Gut Health, Nutrition & Weight Loss Meds- What Actually Matters

Episode 11 | Fertility and Other F Words

In this episode of Fertility and Other F Words, Dr. Amy Pearlman and Dr. Larry Lipshultz sit down with Dr. Michelle Pearlman for a nuanced conversation on nutrition, gut health, and metabolic optimization.

Dr. Michelle Pearlman is board-certified in internal medicine, gastroenterology, and obesity medicine, with a clinical focus on metabolic health, nutrition, and the gut microbiome. She completed her training at Wake Forest, UC San Diego, and UT Southwestern, and previously directed the Medical Weight Management Program at the University of Miami.

Known for breaking down complex science into clear, actionable strategies, Dr. Pearlman shares evidence-based insights you can actually apply to your daily life, whether you're looking to improve gut health, optimize metabolism, or better understand the connection between nutrition and overall wellness.

And full disclosure- she’s also Dr. Amy Pearlman’s twin sister, which makes this episode a little more personal, a lot more fun, and packed with real talk you won’t hear anywhere else.

In this episode, we cover:

• Why the devil is in the details when it comes to nutrition, tailoring choices to your goals, including sauces, seasonings, food prep, and artificial sweeteners
• How to read and interpret ingredient lists on nutrition labels (and what to actually pay attention to)
• The role of key macronutrients, especially protein and fiber, in overall health and satiety
• How certain ingredients, like diet products and gums, can impact GI symptoms and gut health
• Why nutrition is the foundation of gut health and overall well-being
• The evolution of weight loss medications

Key Takeaways

• “Natural flavors” on an ingredient list are not a marker of health or quality,  they’re simply processed flavor additives derived from natural sources
• There is no one-size-fits-all macronutrient ratio, avoid chasing “perfect” macros
• Focus on whole foods: if you can recognize and identify the ingredients, you’re making better choices
• The more you prepare your own meals, the more control you have over your nutrition
• Upgrade your snacks: choose roasted lentils, edamame, and chickpeas for added protein and fiber
• You’ll feel fuller longer eating your calories rather than drinking them
• Fiber is essential for gut health and supports a diverse, healthy microbiome
• What you feed your gut throughout the day directly shapes your microbiome
• Food prep and even food order can impact blood sugar, digestion, and satiety
• A Mediterranean-style nutrition pattern is a strong, evidence-based approach for both athletes and non-athletes
• Hitting your protein targets is critical, especially for individuals on GLP-1 receptor agonists to help preserve lean mass

To learn more about GI health, nutrition, and high-protein, high-fiber options made with minimal ingredients and low added sugar, visit https://bytemd.app and be sure to check out the convenient Shop page for curated recommendations.

Notice: 

The Fertility and Other F Words webcast and YouTube channel are intended for general informational purposes only. They do not constitute the practice of medicine nor do they provide medical advice or create a doctor–patient relationship. Use of the information provided through this webcast, YouTube channel, or any linked materials is at the listener’s/viewer’s own risk. The content is not a substitute for professional medical advice, diagnosis, or treatment. 

Listeners/viewers should never disregard or delay seeking medical advice for any health condition and are strongly encouraged to consult their own qualified health care professional with any questions or concerns.

All content from the Fertility and Other F Words webcast is the pr

Transcript

SPEAKER_08 0:00

So what's the difference between that and me just wanting to have a better orgasm?

SPEAKER_00 0:06

God forbid I interfere with your orgasm. Health Secretary Robert F. Kennedy Jr.'s previous go-to scapegoat for autism was vaccine. Now it's Tylenol and circumcision.

SPEAKER_07 0:20

What I realized soon into my fellowship training was as gastroeneurologist, just like as a urologist, you're trained as a surgeon, I'm trained as a proceduralist. So it wasn't actually into like my 13th year of medical training, in my third year of fellowship training where I learned the nuances of nutrition. And it wasn't even within the gastroenterology fellowship program. I go into the details and I I apologize to my patients. I say, I'm gonna ask really nitpicky questions. How large is that cup? What are you adding to the coffee? If you're adding Fair Life milk, are you doing the chocolate milk? Are you doing the plain? Are you doing the 0% or the 2%? Are you adding sweeteners? What do those sweeteners look like? Are we talking about stevia? Natural flavors contain upwards of 50 to 100 chemical compounds that are created to drive more hunger and cravings. Amy and I used to be splendoholics.

SPEAKER_09 1:13

Yes, we were ketchupholics and splenohics. I know and gumaholics, right?

SPEAKER_07 1:18

The constant chewing is actually causing a lot of air swallowing called aerophagia. So sugar alcohols like erythritol or sorbitol can cause massive GI issues like diarrhea and bloating. So it's those simple things. Yeah, but as a gastroenterologist, what did I used to do? I'd order them an endoscopy, right? So Bob would wake up from his endoscopy, he'd say, Doc, what's wrong with me? I feel terrible. I'd say, but uh, great news, everything's normal. And Bob would look at me and be like, but I don't feel normal. I need a diagnosis, what's wrong with me? And so what I realized, and one of the reasons why I transitioned more into nutrition weight management, is because, listen, I'm a I'm a pretty good endoscopist, but I wasn't moving the field in any regard when it came to being a proceduralist. But really, what my secret sauce pun intended was, was I had the nuanced conversations about nutrition, right? Because we can do these fancy procedures and be very innovative when it comes to these technologies. But if I'm not talking about the basics, I'm never gonna help Bob feel better. No endoscopy is gonna change that. And that's where I think honestly in the whole gastroenterology field, we are missing the boat.

