Dirty White Coat
Mel Herbert, MD, and the creators of EM:RAP, UCMAX, CorePendium, and the collaborators on "The Pitt" and many of the most influential medical education series present a new free podcast: “Dirty White Coat.” Join us twice a month as we dive into all things medicine—from AI to venture capital, long COVID to ketamine, RFK Jr. to Ozempic, and so much more. Created by doctors for clinicians of all levels and anyone interested in medicine, this show delivers expert insights, engaging discussions, and the humor we all desperately need more of!
Dirty White Coat
GLP-1 Agonists: Transforming Weight Management and Understanding Diabetes with Dr. Anne Peters
This episode unravels the complexities of using Ozempic, a GLP-1 receptor agonist, for weight loss—especially among people without diabetes. Dr. Anne Peters highlights the health implications, individual responses to the drug, and the broader context of weight management.
• Examination of Ozempic’s functions and benefits
• Discussion on who should consider using Ozempic
• Clarifying misconceptions about weight loss and obesity
• Insight into the body’s set point and its impact on weight
• Risks associated with using medications for non-diabetic individuals
• Emphasizing the need for a multifaceted approach to health
• Historical context of obesity and diabetes in society
• Conclusion on prioritizing health over aesthetic standards
I'm Dr Anne Peters. I'm a professor of clinical medicine at the University of Southern California, where I run two different diabetes programs, one in Beverly Hills and one in under-resourced East Los Angeles.
Speaker 2:And Dr Peters here is an old friend. I think I met you when I was in my mid-20s and I'm no longer in my mid-20s, so that's a while ago. You are a world expert in diabetes and it was just an opportunity to grab you and ask you about some things, about a Zempik because we've got this podcast and we're talking about lots of different topics. But one of the things that people keep asking over and over again is about this new group of agents and whether they should be using them. This isn't people that are 100 pounds overweight and have diabetes. These are friends who are moderately thin and, like I, just would like to be thinner. Should I use it? So I would like you to tell us about these drugs and who we should be using them in and what are the upsides and downsides for regular folks using them. So let me VO my own VO here and say that Ozempic is a prescription drug here in the United States. It's semaglutide and it is a GLP-1 receptor agonist. So it hits that receptor and it activates it, and so that's glucagon-like peptide 1. So you'll hear this a lot GLP-1. So after you eat, you get this GLP-1 hormone that goes up and that increases the amount of insulin that comes out of your pancreas and that deals with the sugars and stuff that are now in your blood and it puts them into the cells. So this drug mimics that action and we'll be talking a lot about weight loss here and it has a number of different mechanisms, and so one of the ways that it works is that it goes to your brain and says I'm full, I'm done here. So it reduces your hunger cravings in lots of people not everybody, but in lots of people and so you feel satiety, I'm done, I don't have to eat anymore. So that's one of the ways that it works. It also can reduce your GI emptying, so the how quickly the food goes through your stomach and your GI tract. This also can make you feel full, Like you've had a big meal and like I couldn't eat anymore. It gives you that sort of sensation, and there's probably a whole bunch of other ways that it's used, but it's predominantly used, or should be used or is FDA approved, for patients who have obesity and type 2 diabetes. That is the kind of diabetes where you have insulin but you don't have enough of it, and so this can increase the levels and decrease your weight and it tastes great less filling, as it were.
Speaker 2:Oh, and one other thing I'm going to say here because I know it's going to be triggering for some people. We talk a lot about being fat, but not in a derogatory way. We talk a lot about fat and sometimes those two are mixed, but I know for some people it's really triggering. You can't say somebody's fat. We do that here. It is not meant in a derogatory way at all and if that's triggering for you, I'm sorry, don't continue.
Speaker 2:We talk a lot about obesity. We talk a lot about BMI, measuring central circumference. So forgive us if we haven't used always the politically correct terms, because we are people of a certain age and mean nothing derogatory by it. Now let's go back and let's talk about these drugs. And the other thing I should say is that we use a lot of the trade names, not the drug names. They are just easier to remember. If this was a CME program, we would change it, but for the purposes of what we're doing here, we're just going to use the trade names that people use. It's just easier because then people know what we're talking about.
