79. Navigating Obesity and Weight Loss in the Clinic | Jeffrey & Michelle Shukhman, DOs

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Alright, today we touch on obesity. Now I know what you may be thinking, wait, you and Altamash have not discussed obesity throughout the last two years of your podcast? Well, we've touched on it, but we're finally doing a deep dive, yes, on the topic that is constantly on the news, always getting brought up across medical professionals, a lot of convoluted controversy regarding it, and our nation is at about a 40% rate of obesity, and if you include overweight in that category, we are at about 80%. So obviously a hot topic, and so we wanted to delve into it properly, and in order to do that, we brought on two guests, a dynamic duo, Dr. Jeffrey and Michelle Shookman. They're both osteopathic medicine physicians, trained in internal medicine, and also do obesity medicine. So throughout this episode, we're going to learn things like what is obesity, what maybe causes it, and what are the approaches that we use with patients, right? The lifestyle approaches, but even pharmacological approaches. Now, if you have been following the news lately or any medical literature, you may have heard that GLP1 agonists might be quote unquote a savior for obesity and losing weight. So without further ado, let's get to it. I think you guys will really enjoy this episode. All right, welcome back listeners to Medicine Redefined, super excited about this episode, and actually through our 70-some episodes, we have yet to really focus on obesity. So we not only have one expert, but two, we got doctors, Michelle, and Jeff Shookman here with us. So thank you so much for joining Medicine Redefined, excited to have you. Yeah, we're so excited to be here. Thanks for having us. Yeah, I'm very excited. It's a great topic. So obviously, right, we know obesity is on the rise, it's been a hot topic. You can hit it from all different angles, right? But let's talk about what got both of you interested in becoming in terms of specializing in terms of obesity medicine. So Michelle, why don't we start with you and tell us a little bit about your journey? Yeah, so we are both both certified in internal medicine, and so we took care of a lot of different kinds of patients, taking care of a lot of chronic medical conditions, and that's the bread and butter that we learned during residency. However, it was mainly in hospital medicine. We didn't have such an emphasis in primary care, and both of us graduated residency and started working in primary care. So then when we were trying to take care of our patients, the trend was they are overweight, they are struggling with obesity, and if they would just lose weight, their diabetes would get better, their high blood pressure would get better. It's not those acute things that brought them into the hospital. It's this now chronic condition that we want to treat as an outpatient. And what we found, you know, because we don't have a lot of time, 20 minutes to go through everything, all their issues, back pain, this, that we didn't know how to actually address obesity during their visit. We want to talk to them, how to ask questions, and do they even want to talk about it? And essentially we would fall back on a line that I think we all heard just exercise more and eat healthier. And then you see them again, three months later, exercise more and eat healthier. And we felt like really just inadequate and unable to help them the way we wanted to. So then we both decided that we wanted to learn more about obesity, and so we learned about getting obesity certified, and we did that. And then we realized, wow, we didn't know anything. We didn't learn anything during residency that about obesity and how to manage it. And so we were really excited to learn that and all that information, wealth, knowledge. However, we go back to our clinics and we're trying to apply all that knowledge into our clinical practice. And we still felt like we didn't actually know how to engage the patients, help them lose weight. Now we knew all the drugs. We knew how to prescribe them, but we really didn't know, again, what else can we do? And so we had to just trial and error start figuring it out. And we realized so many of our colleagues also struggled just like we did. So after years of practicing obesity and having success and learning the tools that we need to provide the care that we want to provide as a primary care provider, we then created what's now known as obesity made simple. And so the course for other providers to learn how to treat obesity in their practice. So go ahead, Jeff. Yeah. So I have a similar background to Michelle and I kind of went through the internal medicine process. We had a lot of hospital medicine, so we really felt then to disease management and we were experts at managing disease, you know, it's very easy to throw on medications to patients and you know, make those needles and numbers move. But when it comes to actual, you know, getting them healthier, making them want to live a healthier lifestyle, we were very poor at that. And you know, when we started seeing patients in the outpatient, we would talk to each other all the time. And just kind of point out how lack of knowledge we have on like diet and exercise and what really works for obesity and how to talk to our patients and how to convince them that, you know, living a healthier lifestyle is important to them and it's not all about medication. You know, a lot of our patients, even to this day, everyone's looking for a magic bullet. Everyone's looking for that one medication to solve all their problems. And the more we learn about obesity, it's extremely interesting. There's so many pathways. I think that obesity is such a complex topic and that's why we're so poor at managing it. It's because there is not one special bullet to take care of all their problems. And it's really a multifaceted approach that you have to take with patients with obesity. And so, you know, it was something new for us to learn. We were very excited to learn about obesity and go through all the extensive courses and learn all the pathways, but then applying it was its own other ball game. And luckily, there's two of us, so we got to kind of play around with our patients and see what works and doesn't work and use motivational interviewing and really deciding on how we're going to treat our patients better. And we feel that we've become much more successful at it. And even to this day, it's not an easy disease to treat. And as we'll get into, you know, society plays a big role in a lot of what obesity is. And so, yeah, we're excited to talk about it and, you know, we have good backgrounds at it now. You know, I'll echo that. I think one of the statistics that we've thrown out several times on this show and elsewhere is, I think the current rates are somewhere in the 43% of the population, the adult population is a beast, right? And the expectation is that in the next eight years, it'll be 50%. And so, we're certainly headed in the wrong direction. You guys are doing your part. And I find it interesting that over the last, maybe 15 years or so, maybe a little less than that, that conversation has completely just turned 180, right? Initially it was, okay, it's the patient's fault, kind of you alluded to Michelle, that, hey, exercise, eat more, it's on you, it's all on you. And now it's kind of flipped that we're starting to realize, hey, we need to change our approach. Because if that message isn't resonating, oh, hey, is it me, the provider, am I the problem? And so, that's really cool. But you talked about certification. So I think for the listener, the healthcare practitioner, who's not familiar with that process of getting obesity, board certified, is it a fellowship? Talk a little bit about the certification, like what's that like? Yeah, it's a CME fellowship. So what they require is X amount of hours to complete CMEs in the topic of obesity medicine. And then we do the same kind of board exam we would do for internal medicine and a proctor site. And if we pass, we get board certified in obesity medicine. They also do have a fellowship track that is in person, which is one year fellowship. But at the moment, you have these two options. Can somebody do the fellowship track while in training? Like a resident? You have to have already board certification in another field, yeah. Okay. Okay. So that's very cool. Now, Jeff, you talked a little bit about how complex this is. Although you guys make it very simple, I'm sure what you'll talk about. And you