SPEAKER_08 2:22

Welcome to Fertility and Other F-Words, the webcast that tackles fertility, sexual health, and everything in between. No topic too taboo and no question off limits. I'm Dr. Amy Pearlman, board certified urologist with expertise in sexual, hormonal, and genito-urinary health, and co-founder of Prime Institute in Miami, Florida.

SPEAKER_00 2:40

And I'm Dr. Larry Lipschultz, a board-certified urologist, a specialist in men's health and male infertility, professor of urology at Baylor College of Medicine, and director of our division of male reproductive medicine and surgery.

SPEAKER_08 2:54

All right, Larry, I know you've been up to some interesting things lately, so tell me something good from clinic.

SPEAKER_00 2:59

Anyway, so this is interesting. This is a very healthy 20-year-old male who comes to see me from Florida.

SPEAKER_09 3:06

Okay.

SPEAKER_00 3:08

With a chief complaint of inability to achieve orgasm or ejaculation consciously for many years. He does experience nocturnal emissions occasionally every couple of months during sleep, but cannot reach climax when he's awake, either alone or with a partner. He describes decreased sensation during erections. His erections are inconsistent but and sometimes incomplete uh during uh intercourse. He reports a significant decline in libido beginning around eighth grade. So, physical examination, perfectly normal, normal test to size, normal uh phallus.

SPEAKER_08 3:49

Um pallus means penis for those watching. Oh, come on.

SPEAKER_00 3:54

Really? Anyway, I get a routine blood panel, which consisted of mainly uh CMP, comprehensive metabolic panel, and then FSH LH, estradiol testosterone, or prolactin. And his testosterone, which I think is would be pivotal, is 525. And that's very normal for a 20-year-old. Maybe we could take it up a little bit, but I wouldn't do that initially. So what I did do was start him on cabergaline. And the way I use cabergoline, it comes only as 0.5 milligram tabs twice a week, and I gave him one milligram twice. So two tablets twice a week, combined with HCG at 1500 three times a week, daily cialis five milligrams.

SPEAKER_08 4:39

Yeah.

SPEAKER_00 4:39

And then wanted to see what that combination did.

SPEAKER_08 4:42

So you got like the triple cocktail. I did.

SPEAKER_00 4:44

I did.

SPEAKER_08 4:44

So how do you come up with those three medications?

SPEAKER_00 4:46

Well, there are three that I've had good experience with in terms of efficacy. You know, each one and together, why not? So that's why I did it.

SPEAKER_08 4:54

Maybe explain what are you trying to address with each one of those? So the Cialis is gonna help with his erectile function.

SPEAKER_00 4:59

Right. Give him more self-confidence, he'll have consistent better function.

SPEAKER_08 5:03

The HCG is gonna maybe boost his testosterone.

SPEAKER_00 5:06

Yes, but not only that. HCG, I think, from experience, has a unique increase uh libido enhancing property that's unique to the molecule, not just the testosterone, because it's not gonna raise it that much. But uh have you had any use of uh HCG for that purpose?

SPEAKER_08 5:24

I haven't used it really for low libido solely, but I've used it in guys where let's say they don't want to be on testosterone, they want to boost their endogenous production, and so I'll use it selectively as well.

SPEAKER_00 5:33

But I've used it just for this purpose, I've gotten some really good results. Okay.

SPEAKER_08 5:36

All right, and then lastly You know, actually, let me correct myself. I have a patient that I recently put on HCG who has low libido, and he is doing phenomenally well.

SPEAKER_00 5:43

Yeah, so it can work. Yep. And then uh lastly, the cabergoline, uh, which has a central effect on the brain for increasing uh libido.

SPEAKER_08 5:52

But is used, I mean, all these medicines, well, the HCG and Cabergoline are used off label, right, in these indications. Um and you've actually you've published really like the seminal paper on using cabergoline in men who have difficulty reaching climax.

SPEAKER_05 6:04

Right.

SPEAKER_08 6:04

And I think everyone that I've spoken to, and certainly in my practice when I prescribe that medicine, I'm looking at your paper, right? Well, that's right. As like the one paper that um sort of inspires or encourages, hey, this might help.

SPEAKER_00 6:14

Right. And it has no downside.

SPEAKER_08 6:15

Right. So it's a very safe medicine. The question is whether or not it's gonna be helpful, right? And that medicine works on the dopamine pathway. And it's typically used if someone, let's say, has an enlarged pituitary lesion, right, that's causing a raised prolactin level. But you're using it even in the setting of a normal prolactin level.

SPEAKER_00 6:31

Which is the way I reported it initially. Yeah. Yeah, we didn't did not have elevated prolactins. It's just the empirical use of it does work through the dopamine modification.

SPEAKER_04 6:39

Yeah.

SPEAKER_00 6:40

Anyway, uh, so he's gonna get try it for three months, and I haven't heard yet how he's doing. My next step is to go to bromelanotide, pt141, or vileci.

SPEAKER_08 6:52

Yeah, which are just three different names for the same medication. Yeah, yeah, yeah.

SPEAKER_00 6:56

And and and uh now I've been getting the bromalanotide through my compounding pharmacy that I use, it's not mine. Yeah, but uh it does save the patient considerable amount of money because the likelihood of him getting covered with his insurance for Vileci is almost zero.

SPEAKER_08 7:12

Right, right.

SPEAKER_00 7:13

So we'll see how it works. But we were talking about the uh difference between brand versus compounded.

SPEAKER_08 7:20

Yeah.

SPEAKER_00 7:20

Well what is what do you think?