Speaker 1:Well, first of all, these aren't new. The first of this class, which is called the incretin class but specifically what Ozempic is is a GLP-1 receptor agonist. This class was first introduced with Biada, which was a twice a day injection, which was about 20 years ago. So one of the things that comforts me as a physician is that we have a long history of using these drugs and I, as a diabetes specialist and actually a diabetes specialist who writes the guidelines knows the benefits and risks. So I'm completely comfortable using these agents and I'm completely discomfortable making the right choices with patients, helping patients make the right choices when it comes to using them. So they're not so new. It's just that the media made them new because suddenly we had a once a week form instead of a twice a day form, and where everybody has caught on to the fact that you can lose weight and it's relatively easy.
Speaker 2:So let's talk about that as a weight loss drug, so as a diabetic treatment. You've been using it for 20 years. You're quite comfortable with it. Risks, benefits in favor of the medication. So let's talk specifically about its use for weight loss and non-diabetics, which I assume is off-label, fda approved but used all the time.
Speaker 1:Well, it's not off-label. So this is what the drug companies did, and even this started 10 years ago. So there was a drug called Victoza, which is a once a day GLP-1 receptor agonist and we use it in people with diabetes. And these drugs, by the way, are great in people with type 2 diabetes because their glucose levels go down, they lose weight. All the things that are not right about them get better. Their risk of heart disease goes down, their risk of heart failure goes down, their risk of kidney disease goes down. So these are to me, I would suppose, one of the two most miraculous classes of drugs I've ever had to treat people with diabetes. And they work and they're much better than, for instance, insulin. I still use insulin all the time, but these drugs work.
Speaker 1:But I'm not quite so sure. When the drug that was Victoza for diabetes also became Saxenda, which is a drug for weight loss Very same drug once a day it was just three times as strong, and so on label Saxenda has been available for, I'm sure, 10 years. I could be wrong, but it's been a while. And the problem with the drug for weight loss is that insurers didn't want to pay for it. We don't consider obesity a disease. We consider it a condition and therefore insurers don't pay for drugs for a condition.
Speaker 1:Now, I personally am of the belief that people who are overweight are overweight for a variety of different reasons, and it's exceedingly hard for people to lose weight because your body defends your weight and these drugs make it easier, and the reason I like them for people who are overweight is because it takes something that's a real problem for them and makes it. It solves the problem. It doesn't necessarily take away from the desire to eat entirely, but it helps people lose weight, and a headline for me throughout this podcast is that people need to eat well and take these drugs, because it still matters that you eat well, because if you don't eat well and take these medications, you can lose too much of your muscle mass. You can become unhealthy. That's not what we're talking about. What I'm talking about is taking people who are obese or overweight, helping them lose weight, and that helps their health in a thousand different ways.
Speaker 2:So you talked about this sort of the set point that we have. And you know, even I find this sort of the set point that we have. And you know, even I find this I want to lose. I'm 160 pounds, five foot nine, five foot eight, so just about the right. I want to lose 10 pounds. It's really hard, you lose it and then you go right back to this sort of set point that you've had for years. So do these drugs help you change that set point or do you have to stay on the medication to keep the weight off?
Speaker 1:You have to stay on the medication for the rest of your life. Now let me just tell you this. So in my world, I believe in individual response. So when I have a patient who has diabetes or doesn't have diabetes and takes these medications, if somebody wants, for whatever reason, to stop it and again, as I said, I think the cause for people being overweight is multifactorial so there's not just one reason and there are people who I know who eat because they're sad and these drugs don't make you happy. They make you feel healthier perhaps, but not necessarily happy. And so in about 25% of people there is no weight loss response. So people who go on these medications for weight loss may or may not lose weight.
Speaker 1:Like anything in life, there's an individual response. But say you go on these, you lose weight. You get to another point. You feel like you're able to exercise more, you've learned how to eat differently, you've worked with a dietician. Then I say we can try to taper them. I don't stop them, cold turkey, I taper. I say we can try to taper them, I don't stop them, cold turkey, I taper. And then I start by saying, okay, let's take it once every 10 days instead of once every seven days. Then I say once every two weeks, then maybe I'll get to once a week, once a month. But I'll go down slowly and then and also I'll ratchet down the dose. So the maximal dose of Monjaro is 15. You can go down in 2.5 milligram increments, down from 15 to 12.5 to 10 to 75. So I believe in the lowest drug for the most benefit. So I'll tell you about me. Am I allowed to tell you about me?