know, often what we refer to as obesity to simplified, you know, when we're talking about the public health messaging, it's BMI, something that everybody here has tried. Most people go to the doctor and they're like BMI and the criteria is it's like if you're 18 to 24, maybe 25, I'm not really sure what the cutoff is, you're quote, unquote, normal weight. And then it's overweight and then past 30, it's obese. And it's not as simple as that. So could you talk a little bit about why obesity isn't just extra weight or excess weight or just excess adipose in certain areas of the body? What's your definition of it? Absolutely. And you know, this can be defined in so many different ways. And you know, you may have a patient with a BMI of 35 and you look at them and they're pure muscle and you say, do I really call this guy obese? No. You know, that's definitely not obesity. And, you know, and then you have maybe a BMI of 24 year old, I mean, a BMI of 24 and then you look at them and you're like, man, they don't look healthy, their gut is like out to, you know, across the room and you say there's no way this guy has normal weight. And so it's really central obesity that plays such a huge role, you know, when we learn in through med school and everything, the apple shape and the pear shape, but it's very true when you look at your patients, you know, when if you see that central obesity, you know, that's what obesity is, it's not just all on BMI. And we definitely go through BMI, we go through, you know, the limitations of it. Where does it play a role? But there's also waist circumference, there's body fat testing. There's a lot of different, very accurate ways to measure body fat, but when you look at big picture, you know, I think it's about health, it's not about the numbers. And you know, I think telling patients how to let go of the number all the time and start focusing more on their health is very important, you know, I think a lot of us have patients who have very high BMI's, but you look at their labs and everything's pristine, you know, and their weight isn't affecting them that much. And so, you know, there's metabolic syndrome and then there's, you know, a high weight without metabolic syndrome and there's definitely a line between it. And if you just go off of BMI and everyone, you know, you're going to give a lot of people a complex is about their health when they might not meet those complexes and you should be really focusing on more lifestyle, you know, yeah, absolutely no Jeff, when you talked about obesity in your journey, you mentioned that it is a disease, right? But most of the time when people think of that, they think there must be some scientific kind of like reasoning as to why that disease manifests. When it comes to obesity, like obviously it's multifactorial, but if you're talking to a patient, how do you kind of explain what's happening in their body? Like, is there a scientific approach behind why somebody becomes a beast? Yeah, absolutely. So, you know, I think this is part of motivational interviewing too, but, you know, really when you, whenever you start with a patient, you want to really know, you know, how ready are they even to talk about weight? So making sure that, you know, you're not just throwing all this stuff at a patient when, you know, they're so closed off, you have no rapport with them and you're right away attacking their weight. So I just want to start off on that. But yeah, you know, whenever we try to start a conversation on weight with a patient, we first ask their permission, you know, can we discuss your weight? And is that a topic that, you know, you've been struggling with for a long time or, you know, is this something you don't want to touch? But, you know, really a lot of times I'm focusing on their health problems before I even get to their weight. So a lot of times, I already know they have diabetes, hypertension, hyperlipidemia, you know, a lot of these diabetes, you know, you go in there knowing, first of all, if this is even the subject you want to be hitting during that, that so a lot of times the patient will bring up the topic of weight and you already know they're ready to discuss this and it's a big topic for them. And then there's the other side where we really want to discuss their weight because of all these other complications that we're already seeing because of their weight. So when it comes to starting the conversation, it's a little bit of a tiptoeing and you got to really get a patient warmed up before you just detect the weight and we've seen this and heard this from many providers and we've, I've seen a lot of patients that come in and they say, I hate doctors, I never want to see doctors ever again. You know, that one just called me fat, really shamed me, told me to stop eating McDonald's every day and she says, I don't eat McDonald's, I don't eat fast food but, you know, that's how she labeled me right away. And we really ruin our relationship with our patients when we do that kind of stuff. So you know, more primary care doctors need to learn how to discuss weight because we all see it just like you alluded to as far as the statistics go. You know, from 2018 to today, we've seen a dramatic rise in obesity. You know, they're saying by 2030, over half the population in America is going to be suffering from obesity and we're already in like the 35% range in all of America. So this is getting worse and just like you alluded to, I think there's a lot of environmental factors that are playing a huge role on this. And so, yeah, it's, you know, explaining to the patient that it's not their fault because I think a lot of these patients blame themselves. They do have a role in their weight, you know, that's not to completely dismiss that they've gained weight for certain reasons, but it's not all their fault. You know, if our whole society wouldn't be becoming obese or wouldn't be suffering from obesity, if it was all their fault, you know, there's obviously environmental players here that is causing our entire population to gain in size. So Jeff or Michelle, I mean, whoever wants to take this next question, you know, I love that you talk about the application, right? You kind of start off with the application. It's fascinating to me that often, but it makes sense at the same time, sorry, I'm kind of jumping around here. We spent so much time in the first couple of years, right? So basic science, of course, is undergraduate, the first two years in medical school learning about the science and drilling in the science. And it's really the same faculty members that are teaching and you, you know, drilling the same concepts. And then most people will go out of the clerkships, they're in the fourth year and you're learning from different people, different to art of medicine in different aspects. And nobody's really teaching you the application when you're supposed to learn the application, how to have these conversations. I remember a story when I was a third year medical student. I was an intern. I know internal medicine. I was, yeah, third year internal medicine. And I was an outpatient clinic and there was a young female patient I had who was smoking. She was, I forget exactly, but quite a lot. I remember addressing that and trying to talk to her about how that's not good for her. And man, she let me have it. And I just wasn't ready to talk to these things that you're talking about. Motovisha interviewing and really listen, whether it's even, she's even interested, right? I just knew that smoking is bad for you. It's been taught and here's all the data and this is what the science says. And I was like, you must stop. And just like, why I have this reason and this reason and this person who's been okay. And I just, I wasn't equipped to handle it. And, and I think about that conversation today when patients are just, or providers rather are just completely, you know, dare I say incompetent when it comes to having these conversations with the patient because of the stigma that you talked about. And, and really just not understanding the science or even being tactful. And so the first thing you mentioned is building that rapport, right? And the traditional model of medicine where you see a patient, you do the cholesterol management, the diabetes management, medication, whatever you're adjusting. You might not see that patient for six weeks, eight weeks for follow up three months, sometimes six months down the road. It's pretty challenging to build a rapport over that time, right? I mean, if you have 20 minutes, 30 minutes visits over six months, that's, that's not