SPEAKER_08 7:22

Well, it's a very important conversation, especially in today's landscape, right? Because we have this top this conversation all the time on the GLP1 medications, right? All these compounding pharmacies versus the actual like branded product. And for PT 141, I used to offer the compounded formulation because it would save patients money. And you can titrate the medicine, which is nice. But I just didn't find that my patients were getting any benefit from it. And PT 141 or Vilece is actually FDA approved in pre-menopausal women who have hypoactive sexual desire disorder. But like you, I used to.

SPEAKER_00 7:47

You did it just get approved for post-menopausal.

SPEAKER_08 7:48

So Addy did. Addie got approved, is it approved in pre-menopausal women, just got approved in post-menopausal women up to the age of 65. Yeah. And and for this guy that actually you're describing, I would say that is one of the most challenging patients that comes into any urologist clinic.

SPEAKER_00 8:02

And one of the most distressed.

SPEAKER_08 8:03

Right. Because he's young, he's healthy, he's going through this time in his life, which is like this sexual exploration. His libido and his erectile function should be like at its prime and it's not. Right. And the labs are all normal.

SPEAKER_00 8:13

And I think the knee-jerk reaction with somebody like this is to say, it's got to be psychological. Right. But we don't know that, you know, and that's the big problem. And he's such a nice kid. Yeah. And he seems so normal to me.

SPEAKER_08 8:25

Well, he's the picture of health.

SPEAKER_00 8:26

He is.

SPEAKER_08 8:27

Yeah.

SPEAKER_00 8:27

Picture of health, good personality, obviously bright.

SPEAKER_08 8:30

Yeah.

SPEAKER_00 8:30

And things are just not working.

SPEAKER_08 8:32

Right. And the last thing we want to do is tell him that it's all in his head, but it might be in his brain, which is why some of these medicines that you're using are working on the brain. Right. So that's a kind of a subtle difference in how we explain something is brain versus mind. Right. State of mental health.

SPEAKER_00 8:45

Go going back to the brand versus compounding, what I didn't have a lot of success with the compounding.

SPEAKER_08 8:50

So I went to Vileci, which is the brand. And then what I do is when I send in the prescription, I say, you know, don't even submit a prior authorization. Patient is going to pay out of pocket. It ends up being$25 per vial. So it's about$200 for eight pence.

SPEAKER_00 9:02

Oh, that's not bad.

SPEAKER_08 9:03

So it's not that bad. No. And then they pay cash for it, and then they can see if it works. And and the medicine, honestly, is not supposed to be used any more often than eight times a month anyway. So that would be enough for a month period.

SPEAKER_00 9:12

I mean, we I don't know what that's based on how it passed. Right.

SPEAKER_08 9:15

I think the question is why is it limited to eight times a month? It can cause hyperpigmentation. So I think that's one of the reasons. But honestly, if someone wanted to use it more than eight times a month and they tolerated it fine, it's probably how bad is the nausea that comes with it? Um, it's very variable. So I've seen it hit people really strong. I think an important thing to ask someone is like, do you get nauseous? Do you get do you get nauseous easily? You know? I think that's an important question. I also offer to pre-medicate all my patients. So I'll give them an anti-nausea medicine, Zofran, for them to take about an hour before four milligrams. Yeah. Um, and I think that can help kind of take that edge off. And then it seems that like if someone has nausea with that first dose, just like with Cialis, where if someone has side effects, if you take it on repeat occasions, it might get better. I suspect that's also the case for Vileci. You know, I love getting personal on these podcasts, Larry.

SPEAKER_00 10:03

Uh-oh. Where is this going?

SPEAKER_08 10:06

So it's fun in sexual medicine because historically much of what I did was men's health. And so there were a lot of things I recommended to patients that I could never try as a woman, right? But now that I'm delving into female sexual medicine, there are therapies that I can try myself. And honestly, when I'm talking to a patient, there are a lot of different things that will dictate how I explain something to a patient. What does the research show? You know, what do my colleagues tell me? What do my patients tell me about their experience? And when I can try it, what's my experience?

SPEAKER_05 10:30

You know, what was your experience?

SPEAKER_08 10:31

Well, and I had someone post on like one of my Instagram, you know, uh as an Instagram message, because I had mentioned previously in a podcast like what my favorite vibrator is. And she made a comment, like, oh my God, I would never see someone like you. You're so unprofessional because you tell people about your favorite vibrator.

SPEAKER_00 10:46

You didn't tell me someone said that. I said it. It was me.

SPEAKER_08 10:50

But the way that I see it is like, look, I'm a sexual medicine specialist. If I don't try things that I recommend, if I can safely do it, I don't feel like I'm living up to the expectation of my job.

SPEAKER_00 10:58

So, how did you do with Cialis?

SPEAKER_08 11:00

Um, so actually, I started Cialis too.

SPEAKER_00 11:02

I was kidding. I really was kidding.

SPEAKER_08 11:05

Okay, here's the thing with Cialis, and then we'll move on to Bileisi. I love Cialis for four reasons for my patients. Okay. I love it for its erectile function, you know, concerns. And also, we talk about this all the time, performance enhancement versus like treating a pathology or a diagnosis. I have plenty of guys that come in and their erections are fine, right? And I offer them Cialis and they're sometimes they're a little bit unsure, and they might say, like a month later, next time I see them, okay, yeah, I'll try it. And they take and they come back and they say, Amy, I freaking love this medication. And I don't know exactly why they love it because I'm not treating a problem, but they do.

SPEAKER_00 11:36

And I think that's a little, this is a little bit of a controversial topic because some people would say, but you know, people are taking it for muscle enhancement for when they're as a pre-workout. Is that why you were taking it?