Speaker 2:Tell us about you.
Speaker 1:So I was getting diabetes. I found this out from blood tests I did on myself and we doctors are not necessarily good patients, but that's okay. But I'm not just getting diabetes. I'm getting type 1 diabetes and I use these drugs in type 1 diabetes as well, but that's slightly a different story. But I'm getting type 1 diabetes slowly as an adult.
Speaker 2:So perhaps for the non-docs listening to the show, type 1 diabetes is an autoimmune disease where your beta cells, which are in your pancreas, are destroyed by antibodies. It tends to occur in young people that are thin and then they develop diabetes that requires insulin. If they don't have insulin, they die. But now we're learning, as we're about to hear, that this can happen to people that are older, and can happen slowly, which is sort of blowing my mind, which means my beta cells that make insulin still are making insulin.
Speaker 1:They're just not making enough. If I hadn't started myself on Ozambic, I would be on insulin now because if you look at my glucose levels, I go up and down a lot when I eat. So taking Ozempic helps my body make insulin better, like a type two, because that's what it'll do. So I'm taking these to prevent myself from eating insulin and I technically have diabetes at this point, but I take Ozempic and that's how I treat it. On the other hand, I'm skinny but, just like you, I was at the same set point and I was at a set point of 140 pounds and I'm 5'10 on a good day 5'9 if you want to remeasure.
Speaker 2:We're going through the shrinking years. So you know, yeah, the shrinking years are happening.
Speaker 1:And so I took it and I lost. Probably. I lost down to like 128 or something, which on me is a lot of weight, and so now I'm considered underweight. But darn, is it a great weight? Because I look really good in clothes. I mean mean, like you know, 140 was fine, I was normal weight. But you know I hang out and I live in LA and there's Hollywood and my husband's a Hollywood person, so you know I look great in clothes.
Speaker 1:But the problem for someone like me is losing too much weight, and I didn't want to lose too much weight because I would lose too much muscle mass. And so what I did was I clicked up the dose really, really, really slowly. I didn't use the doses on the pen, I used this click method, or micro dosing, till my body tolerated it and I got to about 0.5, which is a really low dose of Ozempic, and I don't go up and I don't go down. If I go down I get hungry, if I go up, I lose more weight. So I take a tiny dose of Ozempic every week and for five years I have reset my set point.
Speaker 1:I am at this lower set point, I don't go up, I don't go down, and I've worked really hard to maintain lean body mass. So I exercise, I eat more protein and I eat more fiber so that the drug doesn't cause me any ill effects. And that's where the drug and I are. We're happy together. And eventually I'll need insulin. I know this, but for now I don't. So it does reset your set point, but I know in me if I skip a week I'm really hungry in a way I've never been before, because I think it's been suppressing my hunger.
Speaker 2:So then let's dive a little bit deeper in that. You said something at a Grand Rounds conference years ago that has stuck with me, that even 10 pounds of abdominal fat can be diabetogenic. Just a little bit of a belly fat is very hormonally active. Is that still our understanding today, and is this a reason why people who look pretty lean might actually benefit from being on medications to drop that weight, or is that overstating it?
Speaker 1:It's not overstating it at all, but this is what we've learned since I gave that lecture. We've learned that there's probably a thousand different types of what we used to call type 2 diabetes and possibly a couple hundred types of what we used to call type 1 diabetes, and so we're no longer at least in the sort of evolution of guidelines, calling them so distinctly type 1 and type 2, that a lot of people will have elements of both. And that belly fat can happen in the lead person or an overweight person, and that can drive insulin resistance and it also drives these hormones that make you have more inflammation. And the problem is is that people who are overweight or obese or even have central fat not only can get diabetes, they can get higher rates of heart disease, they get higher rates of cancer. That fat in all of us is metabolically active. It's not a silent organ and it's you know. You can't do liposuction to get rid of it because it's abdominal, it's inside there, and so for most people, losing that fat and again, I don't care where you start losing fat helps you reduce that metabolically active tissue and your risk for other health problems goes down, and that includes things like joint pain and back pain and sleep apnea, and I think there's 250 other conditions caused by that organ that is fat. So I take that seriously.