easy to protest a sensitive topic. And so do you have any tools, tactics to be able to accelerate that rapport building process to, is there such a thing? I think initially it'd be really good to see patients more regular. So let's say, when I start these conversations a lot of times, just like Jeff, like just asking for their permission, seeing if they're open a lot of times, they're like, oh, thank goodness you asked this because I really want to help losing weight, right? And then you start telling them it's not going to be an easy journey. Essentially, societies against you, there's so much over desire for food. There's food addiction. There's so many things that play that led these patients to where they are today. So I explain, it's not going to be easy. So it can't change overnight. There is no magic pill. So it's going to be a process. It's going to work, we're going to work together to get there where we want to get to, but it's not going to happen overnight. If it took them 50 years to get where they are today, we can't imagine it's going to take them only a couple of months to get where they want to be. And that's the problem. Everybody, all these fast, diet plans, or even weight watches, right? Lifetime, weight watch, remember, why is there such a thing? It's because it always fails. They, everybody can always come up with a plan to be healthy for a short period of time. They don't realize, it's not about the short period of time. It's about their life. What are they going to do to change forever? And so that's my goal is when I'm counseling them. So initially, I start usually by seeing them every couple of weeks. And we talk in depth about their diets, about maybe their current medications are on that might be inhibiting their current weight loss. So an exercise, everybody makes this big deal about exercise. Well, honestly, the data shows it doesn't actually contribute to weight loss that much. So even in the beginning, I actually say we don't need to focus on that actually at all. Yeah, move, you should move, you should be active. But we don't need to be like, you need to exercise three times a week. Because a lot of times that is overwhelming. And patients feel I can't do that all. So we'll just focus on little things. Make little changes slowly over time. And those little changes will end up making big effect later. Yeah, actually on the contrary to your point about exercise and weight loss. I remember one of my attendings quitting a study for me. And I'll find this and put it in the show notes. There was a paper published a couple of years ago that actually rolled that there are these compensators, right? So people who actually exercise end up gaining weight because you eat a surplus of calories after the fact. I don't know if this is actually true or I convinced myself that I feel like I'm in that category because I'm actually more hungry. And then I actually end up overshooting a lot. And so, so yeah, that can actually backfire on you too. Yeah, there's a lot of studies. There was a study right now, I can't remember exactly what it was. But they basically showed that women over 95% of women who exercise actually gained weight rather than lost weight during one of the studies. So exercise, I always tell my patients, it's important for weight for your health, but it has nothing to do with your weight. So a lot of people try and you hear this all the time, you know, a patient comes in, oh, I need to exercise more. You know, the answer is always, I need to exercise more. And that is so far from the truth, you know, and, you know, how we think about losing weight. Because it's much easier to add exercise than it is to eliminate things in your diet. You know, people love food, food is an addiction. And we go a lot about, you know, we talk a lot about this in our course. But, you know, there's a dopamine response. You know, food is an addiction that you see on pet scans. You know, our brain lights up when we see food. Very high calorie, low nutrition, nutritious food, you know, stimulates our brain. And, and this is to say also our society is just so backwards, you know, advertising. There's a reason why it works so well. And, you know, just driving down the street, you got McDonald's and Burger King and all these things. And they've spent tons of money, you know, advertising. And this is all stimulating everyone's brain. So, you're telling people that eat a salad when all they're seeing on every corner is donuts and burgers. And, you know, really easy, cheap, fast food. Highly addictive foods. Yeah. So. Now, to your point right there, I think they call it the bliss point is what these companies are trying to shoot for. Which is like this magic ratio of whatever preservatives and macros and fat just so, like you said, that that dopamine kicks in and then it becomes addictive. And so, they're targeting kids with this, especially, right, with or with cereals. Yeah. That the grocery store. Yeah, it's really bad. And then to Altamash's point, right, like, I think this is why I'm not a fan of saying, you know, some movement is better than none. Right, I think, yes, overall in like a golden box, it's true. You do some movement is better, but you have to realize, is that going to lead somebody, you know, down that rabbit hole saying, oh, I moved today. Now, I can eat that extra food now here and there. Right, so I think it definitely comes down to understanding those mechanisms. Absolutely. And setting those expectations for your patient, you know, explaining to them that you're on their team, you're in their corner. This is a journey. This is a lifelong process. This is a lifestyle change. It's not a quick fix and really assessing, you know, just like we said, readiness for change. Patient isn't ready for change. There's no point for you to waste your energy on them. You know, you can focus on their disease management and all the other things that you have to do during that visit. But don't waste valuable time when a patient isn't ready. Some patients, just like you said, aren't ready to quit smoking. You know, you got to assess their readiness. You know, are they in the pre contemplative phase? Are they in the contemplative phase? Are they in action phase? You know, it really comes down to that really feeling that out. So you use your visits and your valuable time in the best way that you can. So we really go into, you know, honestly, just figuring out how to attack the obesity topic within such a busy practice. And that's what we needed to learn how to do, you know, is really, how do we incorporate this? Because like you said, you know, this is, this is a tough topic. This is a, a lifestyle change and the hardest thing I think for people to do is change their lifestyle. Yeah, and in 20 minutes, it's almost impossible to get anything done. So yeah, it takes way longer than 20 minutes. Yeah, no, it's a, it's a huge topic, right? And you just even mentioned, you're talking about exercise, you're talking about food in itself, the diets, you're talking about medications, which is one that a lot of people don't actually think about in terms of weight gain. So stick it on those topics, you know, I know our listeners are trying to understand a little bit more about how obesity occurs from all these different perspectives. Can we just start with like calories and kind of what the science is currently showing in regards to like do calories matter is calories inverse calories out. You know, it's a highly controversial topic still, but what are your guys thoughts on that? Well, if it was that simple, I think then everybody would just limit calories and it's not we can have two people eating the same exact amount of calories, but one could be eating a very nutritious meal and the other person eating McDonald's and they've done studies on this and the person eating McDonald's with the same amount of calories will gain weight. So it's not just about calories, it's way more complicated that it's what the food actually contains and how your body responds to the food itself and the neural hormone responses from the gut to the brain and how everything is affected through that. Yeah, so, you know, they've done studies looking at unhealthy kind of burgers and fries and all this stuff. You limit the same amount of calories, but then the other person's eating healthy fruits vegetables protein and you would think, hey, the calories and calories out everyone should be gaining the same amount of weight, but it's not the case. There's a lot of research going into gut health, our bacteria and our gut actually changes, depending on the food that