SPEAKER_08 11:45

So that's why I started taking it. So yeah, I use medication. I try to get my patients off a lot of their medications, but I feel very strongly about two in men, testosterone and cialis, right? Um, and so I use Cialis off-label in some guys because they the benefit is worth it, right? So I like it for the erectile function or erectile fitness benefits. I like it because I've had patients say it's great, it's a pre-workout, right? And if they can get a better pump at the gym and I'm not hurting them in the process, and then they're not taking some random pre-workout from GNC or vitamin shop that Lord knows what's in that product.

SPEAKER_00 12:12

I was really asking to hear your so how but I take it as a pre-workout. Uh, nothing else happened.

SPEAKER_08 12:18

Nothing else. No, so so it actually might help also with female sexual function because we don't we have just as much erectile tissue as men do.

SPEAKER_00 12:24

That's what I was thinking.

SPEAKER_08 12:25

I can't say that I've noticed any particular change, but it might be a subtle difference. It's hard to say. Um, I take it before I work out in the morning. I also started going to the sauna the first as soon as I walk into the gym. So between like the sauna and the Cialis, my veins are popping. Okay. Now that's a complete. Yes, you're welcome. That is a complete off-label use, right? Um, but I understand the rest of the game. Right.

SPEAKER_00 12:48

And yes.

SPEAKER_08 12:49

So, and they do fine with it. So I, yeah, so I started Cialis, but I also wanted to try the Vileci.

SPEAKER_00 12:53

Okay, back to the Vileces.

SPEAKER_08 12:54

Back to the Vileci. And I use the commercially available product, so it comes in, you know, each pen is one dose. I pre-medicated with Zofran at 1.75 milligrams. So I don't know how that dose compares to what you're using, which I think is an important question.

SPEAKER_00 13:06

Well, the other thing we're underdosing with the compound. We also don't know purity when you get stuff from the compounding pharmacies, right? Yeah. Whereas the commercial stuff, theoretically, you know, has been pre-tested and it's mass-produced. So it should all be the same.

SPEAKER_08 13:20

So when it's possible, I typically will get the commercially available product over a compounded alternative.

SPEAKER_06 13:27

Yeah.

SPEAKER_08 13:28

Unless the cost is like drastically different or it's just really difficult to get the you know, the commercially available product. Um, so I pre-medicated like an hour before with Zofran. Um, I will tell you, I did have some nausea for probably a day to a day and a half. So here's my recommendation, folks. Like, don't plan a fancy dinner if you're gonna take Vileci earlier in the day, because you might not want to eat that dinner.

SPEAKER_00 13:48

I didn't realize it lasted so long. Is that is that what that's the thing?

SPEAKER_08 13:51

It's so variable in terms of how it impacts people. You know, the instructions will say to take it 45 minutes before desired activity. And I would say I started feeling the effects of it within like that 45 minutes. And and the benefits lasted for probably a day.

SPEAKER_00 14:04

The benefits?

SPEAKER_08 14:05

The benefits. And the nausea also lasted, I'd say, that period of time as well.

SPEAKER_00 14:08

I did you have to bring in a second date, or would I do that?

SPEAKER_08 14:11

Um I no, I didn't. But I will tell you, it was a very obvious change. Now I'm coming from this from a perspective of like, I don't have a problem, I don't have a diagnosis, I wouldn't consider myself having low libido or reduce like arousal or difficulty reaching climax, but it definitely improved arousal. You know, I wasn't measuring like my clitoral blood flow. Now there's technology coming out in 2026 that will measure clitoral blood flow. So I'm curious what that would show, you know? But I can just feel that there was an obvious difference and increased sensitivity. And so, yeah, even though I don't have a problem, my sexual experience for 24 hours was better. I'm gonna be taking that medicine again.

SPEAKER_00 14:48

24 hours. Do you all hear that? 24 hours.

SPEAKER_08 14:52

I do want to be clear, this is an off-label use, but I will say I think the most important question I can ask myself and my patients when I'm treating them or offering them therapy is how can I hurt this person? And the big side effect with Vilecy is nausea. Right. So I plan for that, you know, and you can't use it in patients who have uncontrolled blood pressure.

SPEAKER_00 15:07

No, I'm not so sure we should be advocating treatment with an FDA-approved drug if the person does not have the FDA approved problem.

SPEAKER_08 15:16

Well, let's talk about testosterone therapy in your patient population. What's the difference?

SPEAKER_00 15:19

There isn't any difference. I'm just there isn't it?

SPEAKER_08 15:21

Yeah, but so testosterone is FDA approved in certain populations of people.

SPEAKER_00 15:25

Right.

SPEAKER_08 15:25

But you use it off label all the time.

SPEAKER_00 15:27

Well, we all use it off label.

SPEAKER_08 15:28

Yeah, we all use it off label. So what's the difference between that and me just wanting to have a better orgasm?

SPEAKER_00 15:32

Okay. God forbid I interfere with your orgasm. But the point is that everybody is writing testosterone off label. Consequently, I would say it's become standard of care to write it off label.

SPEAKER_04 15:45

Yeah.

SPEAKER_00 15:46

This you're using this uh as someone who doesn't have a problem is very unique.

SPEAKER_04 15:50

Yeah.

SPEAKER_00 15:50

Right? So for that reason, you can't compare. I don't think it's comparable.

SPEAKER_08 15:54

Yeah, yes. I would say it's unique, but I would say that someone like me who doesn't have a diagnosis, I don't really fit anywhere in the healthcare system. But I want to optimize my performance and performance enhancement gets such a terrible reputation.

SPEAKER_00 16:07

I think I think the the the next question is would you do it next time?

SPEAKER_08 16:12

Yeah, 100%.