Speaker 1:But you can't use these drugs if you're lean without doing it with a doctor or somebody who knows what they're doing, because you'll get too thin and I mean what's good about these drugs can be what's bad about these drugs. So you just you can't just use them. I think you need guidance because otherwise you can get worse. So I have people where I have to beg them to stop the drug. They're too thin, especially if people are older. I'm like you cannot keep doing this. You've got to stop it or reduce the dose. I worry people get dehydrated. I mean, people are writing a lot about side effects of these drugs and I'm like the vast majority of those side effects are because people are just using them without actually being guided in their use.
Speaker 2:So tell us about that weight loss. These by their nature cause a sort of syndrome of losing muscle. You become muscle wasting, and we hear about this ozempic butt. Is that what they're talking about? It's basically just some muscle loss.
Speaker 1:Well, this is the thing, Ozempic. The reason I like it, rather, is that I'm an endocrinologist, which makes me a geek for hormones, and Ozempic is a hormone and Monjaro is two hormones, and these are hormones that are inside of all of us, and so when you give somebody a gut hormone, known as insulin, you're giving them an injection every day, or multiple injections every day that are replacing what their body isn't making. And when you give somebody a gut hormone like Ozempic or Monjaro or Wegovi or Saxenda or Zepbound, whatever they are called, these are hormones that are injected because they're peptides and otherwise your body would destroy them, and I guess that you can get them as a pill, but the injections work better, I think. But the point is is we're replacing a hormone, and it may be that people who are more overweight are more resistant to this hormone or they make less of this hormone, who knows what? But it's not like back when we gave things that sped up your body or did bad things to your heart.
Speaker 1:This is a drug that's known to your body and so you're giving it to your body and it's not going to make you, you know, suddenly grow I don't know a third year. It's basically not going to make you, you know, suddenly grow I don't know, a third year. It's basically just going to make you lose weight. But any weight loss, particularly rapid weight loss, will make you waste muscle. So it's not that these drugs are specifically bad at that, it's that they're fast at that. And if you lose weight fast, you know, if I gave this to you and you lost, you know, 20 pounds in the next six weeks, you wouldn't look so good. Just a thought. You look perfect now.
Speaker 2:Thank you. So that's. I wanted to touch on that because my understanding is that every other single weight loss drug that has been used in the West has resulted in a class action lawsuit because it's resulted in cardiac abnormalities and fen-phen and all these things. So you think these are intrinsically different than those prior weight loss drugs.
Speaker 1:Correct. These are hormones, the others were chemicals. It's completely different. It's not that I don't think these drugs have side effects, but I think they have a side effect that's related to their effect in the body. We're just giving more.
Speaker 1:So people who lose weight fast will end up with gallbladder problems, no matter how you lose the weight, or they slow gastric emptying, so they slow the food transit through your intestines and you know they can give you constipation, they can give you diarrhea, they can give you delaying gastric emptying, particularly if you have a problem with gastric emptying. But most of these side effects can be mitigated by using lower doses, going up slowly and again using them with somebody who knows them. So if I have somebody who has really bad gastrointestinal side effects A, I go down on the dose, but I don't. I use those Ozempic pens because you can click them. You can give a effects A, I go down on the dose, but I don't. I use those ozempic pens because you can click them. You can give a very, very, very low dose compared to if you're using, say, a fixed dose. Pen like Monjaro comes in and I just go on little doses. Or I have people give them less often.
Speaker 1:But if somebody gets too sick from these, I don't keep them on it. I mean, there are people who just don't tolerate them and that's just life. But it's different than the others. So they're not chemicals, I mean. I guess they are, but they're really not. They're hormones. They're hormones that we're giving you, that your body knows. And the other thing is is we've used them for 20 years. So you know there will be lawsuits about almost any drug. But as somebody who's used these, who knows the genius people in this field, I don't really think that there's some horrible scary thing that happens that's worse than the other horrible scary thing which is the consequences of being overweight or obese or having uncontrolled diabetes. I mean, these drugs have so many non-glucose related benefits. So you've got to look at risk and benefit. Nothing is risk-free, nothing is side effect-free. But learn what the side effects are, reduce the risk and then stop the drug if it's not tolerated.