we're eating, so we're absorbing foods differently. There's a top of that, there's nutrition and food and there's fiber, so if you eat a Snickers bar that has this many carbs in it and then you eat, let's say, tons of fruit that also has carbs in it, are you going to absorb that fruit the same way as you do the Snickers bar? The answer is no, because the fruit has a lot of fiber in it as complex carbs, so your body needs to work to break that stuff down. And then the bacteria that you have is breaking down these things differently as well, so we see that patients with obesity have a completely different flora than patients who are thinner. I also think there's a lot in processed foods and how that changes our bodies and how we absorb things. And the role that's played in development of obesity in the last 30 years. Yeah, absolutely. I think that we read a book by Dr. Fung and he's controversial in himself, but I do think he makes a lot of great points. And the theory of insulin and cortisol and stress and sleep and how all these things play a big role on why we're gaining weight. And then on top of that society and how we process our foods, how we process our carbs and so on and so on. And genetics too. So you, a mom who is obese at the time of pregnancy will actually change the ribosomes and how the DNA is replicated and expressed in the baby. Yeah, so you may have heard of epigenetics. So, you know, there's also epigenetics that plays a big role in how how our bodies are even going to, you know, a baby who is in a diabetic female when they are pregnant, changes how they're going to be in real life. You have like 30 or 40% chance higher of getting one obesity, but also developing diabetes. So from just environmental changes in the womb already. So, you know, that's why it's so important also to treat moms with their diabetes and prediabetes and trying to get them optimized before they even have a baby because they're going to affect the next generation. And then you can see as that generation gets affected following generations are going to be affected and it's just leading to a mass of obesity epidemic and a diabetic epidemic. So, you know, there's a lot of societal changes that I think need to happen, but unfortunately, I think there's a lot of money and a lot of these corporations are, you know, gaining a lot of the bottom line they don't care about, you know, unfortunately population health. That's an uphill battle and that's kind of what I explained to the patient as well as, you know, this is a battle that you're going to have to fight your whole life because we're all fighting it. Yeah, there's a lot to unpack there and I certainly want to talk a little bit more about the genetic aspect and the epigenetics that you guys are touching on, but I want to stay on this thread of just talking about hormones and just defining the mechanisms a little bit better. I also want to highlight for the listener that Michelle, you mentioned that, you know, it's not just calories, right? It's also all these other things which we'll talk a little bit more about, but that doesn't mean it's calories don't matter, right? I think often people get into two separate camps and it's either this or that and a previous guest came back and says, why can't we just use the word and, right? What you're saying is calories matter and good quality and nutritious foods also matter, right? You can't separate the two and I think most of the experts who are kind of in the middle there are usually the ones that probably know what they're talking about it and right off the outside of the conversation we talked about it is very, very complex and for us to reduce it down to one simple simple thing. This is the answer that's usually assigned that we should turn around and run away really fast, but you know, you guys talked a little bit about, oh, so Jeff, you alluded to Jason Fungan, I think for the people, great book, the obesity code, I think it is and he makes a compelling case for the carbohydrate insulin model, which we've touched on before, but Jeff, if you could maybe expand on that a little bit for those who might have forgotten exactly what the role of insulin is and not also be curious to kind of get you guys thoughts on some of the other. Some of the other popular hormones like, you know, leptin and ghrelin and how they have this interplay with insulin, if we could, I know this is like a full course I'm sure, but maybe just high level stuff for the listener. Yeah, absolutely, you know, really we try to break it down that you know there's the brain there's satiety and then there's hunger hormones and so all these hormones are playing on our brain and then our gut plays a huge role on those hormones that then feedback the loop to our brain to tell us whether we're full or hungry. So he has this model of, you know, insulin and sugar and how insulin is secreted and his theory is, you know, I don't think we really know why it, but we like to talk about this thermostat model. Our brain is very much like a thermostat and something is resetting our thermostat to a higher weight so you may see your patients, you know, they're always around 220, you know, they'll gain 10 pounds and then they'll get back down to 20 where they go back down to 210 and then all of a sudden three months later they're back to 220 and it's this thought that the set point changes and there's definitely we can see that patients with obesity have higher insulin levels. So we definitely know that insulin plays a big role in whether it's completely the reason for that set point changes chronically having high insulin levels, but Dr. Fung really talks about, you know, trying to reduce insulin through intermittent fasting as one way of doing it. But by keeping our insulin levels low through fasting, it may reset that set point lower, but I don't think anyone knows if that's really the case yet. I think they're still working on studies, but just like you alluded to, there's a ton of hormones involved in weight, GOP1, GIP, Grelin, leptin. So our fat cells have a lot of hormones that are active, our GI tract has a lot of hormones that are active, there's neurotransmitters in our brain that are involved. And all these medications that target obesity are literally hitting all these mechanisms of action and these pathways. Because they're all dysregulated in obesity. Yeah, so it's all about homeostasis and our body reaches a new homeostasis that's, you know, it's a, they kind of get what it called a dysregulated homeostasis and they develop this new set point. So it's about trying to figure out how do you get them out of that new set point. And, you know, I think a lot of patients, and you may have seen this with your patients with depression or anxiety, you know, they, they think, oh, it's all mind over matter, but they don't realize all these mechanisms inside of them are driving them to gain more weight or to be depressed. Luckily, there are some medications that may target those, those pathways. And so it's really about knowing which pathway you want to target for each patient, rather than, you know, a shotgun approach, you know, this is one medication and everyone's going to lose a bunch of weight. And, you know, what was very interesting to me too was about bariatric surgery. I used to think, okay, they cut the stomach, you eat less, you can't eat as much and they're, and you're not absorbing as much so you lose weight that way. Really, those surgeries affect a lot of the hormones involved in weight gain and satiety in hunger. And, and therefore, you know, we have two ways of now hitting these things. It's medication and surgery, but surgery really can be a great option. It's not a cop out. You know, I think that doesn't mean the patient was a failure, which I think a lot of patients feel that, oh, if I am often for bariatric surgery, it means I just can do it myself. But reality is if you're BMI's of a 40, it's really hard to lose weight. It's like to the point where your quote unquote normal probably it won't happen. So bariatric surgery is a great way to reset that set point and give them more ability to succeed. Yeah, and I'll say I was listening to a recent episode with David Allison. I think he's out somewhere in the Boston area. Maybe I could begin that wrong, but he's a professor essentially, you know, epidemiologist looking at obesity. I'm not sure if you guys from there, but I was listening to him on Peter Tia talking about out of the current treatments that we have in terms of the options like bariatric surgery has shown to be the most beneficial. Like, I mean, there are some