SPEAKER_00 16:12

There. So you're on it now.

SPEAKER_08 16:14

I'm yeah, I will use it on occasion when I want a different experience. And it's coming from a place partner dependent? Is it partner dependent? Well, that's a really good question. Absolutely. Right? Absolutely. I think part of why I enjoyed this medicine so much is because we don't even know. You have to look at the whole biopsychosocial approach, right? If I were with a partner that wasn't fun and we weren't having, you know, great intimacy, would I have said the same thing about Vileese? Probably not, right? But when all the stars are kind of aligned, then this medicine can be incredibly beneficial.

SPEAKER_00 16:48

So you had you had known this person from before. Yeah. Because you knew that you wanted to optimize.

SPEAKER_08 16:54

Correct. Yeah. Oh, yeah, yeah. Yeah.

SPEAKER_00 16:55

So it's not a first date drug.

SPEAKER_08 16:56

It was not a first date drug. But I think there's value in understanding the role of pharmaceuticals in performance enhancement coming from a place of abundancy rather than from a place of deficiency. I don't want to wait until I have a problem.

SPEAKER_00 17:09

Right. Yeah, but I think also one thing you said that I think is very important is if I prescribe this, is there a downside? Right. And there wasn't.

SPEAKER_08 17:16

Right. So and just think about all the medicines that we use now. A lot of them are FDA approved and we use them off label. A lot of them are not FDA approved and probably will never be FDA approved. And people use them off label.

SPEAKER_00 17:28

In that group, which we'll talk about in the next podcast. Exactly.

SPEAKER_08 17:32

Now I will say, I do think there's a role for Vileci in the male population. And I've had some patients, this is like the most difficult patient population for us to treat. I've had patients say that Vilece is helpful for them to reach climax. I've seen the um improved sensitivity of the penis in this patient population. So I think it's a great thing to try, but it isn't injectable. And some young people that are in, let's say 20 years old, might be hesitant to use it. Well, he's already doing HCG.

SPEAKER_00 17:57

I mean, he's not gonna have any problem.

SPEAKER_08 17:59

And this medicine is non-hormonal, right? So I'm not worried about its implications for fertility. And it works on the brain.

SPEAKER_00 18:05

Is it a peptide? I think it's a peptide, isn't it?

SPEAKER_08 18:08

So I think you're onto something.

SPEAKER_00 18:09

So this is what we're gonna do next with this young guy, and we're offering the but I'll get him brand. Because he he can afford the two, four of them for 200.

SPEAKER_08 18:16

Yeah. Eight for 200. Eight for two hundred. Yeah. Yeah.

SPEAKER_00 18:19

But we solved his problem and yours. It didn't exist. We solved the problem where there was no. I know, but here's the thing with like low.

SPEAKER_08 18:28

Here's the thing with like low libido or difficulty reaching climax. There's no standard deviation. There's no standard definition.

SPEAKER_05 18:34

Right.

SPEAKER_08 18:34

Right? So, I mean, if I could just say like I have my libido is lower than I want it to be, okay. Well then I'd qualify.

SPEAKER_00 18:42

Right.

SPEAKER_08 18:42

Right?

SPEAKER_00 18:43

Right, but it's not. But but that's okay. I don't want you to feel picked upon or something.

SPEAKER_08 18:49

The one thing I do want to add though, you're so welcome. The one thing I do want to add in terms of what I've seen Vileci do in some men is cause a prolonged erection.

SPEAKER_00 18:58

Yes, me too. I've seen that as well.

SPEAKER_08 19:00

Now, we worry about that in medications like Trimix, where it causes an ischemic event, which can worsen erectile function over time. It doesn't seem that this prolonged erection from PT141 is the same mechanism. It's not ischemic, right? But I did have a guy in his 70s do a Vileci injection the next day he's playing golf with a boner all day. So he was like, that's not ideal. So it can be uncomfortable. It's a not helpful game. So it can be uncomfortable because the erection's not going away, but it doesn't appear to have the same risk or danger.

SPEAKER_00 19:26

So what is the mechanism of increased blood flow?

SPEAKER_08 19:29

I think it's just a high flow state where there's just like so much like arousal and blood going to the penis.

SPEAKER_00 19:34

Yeah. Yeah. So would it do that in somebody who had a problem? So what happens if you give that to somebody who shows that he has arterial insufficiency or even a venous leak that begs increased arterial flow to overcome it? Yeah. What happens if you give them Vileces?

SPEAKER_08 19:49

Well, I started using Vileci for men with ED. And it can work amazingly well. In fact, it can work. So for guys who, let's say, are on penile injection medications, we know that, you know, ICI or penal injection medications like Trimex are the most effective medicine we have to treat erectile dysfunction, but it also stops working after a period of time in a lot of guys, right? So there's like one case.

SPEAKER_00 20:08

It stops working because they're getting worse. It's not getting, it's you don't get tachyphylaxis.

SPEAKER_08 20:12

Right, right, right. Or they develop scar tissue. Whatever.

SPEAKER_00 20:14

Yeah, but it's not because the drug is weird.

SPEAKER_08 20:15

Right, right, right. But a lot of those guys develop scar tissue in their penis, right? And so I had a guy where that medicine wasn't working well anymore for him. I put him on PT1 or the Vileci, he no longer has to do the penile injections. The Vileci works great for him.

SPEAKER_00 20:25

The one problem that I have prescribing it is telling the man when to take it. Because we know about Trimix, it's almost instantaneous. Yeah. We know about Viagra.

SPEAKER_04 20:36

Yeah.

SPEAKER_00 20:36

But when you get to this medicine, sometimes it doesn't work till the next day. Yeah. I've seen that.