Speaker 2:This begs the question of who should be on it. I want to go back to that. I'm kind of stunned that you're developing diabetes, because I have this old school understanding of diabetes which has completely changed and you've been the person, probably as managed as anybody in the world, that's helped us understand this. When I was in medical school, there were two types of diabetes autoimmune destruction of your beta cells, insulin dependent DKA that one, skinny people and then there was obesity, long-term insulin resistance. And now you've made it all blurry and you're a perfect example, super lean, active, and you're developing what is sort of this mixed picture of your beta cells. Are they autoimmune destruction? Are they just getting old and they die? Or this happened to my father-in-law as well. He was 87 and he developed diabetes Fit, healthy, lean. I'm like what is happening to my worldview of diabetes?
Speaker 1:Well, your worldview should change completely. I have sky high antibodies. I am getting true type 1 diabetes, but nobody knows because nobody's even studied it in people greater than 45 years of age. My oldest patient with new onset type 2 diabetes was 94. So you can get type 1 at any age, and now we know that it's more common if you're an adult than a child. But it looks a lot like type 2 diabetes in some people Like I.
Speaker 1:Have an entire clinic in East LA of people who you would think have type 2 because they're centrally obese, they're overweight, have hypertension, they have a family history of type 2. And yet I measure their antibodies and they actually have type 1. But type 1 in adults, the onset is much more like a type 2. You just don't know it. So it's very important that people who are atypical get their antibodies tested and then people like me who are atypical, end up on insulin sooner than somebody else. But I would typically just be on insulin, but I don't want to be on insulin. I'm not against insulin. I'll take it when I have to, but I like being on a little bit of Ozempic and, like I said, I've been on it for five years and it and I seem to be happy together, so it's fine.
Speaker 2:What is overweight now? So is it true I'll make some statements which may or may not be true that obesity or being overweight over the long term produces insulin resistance and maybe you wear out your beta cells? I don't know if that's true or not. What is the right weight and at what point should you say I need to start a drug to drop my weight a little further? Do you just look at the person or is there a BMI? What do you use?
Speaker 1:Well, that's a very fraught question, like all things in medicine. So, first off, if somebody puts on a continuous glucose monitor, which you can now get over the counter, and you find out that you're having spikes either in the morning or after eating, you may have prediabetes, and that one's easy, because in that case you need to see a physician. You need to exercise, lose weight if you're overweight at all and again, that 10 pound of central fat can cause it. And I've had patients who are lean, if you looked at them, lose 10 pounds and their pre-diabetes goes away. So you want to look for a manifestation of the fact that that weight isn't good for you. But if you look at a body mass index, it depends on if you're Asian or not.
Speaker 2:So I actually didn't know this, but it turns out that in Asian populations the BMI is generally not considered to be interpreted as the same as other ethnicities, because Asians tend to have a higher percent body fat and a lower BMI compared to other groups. All this is way above my pay grade, because then it's sort of like which type of Asian or how Asian, because I have lots of friends who are half Asian, half Caucasian, etc. That's why we have experts that do this all day, like Dr Peters.
Speaker 1:But in a non-Asian individual, a body mass index of more than 25 is considered overweight and greater than 30 is obese. And then there are other classes of it. But there are bigger people and leaner people by nature. I mean, I have the world's skinniest bones, so you know, on me, you don't want me. You would want my body mass index, which has always been about 19. I mean, I'm lean and that's just who I am, and not that I can't get, you know, flub here or there. We're all aging, but I'm lean. But I have these guys who are, you know, big guys and I know their body mass index. If they had a body mass index of 19, they'd look like they were skeletons. So I think there's an individualization for this.
Speaker 1:And then people say that you should measure waist circumference. And if you look at waist circumference, that tells you about that center fat and that tells you about that metabolically bad for you, worse for you, because all fat is not so good, although there's fat as a storage form of nutrition. So it's not entirely bad for you, it helps you survive. So they say measure around the waist. Well, the problem with that is that you have to actually have something that makes you and I'm showing you but I'm going to say it in words is you have to have something that stabilizes the weight the tape measure around your center and you have to do it in exactly the right spot.