pharmacological stuff that we'll talk about down the road. You alluded to some of those Jeff, but when it comes to quote unquote lifestyle interventions or public health messaging. Unfortunately, over the last several years, that hasn't turned out to be as effective. I'm sure we could discuss how we could reframe that and do a better job at that. But, you know, at the end, when Peter Tia, like asked him to pin down, hey, what's the one thing that you try to get across? And I was actually quite surprised. I can, because my bias is, right, because I'm not a surgeon. Maybe that's why. The bias is to be able, hey, there's what I can offer you. And so I found that to be very interesting. Yeah, absolutely. And, you know, surgery is very effective, you know, 70 to 80% depending on what type of surgery they go for, but there's still that 20 to 30% that fail even after surgery. And sometimes you need even medication after that. So you can see that a lot of these driving forces are not that easy to fix. Yeah. And so let's go back to the role of genetics a little bit more. You know, you guys mentioned how, again, you know, the DNA replication process can be altered. And often when in medical school, really in health care professional, when we're taking a history, we know that for specific diseases, family history is so critical, right? Because it's a strong association that is going to be passed like a hypertension, maybe clustered hypercluster, leave me those kinds of things. Do we have a sense of how strong I'm an association it is? And are like one of the ways that that's a really elegant way to kind of look at this. If sometimes they have these studies where you have monozygotic twins and you kind of follow them out for the remainder of their lives, are you familiar with any studies like that? Something I might have heard at some point, but maybe you guys have a citation or something off the top of your head. Yeah, we just read a study, but I don't remember the exact the article or what was it? It was a. What was the study where they followed the twins? There's the. Well, that was if the gene was mutated, right? No, I think. What was that study where they followed the two twins and they were in similar socioeconomic environments, but they both ended up having the same amount of weight gain. Oh, you mean they were raised by two different families with different socioeconomic backgrounds, but yeah, and they both had the same amount of weight gain. So they're genetics played the role. Yeah, right. So that was suggested genetic plays an extremely strong role. Right. Despite the the external factors, right? Right. Right. So that's that's pretty interesting. Yeah, absolutely. So yeah, definitely there's tons of these studies that show that, you know, monozygotic twins. There's a correlation between their genes and how likely they are to suffer from the same diseases. Yeah. So here's the challenge that I see with this, right? I think again, I think Jeff, Jeff, it was you who mentioned that, you know, people come who are who have these predispositions, right? Where it's not your fault that you're here. And so we just kind of reference somebody might hear then say, well, look, hey, it's my parents fault, right? Or it's my grandparents, whoever. And therefore, you know, I am the way that I am. And but you also said that, you know, that doesn't mean that you don't have a role in your current state and what your future might look like, right? And so I'm curious to get your take on how you guys approach that aspect of the conversation, right? As, okay, we got here and maybe you didn't get here by yourself. Maybe somebody pushed you or whatever, metaphorically, kind of use. But moving forward, let's change our trajectory. Like, how do you approach that? How do you, you know, how do you visit that conversation? Yeah, it all comes down to the question, why? Why is a patient doing something? What is their goal? You know, if their goal is not to lose weight or improve their their diabetes naturally or improve their blood pressure naturally. Or be alive for their kids to get older, right? And get their weddings and this and that. Yeah, so you really got to find the reason what their why is. You know, I think it's really targeting and giving them goals that they want to achieve. You know, you're not going to put your goals on them. They need to create their own goals. And so I think that every conversation with every patient needs to start with, you know, why they're asking to do something. And I tell them to write it down somewhere and put it somewhere they could see it. And so they know their why, whether it's on their fridge or wherever. So when they're thinking like, Oh, you know, I had a hard day. I really feel like a cookie right now. You know, they remember that's not what my goal is right now. This is why I'm choosing not to do this. Yeah, all of us, all of us have, you know, some of us don't really care, you know, I think some people are just like, Hey, this is what it is. There's medications. They'll keep me alive in other five years. And I'm cool with that. You know, and who are we as doctors to be like, No, that's not, you know, that's not right. You got to, you got to really work on your lifestyle. You know, of course you can try and change their minds a little by little, but I wouldn't waste a ton of energy on those patients because if they don't have a strong why they're never going to lose weight. You know, like those patients that I'm sure we've all experienced that, you know, a diabetic that the A1C is off the charts. You're like, we need to start medication. We need to do this. We need to do that three months later. Same never started any of the meds. Three months later, same never did anything that you said. And so there are those patients that just no matter what you do, how hard you try, whatever you tell them, they're not going to change. And that is unfortunate. And there are, it's, but it's a small percentage. I think most people have a strong why why they want to be healthy. Why did they go to the doctor in the first place, right? So I think trying to figure that out, whatever it is is really an education plays a big role. You know, educating your patient, what obesity can do to them. You know, what are the complications? Why do we care so much? You know, why we as physicians care about their obesity and seeing if they're even open or receptive to that information. But drilling it into someone isn't isn't going to work. You know, I think a lot of physicians have this paternalistic mindset where they're going to change and control what their patients are going to do. But you have to understand the patient has a life and they have their own decisions. So the economic situations that we might not understand, which plays a big role on what foods they can afford and things like that. So, you know, it's really finding a good why for your patient and then finding the barriers that are keeping them from getting to that why and you're working with them. You're on their team, you know, you're not there to dictate to them. Many times healthy food costs so much more money than processed and fast food. So patients feel like I can't eat healthy. I can't afford it. And so you kind of work with them either within what they're already doing. So every fast food now has, quote unquote, healthier choices. So a lot of times we'll go through the menu and see what they could eat, maybe better, more nutritious. If that's all they're open to or like I have a lot of men, for instance, who are like, I just can't cook for myself. I don't have time for that. So it's just so easy to go and, you know, eat whatever. So in those kind of patients, I try to maybe offer meal replacement and things like that that are easy for them. They don't have to think about it, keep some, you know, satisfied. So you just have to find like what their barriers are and what their situation is and try to work within it. Yeah. And I think as the listener started to appreciate, there's a lot of nuance to it, right? I want to go a little further into something that you mentioned, Michelle, you know, you talked about how you asked them to maybe write down the goal. Right. So of course you get to the Y and then write down like why this is so meaningful so they can reflect. And that to me, of course, sounds like that it's a way to keep yourself accountable. Right. Often we hear that, you know, people who are going on this fitness journey or transformation journey, whatever that people will suggest. Hey, maybe you should post on social media or so you have external accountability or validation