SPEAKER_08 20:41

Yeah. So then how I mean You just haven't played around with it.

SPEAKER_00 20:44

Yeah.

SPEAKER_08 20:44

You know? And you know it being the Vile. The Vilece. Because I've had like one patient say immediately as soon as he did the injection, he felt like this whole body response. I felt like a tingling in my leg, like, you know, very shortly after I did the injection. But yeah, some people it impacts on the day after. So it's, I would say don't plan anything super important, you know, one or two days after you're giving yourself an injection.

SPEAKER_06 21:04

Right.

SPEAKER_08 21:04

But that I want to tell you about a patient that I recently saw, because it's it's kind of similar uh to this topic. So he's 87 years old. He's one of my favorite patients of all time, a good friend. And he sees me for a low testosterone and erectile dysfunction.

SPEAKER_00 21:14

He didn't ask you out, did he?

SPEAKER_08 21:16

He did not ask me out.

unknown 21:16

No, no, no.

SPEAKER_08 21:18

And he's currently going through like a separation with his partner, but he is currently having sex with two women, two younger women.

SPEAKER_00 21:24

At the same time.

SPEAKER_08 21:24

And not at the same, like not at the same, like not in the same location. Okay. And um, and his erections are great with these uh two women. And he tells me, he specifically says, Amy, ED is not just about testosterone and medications, right? It also is like who your partner is. And he's loving this new chapter in his life, which begs the question how much of ED is partner related? Right. Right, is the psychosocial aspect. It's there for sure for sure, you know.

SPEAKER_00 21:50

And especially with long term married couples.

SPEAKER_08 21:52

Right. It's like the monotony of heterosexual monogamy, right? And that's why I'm big on helping my patients explore and be curious on how. To make their relationships and intimacy life uh much more fun, right? Because people get bored.

SPEAKER_00 22:05

Have you ever brought that up to a man that maybe it's just the fact that you're no longer attracted to your partner?

SPEAKER_08 22:12

Um I mean, you know, oftentimes I'll send them to a sex therapist, you know, but I will ask patients, like, tell me about your relationship with your partner. And there are some guys that like their faces just light up with joy, and they're like, my wife is so amazing, and I can tell their intimacy is awesome. And then I have other patients who will sit down with me. And then I have other patients that talk about their partners in a way where I question why are they still together? Yeah. You know, I mean, I had one patient that was like, This is a person complaining of ED? Of ED, yeah. I mean, I have another patient that, you know, that I see for ED. He also has a history of prostate cancer and had that treated with focal therapy. And he talks about how his wife is a narcissist and they have a terrible relationship and they're always fighting and she doesn't want to have sex. And I actually had I actually had him use a tech ring, which is a wearable device where he can track his erectile function, right? And it showed that he was getting great erectile function at nighttime. While I think that was while he was asleep.

SPEAKER_00 23:11

So there you go.

SPEAKER_08 23:12

And that was very helpful for him to understand that his plumbing is working, but the psychosocial aspect of his relationship is killing his boner, right? And that's where you get into the biopsychosocial approach where we can't just hand out Cials and Viagra like candy and not address the other aspects, right? And yes, oftentimes it is diabetes and heart disease and medications that's causing the ED. But if a person, whether you know, whatever gender they are, if they don't have a good relationship with their partner, or if the sex isn't worth wanting, right, then why would they want it and why would they function the way that they want to find it?

SPEAKER_00 23:42

Well, then why would he come in and complain about ED? In other words, if this is not something I mean he wants or something that's gonna make him happy.

SPEAKER_08 23:50

Well, he wants to have sex with his wife. Right. He wants to have sex. Yes. Yes, he wants to have sex. Yeah. So it's challenging. Some you know, oftentimes we can't fix everything for our patients. I know.

SPEAKER_00 23:59

And uh, it's harder for you than it would be for me.

SPEAKER_08 24:02

Oh, why do you say that? I don't know.

SPEAKER_00 24:03

I would think for me to say, I mean, I have said to people, yeah, you know, come on now. I mean, you know, what are we talking about? You obviously don't want to have sex with your wife.

SPEAKER_08 24:11

Yeah.

SPEAKER_00 24:11

I mean, I've said it.

SPEAKER_08 24:12

I mean, I've said it too.

SPEAKER_00 24:13

Oh, I thought you were kind of like dancing around because it depends on the situation.

SPEAKER_08 24:16

Like, I specifically had this guy that I was telling you about ask me, should I get a divorce from my wife?

SPEAKER_06 24:22

Yeah.

SPEAKER_08 24:22

And so I said, and I'm definitely not a therapist, but I said, based on what you're telling me, it seems like that's what you need to do. And he was like, Whoa, I've never had a doctor tell me I should actually get a divorce. And I'm like, but I think you should also see a therapist about it.

SPEAKER_06 24:34

Yeah.

SPEAKER_08 24:34

Yeah. But sometimes sometimes the answer is you need a new partner.

SPEAKER_00 24:38

Yeah.

SPEAKER_08 24:38

Hey, I said it. Yeah.

SPEAKER_00 24:40

And you will not be punished.

SPEAKER_08 24:43

All right. So why don't we get in some breaking, some breaking bedside news there?

SPEAKER_00 24:47

Okay, breaking bedside news.

SPEAKER_08 24:48

And it's not really, um, maybe it's not breaking bedside news because you were going to talk about a paper from like 10 years ago that you published.