Speaker 1:So the New York Times recently ran an article about the fact that waist measurements are better than BMIs, and they had a picture of somebody measuring somebody's waist and the top part of the tape measure was high up and the bottom part was down low, and that picture was exactly the reason we can't do waist measurements accurately, because you have to have something that makes the tape measure going exactly horizontally, and nobody does that and nobody has it. I've been doing it in research for years, but in random practice people don't measure the waist circumference correctly and so it becomes really hard to do that. But I think most of us know where do you gain your weight, and as you get older you're going to gain it in your center. That's just where our bodies are doing it on purpose, because your body wants weight in the center to help you survive famine and you want to have a higher body mass index as you get older to survive old age. I mean you're not going to survive it forever, but at least it helps.
Speaker 2:Yeah, okay, so it's complicated and working with a physician to determine if weight loss is enough, whether you should be on one of these medications. One of my physician friends said she goes to the gym and she's got all these skinny girlfriends and all of them are on Ozempic. That really concerns me, just trying to get that extra five or 10 pounds weight loss. It concerns me because you're taking this from a group of people with diabetes or pre-diabetes and then you're doing it in a population of people who basically don't have any of those things. There's got to be more downsides than upsides. What do you think about that?
Speaker 1:I don't know exactly, because if these people are the same people who are going to go have plastic surgery and have liposuction or something, there's also a risk to surgery. I mean, again in life, I'm always comparing it to whatever the alternative is In a universe where everything was available. Maybe it's not so bad because people are going to do something to lose weight. By the way, you don't lose weight by exercise unless you've exercised two hours or more a day. Exercise is incredibly good for you. It makes you much fitter, but it's not going to cause weight loss because exercise makes you more hungry and it also slows down your basal metabolic rate. But I think the goal is to be fit and healthy, and I think you can be too thin, and so I would say that the best way to lose weight is through diet and then exercise to keep yourself fit.
Speaker 1:And I don't know. You know it's very hard for me to answer this question. I don't think, as a you know human who cares about public health, that we should be giving people a drug like Ozempic to lose five to 10 pounds. But people do all sorts of things to look better. I mean you can tell, looking at my wrinkles, that I do not do Botox, facelifts or any other thing and my gray hair and everything else, because I just believe that you should age and healthy and age in a healthy way, and I just feel like that. A lot of that stuff is, I don't know, in a world that I don't really agree with. But again, if you look at, maybe, what they might otherwise do, maybe it's that your friend who isn't that skinny is the healthier person, but I just don't know. You've got to individualize this.
Speaker 1:But as the body mass index gets above 28, people get concerned and the insurance companies have cutoffs for where they'll pay for weight loss drugs now, and it's a higher body mass index. But if you have diabetes, hypertension or abnormal cholesterol levels, it's a lower cut point, so it's hard to know, but right now it's a lower cut point, so it's hard to know, but right now we have a huge supply problem. Let's take away those people who are fancy and let's just talk about regular people. And again, I think that becoming leaner if you are obese or overweight, and coming down to a healthy body mass index, which isn't going to be 19, it's going to be 23, 24, 25. That's great, and as you're older, going down there is great too.
Speaker 1:And I feel like we don't need to have a society that focuses on ultra thinness. We need to have a society that focuses on health and I think that no matter what your weight, you can be healthier or less healthy. So even if you're, you know, I have patients who have body mass indexes who are significantly overweight. They're in their, you know, the body mass index is 34 and they can't tolerate Ozempic and they can take Monjaro, but they don't really lose any weight and you know I don't tell them to give up. I say I can help lower your cholesterol, you can eat better, you can exercise more and you can be healthy heavier. It's just that if you're healthy and leaner you are continuing to enhance things. But I don't tell people ever to give up and I think that you really can have health at nearly every weight. But it just becomes somewhat easier on some of these drugs to achieve weight targets. But I really believe in giving people what they need to be healthy period, and sometimes that's this image that they should be way thin and I get that. To me some of that becomes on the side of disorder, eating a disorder, body perception. And I have patients ironically I have patients with bulimia who I've given a low dose of a drug like Ozempic or Ozempic where the bulimia stopped because the cravings got better and they started to eat more normally and actually regain some weight.
Speaker 1:But again, this is all under medical supervision. You have a problem. You're binging and purging. Let's see if we can get that to a better place. And it's amazing, used correctly these drugs are life-altering in a really good way.
