of Medicine Redefined.\n\n1209\n00:41:52.599 --> 00:41:55.880\n If you enjoyed this episode, please be sure to check out some of the additional resources\n\n1210\n00:41:55.880 --> 00:42:01.079\n in the show notes. Please also check out our social media platforms where you can find more content\n\n1211\n00:42:01.079 --> 00:42:06.360\n like this. You can follow us on Instagram, Twitter, and TikTok at Med Redefined.\n\n1212\n00:42:07.079 --> 00:42:11.159\n We also want to thank our team for the production of this podcast, specifically Ethan Jewel\n\n1213\n00:42:11.159 --> 00:42:16.519\n video, Harita Yeporian social media, Zana Blugmani on research and Sarah Hahn for newsletter.\n\n1214\n00:42:16.519 --> 00:42:21.400\n Oh, and if you want to get similar bite-sized information delivered to your inbox every Sunday,\n\n1215\n00:42:21.400 --> 00:42:25.240\n please be sure to sign up for our newsletter. Also, if you enjoyed the show,\n\n1216\n00:42:25.240 --> 00:42:29.000\n please be sure to subscribe, review, and share with anyone who you think will gain value from this\n\n1217\n00:42:29.000 --> 00:42:36.039\n as well. Now, time for the ever-so-important disclaimer. This podcast is intended for general\n\n1218\n00:42:36.039 --> 00:42:40.599\n public use and is for educational purposes only. It does not constitute the practice of medicine,\n\n1219\n00:42:40.599 --> 00:42:44.519\n nor should be construed as medical advice. No physician-patient relationship is formed,\n\n1220\n00:42:44.519 --> 00:42:49.480\n and anything discussed in this podcast does not represent the views of our employers. We recommend\n\n1221\n00:42:49.480 --> 00:42:54.519\n that you seek the guidance of your personal physician regarding any specific health-related issues.\n","transcription_info":{"language":"en","language_probability":1,"duration":2574.52,"duration_after_vad":2574.52}}