SPEAKER_00 24:54

No, I was going to bring that in. I really want to start off with this other thing. Okay. Because I thought it was so fascinating. Okay. So this is an article that I found uh in one of my most prestigious journals, Men's Health. Because they'll go while no one else will go, right? So this is entitled Health Secretary Robert F. Kennedy Jr.'s previous go-to scapegoat for autism was vaccine. Now it's Tylenol and circumcision. Circumcision.

SPEAKER_08 25:23

As if circumcisions weren't polarizing enough to discuss.

SPEAKER_00 25:27

In a cabinet meeting, Kennedy, who is neither a medical doctor nor an autism researcher. Now I'm reading this. I don't necessarily use this. Reignited a controversial, long-debunked claim that boys who undergo circumcision are twice as likely to be later diagnosed with autism as those with intact penises. And I thought, oh, come on, this is just men's health poking fun at Kennedy or something. And then I went to open evidence, which is indeed a very well-respected online source of information, because they pull only from New England Journal and JAM, right? And it starts out, I didn't, I thought it was going to say, oh, this is crazy. We won't answer. And it says, bold face, current evidence suggests a possible association between circumcision and autism risk in boys.

SPEAKER_08 26:15

Yeah.

SPEAKER_00 26:15

And then it says, but causality is unproven. Right.

SPEAKER_08 26:18

Well, that's a key.

SPEAKER_00 26:19

But then it goes on.

SPEAKER_08 26:20

Okay.

unknown 26:20

No.

SPEAKER_00 26:21

A large Danish cohort study of over 300,000 boys found that those who underwent ritual circumcision had an increased risk of developing autism spectrum disorder before age 10 with a hazard ratio of 1.46. With particularly elevated risk for infantile autism before age 5, hazard ratio 2.0. So they then go on to say, yes, but we can't roll out the fact that these were people higher socioeconomic group who had the circumcisions or who had more previous uh relationship with healthcare so that um they would see maybe the autist autism symptoms and bring them in faster. So so again, you know, causality is unproven. But I just thought it was so interesting to me when I was all ready to debunk it and then found open evidence is uh uh going there. Now, when I was reading this article, they were talking about, you know, the impact of genitourinary malformations um with autism. Uh and then they went to studies examining biomarkers of prenatal androgen exposure, such as anogenital distance, have not found consistent relationships. Which brings us to Which brings us to, and then I thought, my God, you know, we wrote an article that was I thought was I went back and read it and it was really interesting. So anogenital distance.

SPEAKER_08 27:43

Well, anyway, first of all, no, wait, wait.

SPEAKER_00 27:46

Do you have any comment on the Kennedy autism? And then they go into the fact that these boys may have had more Tylenol.

SPEAKER_08 27:52

Yeah. Because they had Tylenol like for their circumcision procedure. Yeah. Um, I think it's clickbait. Um, although people are gonna be concerned right after they hear this information because circumcision already is a very polarizing topic for some people.

SPEAKER_00 28:06

Why is it so polarizing?

SPEAKER_08 28:08

Why is it so polarizing? Because it doesn't give that person bodily bodily autonomy to decide what they want with their genitals. That newborns, you know? Yeah, newborns. Um and then you think about it too, and we talk about well, it's helpful to reduce the risk of sexually transmitted infections, and yet much of that research is in developing countries. So can you say that that same benefit is helpful or is relevant for people in the United States, which is a developed country? You know what I'm saying? So I don't know that we can say that the benefit is true for all people. Right, you know, and also a lot of boys are not taught appropriate penile hygiene. I think that's an underlying issue as well.

SPEAKER_00 28:42

So it'd be better if those boys were circumcised.

SPEAKER_08 28:46

Well, it would be better if we taught young boys appropriate penile hygiene and you know, had the sexual health conversations with them on all the ways to reduce risk for SD.

SPEAKER_00 28:55

We've had discussions, you and I, about lack of education of young boys and men in school. I mean, then no one knows what to do about STD prevention and or birth control prevention, whatever.

SPEAKER_08 29:06

Yeah. But the big concern is that there's concern that if someone is circumcised, it's going to reduce their penal sensitivity, right? And you think about the patient that you just described where he's reporting some reduced penal sensitivity. Can you blame it on being previously circumcised? I'm not sure if he was circumcised or uncircumcised. He was circumcised. Yeah, yeah. Um, so I think it's challenging, but it talks about the association, not causality. There are so many factors that are compounding in this situation that we are not accounting for in this database.

SPEAKER_00 29:33

You think? Just thought I'd bring it up. Anyway, yeah, in closing, uh, we talked about the andogenital distance measuring to assess the degree of uh exposure prenatally to estrogens or androgens, because the longer the distance, the more masculinizing that individual is.

SPEAKER_08 29:53

Uh but describe what that measurement is.

SPEAKER_00 29:55

Okay. You don't, I know you think there's and I had a diagram. I didn't bring my diagram. So it's measuring the distance between the anal verge, the top of the anus, and the beginning of the scrotum. It's not a complicated so we did a study when Mike Eisenberg, who's now at Stanford, was with me, and which we measured this in uh, I think 150 men coming in with infertility versus controls, right? Appropriate number of controls. And we found out that the longer the distance, the higher the semen quality, the more effective the androgens, the more masculinized. As you cut back, each sonometer closer to the rectum dropped the sperm density by four million.

SPEAKER_04 30:37

Wow.

SPEAKER_00 30:37

I know. And I read that, I I thought that was really very, very interesting. Because we don't do it anymore, we don't think about it anymore.

SPEAKER_08 30:44

But you need to, I I have a Could that be like a poor man's test for fertility?

SPEAKER_00 30:48

I don't know. Maybe we didn't do it prospectively to look.

SPEAKER_08 30:53

Yeah. But you had these guys, like, how did you have to position them to measure this distance?