be accountability. Actually, Darshan's talked a little bit about this on his social media journey. A lot of things that he does is to, so, you know, his followers or he is accountable to the people who are kind of following his journey. And I'm wondering if you found that approach that, hey, maybe not necessarily share on social media, but tell your partner, tell your best friend, tell somebody, hey, here is my goal. And this is the reason for my goal, not that I want to fit into the, you know, fitting into the dress can be a great goal. But deeper than that, right? I want to be able to pray with my grandchildren like 30 years from now or something like that is one approach more powerful than the other. I think it depends how they feel like, like some patients are really as unfortunately ashamed, you know, that they are so, like they know they are, they, they know their obese and they, they know that probably everyone around them knows too. Right. But the admission and putting it out there sometimes is very difficult for patients. And so a lot of patients don't want to tell anybody that they're quote unquote on a diet or anything because if they fail, right? Now they have to own up to that too. And so sometimes it can work. Some patients, I think that could be really motivating. So then if you go to a restaurant, maybe, you know, everybody eats better and doesn't order so much alcohol and things like that. So maybe in that setting, that might be great for some patients, but other patients, it's like a quiet internal journey and they're not ready to share. Yeah, I think there's no right answer to this. I think it's all, you know, individualized and that's why, you know, there's the art of medicine. It's not everyone fits in the square box. And so you got to find what is going to motivate them for some people knowing what their weight is getting on a scale every day helps them. And then there's the other patients who knowing that number just stresses them out and makes them want to go into a tub of ice cream. Okay. So, you know, it's, you got to, you got to trigger it exactly. You got a trigger for them. And so, you know, I think there's, there's no right answer here. I think the right answer is what's right for your patient. And I think what's important is like, wow, how do I gain all this information? I think for primary care doctors, especially it's like, who has time to talk about all this stuff? So what we really try to do is dive really deep on an intake, you know? And so that could be done just by the patient before they ever arrive, just going through their history, what weight, you know, what was their lowest weight, what's their highest weight? When do they start gaining weight and try to learn a lot of that information before you ever step in the room? So that way you're not spending so much time, you know, with the patient going over all this stuff. Because again, it's very time consuming and we want to be most time efficient and effective. Yeah, and really, you know, I think, you know, a little tidbit for providers or I should say physicians, the word providers, but, you know, is to really look at, you know, where did their weight gain start? You know, there's usually, if you look at their history, it's so important to really look, you know, when did it start, that it start when they were a little kid, that it start all of a sudden, you know, when they got on their antidepressant, that it start when, you know, they started a medication for whatever, that it start because of a life event, you know, there's usually a trigger that starts this whole, you know, process. If you can find that, you can then target, you know, what your treatment is to that, rather than, you know, just, you know, depression, you know, then it or overeating disorder, all these different things, you can then make sure they see a mental health provider, because that is always going to keep them, you know, that's always going to be against them, if that's the problem, you know, so it's, yeah, it's very important. So that's a very good point, I feel like, you know, a lot of us are so hyper focused on the present, right, because also we're told to focus on the present moment, right, let's get this obesity down, let's, let's bring the weight down, but the past can give you so many clues, like you said, whether it's the trauma, whether it's the inciting event. You have the goal, and now we're going to work with the patient in terms of bringing down this obesity. So is your overall goal to decrease fat percentage, or is it weight, how do you kind of discern between the two, if you do it all. My approach personally and my practice is because BMI is the easy, like we measured every visit, it's the easy thing to look at, it's the easy measure, it might not be the perfect thing, but the, and the weights are conference. I look at that, and that's what we, we look at over time, just because in my clinic, that's the easiest thing to do. I don't have a body for a percentage machine, I know other practices might, and that could be helpful, and maybe motivating patients. If the scale doesn't move so much, but that is decreasing, they might get motivation from that. But the waist or conference is actually a pretty good indicator of that as well. So doing both of those is usually very helpful and determining how successful we are. Yeah, it's a very cheap tool, you know, you gravitate measure and you do a waist or conference. But, you know, that might be also, you know, some of our patients are kind of sensitive to that topic or area. So a lot of times I wouldn't even measure anything, I'll just ask them if they're pant size, if it's going down. And, you know, that's usually a nice successful thing. I don't push patients to weigh themselves all the time, because they get so focused on the number. So I'm looking at the weight and how much they're dropping, and if they're not dropping, is their waist or conference dropping? Because a lot of these patients might actually be exercising and they're gaining muscle and they're doing other things. So you won't always see the number, the scale drop. So there's all these ways of looking at it. So I think it's always looking globally. Insurance, though, however, want to see, you know, this much drop and BMI and this and that. So you've got to always document the BMI and that's what I tell patients, you know, we need to do follow ups. So I can get your medications covered and we can get all these things going. So, but as far as, you know, what motivates them, I try to focus on health, you know, being there for your kids, improving their A1Cs, improving their blood pressures, trying to be a natural. They're getting off of beds, right? They hate these beds. Well, if you lost the weight, we could, I think we could really do this. Yeah, and giving them those goals, you know, hey, you can take less pills, you know, a lot of our patients, that's a motivation for them. So, so yeah, you know, again, it's so, as you can see, obesity is super complex, which is what's exciting about it. And the more we learned about it, you know, the more we're just like, oh my god, like no one taught us this stuff. We were in the hospital, we knew how to treat things. We love seeing A1Cs drop, you know, that's, that's one thing we all, you know, give ourselves a pat on the back when we get a patient on a nice medication or whatever, and it brings it down. But it feels just as good when patients lose weight on their own, just because of something you told them, and you motivated them, and they come back a year later, I've had patients drop, you know, up to 10% of their body fat, just, just on lifestyle changes, just educating them, you know, about food and how they're working. You're saying, oh, I'm eating healthier, and they're like eating like a granola bar that's high in sugar, right, or making those juices that are super high in sugar, but they think they're eating healthy. So, it's like re-educating what is healthy and what's important and what's not important. Yeah, it's got, you just got to change the mindset, right, shifting that mindset in terms of, hey, let's focus on health, like you said. So, I am curious, right, obesity has a lot of these downstream effects, as we know. But I believe the studies are also showing, right, if you're at a higher fat percentage, but you have more muscle that goes with that, it actually becomes more protective than, let's say, somebody with a lower fat, with not much muscle. Are you guys approaching your patients in, you know, quote unquote, being more muscle-centric as, you know, Dr. Lyon, who talks about