Speaker 1:But what we've done in the County of Los Angeles, and I'm very proud of us, is that even though these medications are more expensive, most of the Medi-Cal programs, most of the county programs, will. If someone fits the criteria, which in general is having diabetes but in some cases being significantly overweight, they can get these medications. And so I feel like, as a public health person, that I'm using it in these patients who otherwise have poorly controlled diabetes and they use these medications and I get them better. That to me, is a miracle. That's where I care the most is helping people become healthier who have diabetes. But you could have anybody get healthier, but again, I'm not so sure that what you're talking about in those people in the gym is about health. It's more about vanity and you can be who you are with that. That's not who I'm going to prescribe these medications for this is a more sort of general question.
Speaker 2:Again, I feel like everything I was taught about health and weight was wrong, and that's I remember in medical school. The dean of the medical school said to us and this was in the 80s half of the things that we're going to teach you are wrong. We just don't know which half, and I felt like that's absolutely been true. Is this historically? Is obesity and hypertension and metabolic syndrome? Is this a new phenomenon? Is this a Western world high fructose corn syrup issue, or has this been an issue at different times through human history?
Speaker 1:Well, it's been an issue not the same issue but we've never had so many people, we've never had such an abundance of food, we've never had such an abundance of unhealthy food. But again, it's complicated and because places where there's food insecurity you often see the highest weights, because poverty and being overweight are related, because you get even poorer quality food. But they think these genes for diabetes at least are survival genes and the genes for hanging on to fat are survival genes, so that if you took me and put me on a mountaintop and somebody who's got a bigger BMI, who's got type 2 diabetes, they could last a year living off their fat stores and drinking water, whereas I'd probably be dead in two weeks. So there's an incredible survival advantage to genes that make you eat more and there's a survival advantage to genes that put fat in your center. And the whole point is is that you need to be in an environment where there's not excess food. So if you have these genes and you were living in rural, mountainous Mexico, you never had type two diabetes because you weren't eating enough. But then if you moved to the United States and you suddenly were in a place where you ate a lot of junk food, and it's not just junk food, it's overall eating more you're going to gain weight, and then they all got diabetes. So the highest rates of diabetes are in those people who came from a place where there was no diabetes. It's about the environment in which you live less exercise, more food. But one of the interesting things is and again, these are survival genes. These are really good for you.
Speaker 1:If you're living in sub-Saharan Africa, if you're living in Central and South America, you're working really hard for your food, and probably our ancestors, who were chasing around after something that they had to kill and then they'd eat, and then they wouldn't eat again for two weeks. They needed to live on their fat stores. They think that in Northern Europe that these genes happened a long, long, long time ago, and then the upper class got more food and they became more obese. So if you look at the pictures of people in that we have, of the paintings, we see that they became more and more overweight at least the wealthy did and we think that they might've actually died out, because these genes, in the presence of too much food, give you cardiovascular disease, cancer, hypertension, and those are going to kill you. And so if you don't have modern medicine to treat those things. It may be that these genes were eliminated in a Darwinian kind of way from Northern Europeans because we don't see nearly as much type two there as we see in Southern climates. So it's possible that historically these genes were eliminated from a subset, but now they're expressed, because to be eliminated you have to cause something to happen at birth that you can't pass on these genes, right? Because if they are expressed in your 40s and 50s, you've already passed them on. And it turns out that gestational diabetes is a condition where the moms get diabetes and can cause babies to be born less often or born with more complications, and so these genes actually could theoretically be eliminated because they could cause harm early.
Speaker 1:It's fascinating to me. We don't know for sure all of this stuff, but we do know that these are very good genes for survival, and that's what I tell people when they're feeling really bad about themselves. It's like well, this is your genetic makeup and there are thousands of genes that have to do with your weight maintenance. So, as another comment about myself, a while ago I did some analysis of my genes and I found out that I have many of the known obesity genes. And I looked at my family tree. My grandmother had like 19 siblings and nobody in my entire genetic lineage has ever been overweight. And you know, we're good Midwestern Mennonites and we, you know, ate well and I don't know, worked on the farms but there's no obesity. And actually in those families there was some obesity, but they were the adopted children, which is again interesting, because genes have a lot to do with how you eat and metabolize things. But we should be all overweight, but we're not. And so I looked further into my own genes and this is like crazy.