this. Absolutely. Yeah, I mean, you know, there's a lot of studies that show that, you know, resistance training rather than cardio is more effective at weight loss. So, you know, if your patient is trying to lose weight, you know, resistance training and gaining muscle mass is an effective way to make yourself healthier. So, I do think it plays a role, and in the overall picture, and it is something to focus on once you get, you know, the diet in line. Yeah, absolutely. Now, Michelle, you mentioned earlier that, you know, sometimes individuals just get a bad hand, right, it could be the genetics things that we've touched on. It could be the environment that you're growing up in, inaccessibility to a safe community where you're exercise, just food, all that kind of stuff. And sometimes pharmacological assistance is necessary. And so, one of the things I think recently in paper came out in English journal medicine, or something looking at GLP1 agonist. Could you guys talk a little bit about what pharmacological treatment you use that, you know, things that are potent in your toolbox? And specifically, I would be interested in learning more about GLP1 agonist, and if that's something you guys are using in your practice, and maybe define for folks who aren't familiar with what that is and how it might work. Yeah, so what's exciting is, you know, just a few years ago, there really wasn't obesity treatment. There was short-term obesity treatment, like with phinteramine, and essentially none of these drugs like existed. And then all of a sudden, in the last 10 years, we have now many long-term weight loss drugs. The first one that came out, well, first two that came out around the same time, was contrab, which is well-butrin and nilchrexone combination. And then cusymia, which is actually topier and phinteramine combination, in terms of effectiveness, cusymia is definitely more effective than contrab, but they target also different things. So contrab targets, emotional eating, and addiction with food, and so patients are struggling with those kind of things. It's a great tool, plus if they have underlying depression, you're kind of killing two birds with one stone. And then if you cusymia, which has phinteramine and topieramate, that's targeting more cravings, nighttime cravings, appetite, suppressing the appetite. And if they have like migraines, or seizure disorders, again, killing multiple things with one medication is also helpful. And then shortly after those medications were created, they realized some of the diabetic drugs were actually really good at losing weight. So a side effect of the first drug, Vectosa, which is what is the generic of layer glutide was found to be very effective at weight loss. So then they did their own studies and got it FDA approved as succenda. So that was the first GLP1 agonist that was approved for weight loss. And the way it works is that it affects the GLP1 hormone is secreted in the small intestine and it affects appetite and hunger. And so if we are injecting that into the patient, they tend to be less hungry and more full after meals. So most of my patients say they just don't feel as hungry. A side effect of it is nausea. And in some people say that actually helps them not eat as much. So might be a good side effect to in terms of that. But sometimes it's a limiting side effects. People just don't tolerate it. So that was the first one that was created or approved. And then the second one was approved, which was approved as ozemic again for diabetes. And then found, oh, this even works even better than the victosa or layer of glutide. So they got it FDA approved as wagobi, which is more recent. And it's a little bit more effective than succenda and works the same way. And just recently there's a new drug that came out on the market for diabetes again, which is called moongjaro. I don't know if you guys heard of it, but super exciting. It is a GIP GLP1 combination. And it is, it's a GIP GLP1 combination. That's even found to be more effective. The ozemic or wagobi or a victosa and succenda improved like helped with up to like 10% of weight loss to 12% of weight loss, moongjaro 20% of body weight loss. So a lot more effective than those other ones. And that's right now trying to get expedited FDA approval for weight loss. How easy is it or how good are insurance companies for approving this? And if so, what is the criteria to get that approved by insurance? Because my understanding is the out of pocket costs for these drugs are as astronomical. Yeah. And that is I think the biggest limiting factor. So all these drugs, super exciting, help with weight loss, tools in our toolbox. And then we prescribe them and the patients can't get them. That is the most frustrating thing I think for us as providers. We have gotten creative in certain ways. So with the contrab and the cusimia, a lot of times we break them up into their original components and just prescribe them separately. And just kind of off label separate prescription and they work just as effectively I will say as that. Not perfect doses, but effective. And then the GLP ones, it helps if they have pre diabetes and have tried metformin. That will help them get those approved more. So sometimes insurance firms have complete carve outs for weight loss drug. So they will never cover a weight loss drug for some reason. If they don't have another underlying condition, we're trying to treat. It's it's almost impossible to get it covered. Medicare is very difficult as well coupons don't work with Medicare. So those patients also very difficult to get them covered. So there's definitely barriers we're still need to climb. And I think that's where unfortunately it would be nice if our government or you know our health system improved on is making these drugs available and affordable. And we didn't have to use all these other drugs to treat their diabetes and high blood pressure and all these other things. Yeah, you got to love that right we got this amazing tool, but can't use it. So it's essentially useless. Just one of the frustrating things on being in this yet I imagine a lot more for you because this is routine party practice and you know it's there. Yeah, and I think a lot of insurance are very short sided. They look what they're going to save on money right now, but they don't look at the big scheme of things. Right, the global health burden. Let's shift gears. I know we don't have a lot of time left and I certainly want to get your take on this concept of NWO and to my listeners and my wrestling fans. I'm sure your ears just perked up and no, we're not talking about NWO from wrestling. It's this is a normal way to be city right the term that I've recently learned. And I think the more popular term is skinny fat. You alluded to this earlier, Jeff, when you talked about the apple shape and the pear shape and how we learn about that. But you know what we're learning more and more is that perhaps it's not just the overall obesity, but specifically the visceral adiposity in that apple shape. That's maybe even more detrimental to long term health. Right, because that adipose in those stories like around the organs, heart for those who don't know the show, like you know, that's essentially metabolically active. And some people will say it's an organ in itself because of the the side of kinds that releases an inflammatory stuff that ultimately will be detrimental down on the road. I'd love to kind of hear you guys talk a little bit more about that. And especially if you see folks who maybe don't like have a, you know, BMI of like 3536 or just like overtly, hey, you clearly have obesity. But you, you know, you can see that they have a lot of visceral adipose tissue. You know, what kind of markers are you looking at? Are you doing like an MRI, some type of imaging study to identify for that? And, and is that something that you measure? Just this your overall take on that. Yeah, so, you know, when it comes to visceral fat, you know, there's fat mass disease and then there is the metabolically active fat. So you got to look at fat from two different perspectives. Fat mass diseases, you know, you may have obesity hypoventilation syndrome. So the actual mass of their fat is causing them not to be able to breathe properly. Also, all this fat is coating your organs and all these things. And you see renal disease and all kinds of, you know, fatty liver disease and all these things of what fat infiltrating our organs does to our organ function. And, and then there's the visceral fat that metabolically active fat, just like you said, leptin is secreted from