Speaker 1:But I have something I call the wiggle gene, and I've invented this term, and that means I have a thermic response to exercise, which means when I exercise I lose weight. When most people exercise, as I mentioned, they don't lose weight, but when I exercise I lose weight and I wiggle all the time. You can see, I've wiggled a thousand times since I've been sitting here, and so I think that I wiggle my weight away while I'm just in life. But that's the point. It's not just one thing, it's like oh well, I have the wiggle gene and oh, I have the obesity gene, oh, I have this gene, and oh, I have that gene, and so type two diabetes is so polygenic. There's so many genes that have to interact in a person, and then that person interacts with the food environment, and then that person interacts with the pollution in the air, and you know how much we exercise and all of that.
Speaker 1:So it's what you learned in medical school wasn't wrong. It was just what we knew at the time and we thought it was simple, and it isn't. But very little in human health is simple, and that's actually why medications can be fraught, because often if you do one thing, another thing turns out to be worse. But because we've had these medications up for long enough for me to feel safe, and I didn't at first. I'm not a person who jumps on the bandwagon of new medications. I feel like I've had enough experience to use them knowledgeably and calmly. I'm not like here give you this, this is going to be magical. It's like well, let's see how it does.
Speaker 2:You say that these are survival genes, but they're basically survival genes in a food-poor environment. They're not survival genes when you've got lots of food. They're actually the exact opposite of that, because you become obese and you develop other. But they come from a time when we were running on the Maasai Mara eating the deer, not the deer, the elk, zebras eating the zebras, and they're not eating for two weeks. In an environment where we have so much food then they work against us.
Speaker 1:Exactly, and there are other genes that way too, like sickle cell I mean genes that can protect you from malaria can cause a horrible disease. Our genes are meant to adapt to our environment, and our genes haven't been able to adapt yet to this environment. A and B. We're not necessarily letting our genes adapt anymore, because we do a lot to make sure that people survive, and so that means these genes are carried forward.
Speaker 2:It's also interesting to me that you talk about those Northern European paintings and how everybody got fatter and fatter and it was a positive thing in my understanding was like to be called fat, was like if I said you're fat, that means you're rich, you're doing great in life, and now being fat is the exact opposite of that. You're more likely to be impoverished, to have poor food choices. It is really interesting to follow the arc of history in this.
Speaker 1:Yes, and I think that it gets down to I just I think that it gets down to, again, an individual and how people feel about themselves, and I think that you know it's important to do sort of a self-analysis of what is important and what matters. And who do you want to be? You want to eat healthy, you want to exercise, you want to make sure you take the medications that your body needs and no more. You know it's a balance and I'm very careful.
Speaker 2:And thank you so much for your time. I think this has been really helpful. It's complicated, and I hate that. I wanted you to give me an answer yes, no, this weight, this BMI, but it is complicated and you've got to balance all of these things. And so go and see a clinician and have this managed correctly.
Speaker 2:Don't just take it willy-nilly, because there are other issues. It's about and I really want to emphasize it's about being healthy. It's not about being a particular weight, it's not about looking a particular way. It's about being healthy, and I always like this idea of the concept of compression of morbidity. We're all going to die. All you can hope to do is make that time period where you're frail as short as possible, and one of the ways to do that is to eat healthy and be lean and be strong and then maybe, instead of for 20 years, being able to sit on the couch and that's all you can do, maybe you can get that to five years, and that's what we want Compression of morbidity. Be as healthy as you can for as long as you can.
Speaker 1:Exactly. You want your health span and your lifespan to be equivalent. I must say, as a corollary to all this is that I decided to become a lunatic backpacker. I have a bad back. I don't know what happened to me, but I just decided that was my road to health, because I don't like exercising on a machine and I think I'm probably fitter than I was when I was 45. I can hike up mountains, I go to the Sierras, I do all this stuff and I really think that if you're careful and again, as you get older you break more you can actually be healthy, hearty, in a really good condition as you age. But again, it's about what you focus on. I focus on health and I think we can keep each other much more healthy without worrying so much about you know every pound you gain or lose or how you look on the outside nearly as much as how you are on the inside Again, thanks to Professor Anne Peters.
Speaker 2:She literally is the world expert in this, has written books about it, guidelines, research Amazing that we got to have 40 minutes of her time and I hope this has been useful to you and I hope you've heard that message over and over again. These drugs are very powerful and very positive about them, but you should be doing this under supervision of somebody who actually knows what they're doing. It's about being healthy, it's not about being a particular weight. I love that.