our fat cells. And the more fat we have, we know about insulin resistance and, and how fat plays a big role hormonally in how our body functions. And so, you know, there's, I think no real measurement for one or the other. I don't scan everyone, but we're learning a lot more. I think about fatty liver disease. And so I think ultrasounds and looking at livers and seeing inflamed livers and elevated liver enzymes and how many patients now have elevated liver enzymes, you know, we see it all the time. So we are seeing, I think that's a good marker for visceral fat diseases is starting to see liver enzymes rise in our patients. So, you know, I think, yeah, there's still a lot of mechanisms that we got to look at and a lot of targets. And, yeah, and, and so in some practices, I think some people do measure like CRP to look at inflammation or actually insulin numbers and all that kind of stuff. And depends how specific your obesity practice is to or geared toward that, but because we're primary care providers, it's not our general practice, although it can be helpful, just like it is in other diseases to look for those things. But, you know, I tried to practice kind of more cost effective medicine. So, you know, there's a million markers you can, you know, can take insulin levels and all these things. Homelessly see. Yeah, homelessly seeing CRPs, you know, you got out on a ton of labs that you can look at, but will it change your big picture or change your medical management? No, you know, so, you know, I think in research, all this stuff is great to look at, but when it comes to really, you know, giving care, it's, it's really about focusing on the big picture items. Seeing their, you know, we've got already great markers, A1Cs, liver enzymes, you know, all these things that we can look at to see, you know, is there disease progressing? Or is it getting better? And prediabetes, you know, I think not enough of us attack prediabetes strong enough. You know, it's really, you know, you're looking down the road, this is going to turn into diabetes. So, you know, why are we not being more aggressive with prediabetes? So, you know, I think that we've got tons of markers to look at. I don't think there's one scan or, you know, all these, there's all kinds of expensive stuff you can do out there, but really it comes down to the same goal. And that's improving health care and improving health of the patient. It's a sort of our mission here. Now, I love that, you know, again, we were as we were talking about offline, you know, Darcia and I, we go back and forth, right? We love this idea of precision medicine, of taking care of each individual in front of you. And there's so many things that we touched on, you know, some of the things that come to mind, of course you can do an MRI, which is grossly expensive, but it takes a scans much cheaper, but gives you a lot of that information. But the question becomes, is it going to be actionable? I can tell you, I had a DEXA scan done not for this purpose just because, you know, for learning purposes, and I had that got that information and I haven't done anything with it. And so, really, ultimately, it's like, is the data going to be actionable? Otherwise, you know, it's like rule number one that you learn in medical school ordering a test is, does it going to change anything? And so, so I love that. That's the art of medicine that you're talking about. But it's certainly interesting to kind of get your take, just because you do this day in and day out. And to your point, Jeff, you know, I, I don't want to be quoted on this, but I think we're talking about an Apple D that might be the leading cause of liver transplant in the United States at this point. If not, certainly the next couple of years, it's supposed to be. Is that the case? Yeah, it is, right? Which is, which is terrifying, right? That that's where we are. But guys, I want to thank you so much. You know, I think with time and time, we've mentioned how complex this topic is and you guys have done, I think a phenomenal job trying to make it simple today. And this is what you guys do a day and do it out. So if you wouldn't mind, please talk a little bit about what obesity made simple really is. You know, what you guys offer. Who is it for? You know, that kind of stuff. And I also be curious to learn about, you know, what's next for you guys for obesity made simple. Yeah, so we created a six week online course that is self-paced for other providers. Anybody who takes care of patients, it could be cardiologists, OB-GYN, PM and R. It could be anybody who wants to learn more to learn more about the disease, how to help your patients in the moment, tips to actually actionable steps you could take today to make effective change in your practice. We go through all the medication, all these motivational interviewing. It is about an hour each module, which is not that long. So it's about six hours total and you get all this information. Yeah, absolutely. You know, we created this course more for just seeing how hard it is to incorporate this stuff into your practice. And, you know, it took a lot of time to create the course. We didn't realize how hard it would be, but we really wanted to help our community to for primary care doctors and stuff. We talked about stuff. We wish we would have known. And you get also CV credit by doing it as well. Yeah, so it's really a cool course. I think we give a lot of great information for it. And yeah. Yeah, and you could find us at obesity made symbol dot com and also on social media at obesity made symbol. Awesome. We will definitely put those in the show notes for those of you that just want to click on and get easy access to the website and definitely check out the course. I also just want to thank you guys so much. You know, I mean, as ultimately I said, this is a complex topic. I think you guys have done an awesome job in terms of really just making it easy to understand at least what we can. I know there's a lot on the horizon. So we're all looking forward to that. And this is not just a US issue, right? This is global. So I think by the work you're doing, just affecting one person that downstream effect it could have to another family member, another friend really makes all the difference. So with that last question, we ask everyone is, how do we put the health back in health care? I think focusing on the people and focusing on the big issues and not just ignoring what the actual problems are. Yeah, I think individualizing care and trying to get away from this, you know, very cookie cutter model, bringing back our relationship with patients. So, you know, being more time effective in this very financially crushing world that we have right now, you know, I think focusing on health and enjoying bringing back the joy and helping people and seeing results in their care. You're sure? Perfect. Thank you guys. Thank you. Thank you so much. As always, thanks so much for tuning into that episode. I really hope that it was made simple for you, at least the topic of obesity. Now, if you have any lingering questions, any offshoots of the topics that we discussed today, please email us at medredefinedatgmail.com. And by doing that, you know, it gives us a better idea of bringing up topics with our next potential guests. You know, we would love to bring the shook men's back on, but there are other practitioners out there who practice obesity medicine as well. And, you know, one of the greatest things about this podcast is that we bring on different perspectives. And that's exactly the way we build healthcare, right, at least reform healthcare and redefine healthcare is by bringing in all these fabulous perspectives and really changing the culture and shaping the way that we think about challenging topics. And, you know, if you are a physician, definitely check out obesitymadesimple.com, check out the shook men's courses. As you can tell by the way that they talk throughout this entire episode, obesity doesn't have to be as complicated as we make it. And if you are just a listener and you're here through and through with all of our episodes, it would mean the world to us if you could take the time to great and review this podcast on whatever you may be listening to. And as always, please share this episode with anyone that you may find would benefit from it. As always, our medical disclaimer, anything in this podcast is for educational purposes only. It does not constitute the practice of medicine and we are not providing 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, alternative, related issues. See you next time.