SPEAKER_00 30:57

That's an interesting question. They have to be frog-legged. But weren't you going to share you you thought that that was an unusual.

SPEAKER_08 31:03

Yeah, you were telling me about this paper earlier.

SPEAKER_00 31:06

It brought to mind one of your personal.

SPEAKER_08 31:11

I recently got my first Brazilian one axe, and it reminded me of the kind of position you have to be in to have that type of exam.

SPEAKER_00 31:19

Yes, but that must be so embarrassing. But you you voluntarily went to the example. You know what?

SPEAKER_08 31:23

It actually was not embarrassing at all. Because I think it's the same thing when a guy comes in to see someone like you, they know why they're there. They've mentally prepared themselves, you know. So I went into that visit. I was mentally prepared to be brutalized, you know.

SPEAKER_09 31:36

I finished that and I was like, that is the most painful thing I have ever done in my life.

SPEAKER_00 31:42

Would you go back?

SPEAKER_09 31:43

I would go back.

SPEAKER_00 31:46

All right, so we've we've settled the Kennedy thing. And you guys out there who are not circumcised, hey, your choice. It's not gonna hurt you.

SPEAKER_08 31:54

All right, so let's get into today's episode, shall we?

SPEAKER_00 31:56

Yes, please.

SPEAKER_08 31:57

All right, welcome to today's episode. I am thrilled to introduce our remarkable guest today, Dr. Michelle Perlman.

SPEAKER_00 32:04

Dr. Perlman is a board-certified physician in internal medicine, gastroenterology, and obesity medicine with a clinical focus on metabolic health, nutrition, and the gut microbiome. She completed her medical training at Wake Forest, University of California, San Diego, and University of Texas Southwestern, and then went on to direct the Medical Weight Management Program at the University of Miami.

SPEAKER_08 32:30

She's widely known for her ability to translate complex science into practical, evidence-based strategies patients can actually implement. And full disclosure, she also happens to be my twin sister, which makes today's conversation even more fun and meaningful. Michelle, thank you so much for joining us today. Michelle's my sister. Larry, you know that. I know that. Yeah.

SPEAKER_00 32:51

I would have never guessed it looking at you. You would have never guessed it.

SPEAKER_08 32:53

We actually wore matching dresses today as well.

SPEAKER_00 32:55

Oh my god, I didn't even notice.

SPEAKER_08 32:58

So Michelle traveled with me to Houston to spend some time with you, Larry. And I'm so glad, Michelle, that you're joining us today because you are the guru of nutrition as a gastroenterologist. How the heck did you get into nutrition as a gastro?

SPEAKER_07 33:11

Um, I think, you know, one of the reasons why I went into gastroneurology was because I was always fascinated by nutrition, as you know. And I thought I would be able to learn a lot more about it from the science aspect of it. Um, what I realized soon into my fellowship training was as gastroenterologists, just like as a urologist, you're trained as a surgeon, I'm trained as a proceduralist, we are learning about disease and not about optimizing health. I learned how to do endoscopies, colonoscopies, and make diagnoses, not actually learn about nutrition. So it wasn't actually into like my 13th year of medical training, in my third year of fellowship training where I learned the nuances of nutrition. And it wasn't even within the gastroenterology fellowship program. It was with uh, Larry, you mentioned, you know, endocrinologists can sometimes be a challenging specialty to deal with when we have conflicting recommendations. It was actually by an endocrinologist who started the medical weight management program at UT Southwestern. So interesting. I I would say not all endocrinologists practice the same way. Right. This one in particular changed the trajectory of my career.

SPEAKER_00 34:11

But we're also in a completely different space with you than we were in our other uh previous discussions.

SPEAKER_08 34:16

Yeah, well, we've spoken before about testosterone, and I've had patients say, Well, who's the best specialist to see? An endocrinologist, a urologist, a primary care, a functional medicine specialist, all of them and yet none of them. Somebody who has expertise and interest in managing low testosterone. And I'd probably say that's the same thing for what nutrition? Who's the best person to see? Someone who can sit down with you and have a nuanced discussion. So, what did you learn from the endocrinologist?

SPEAKER_07 34:38

Well, he had he, so he worked with a dietitian, but he also got somewhat into the weeds when it came to nutrition. But he had very comprehensive visits. So it wasn't people coming in saying, give me the jab, right? It was people who really wanted to understand how they could lose weight, but more importantly, maintain their weight loss. So he had a very comprehensive approach, which really didn't have anything to do with his specialty. It was the way that he built that comprehensive weight management program. But I learned that it's all, it's, it's, you know, obviously nutrition is key, but it's all these other things, like Mo was talking about. It has to do with sleep, stress management, obviously, nutrition and exercise, and nutrition is just part of that equation, but a very significant one.

SPEAKER_08 35:16

So, what does a typical visit look like when someone is coming to see you for a nutrition consultation? What kinds of questions do you ask them? Is it enough to say I have a question? Okay, yeah, yeah.

SPEAKER_00 35:24

Do people come to you for a nutrition consultation or do they come to you because they're trying to lose weight or gain weight?

SPEAKER_07 35:31

So all the above, actually.

SPEAKER_00 35:32

But what is the most common person walks in the door while you're there, Mrs. Smith, Mr. Smith? What do they say?

SPEAKER_07 35:38

Well, it's evolved. Initially, when I started, I was, you know, really focusing on weight management. So patients knew that I had expertise in GLP1 therapy. And so they would come to me specifically because they had already, you know, failed more of the conservative measures and they were interested in talking about uh pharmacotherapy. So that was how my practice was initially. Um, but I am a gastroenterologist and I do understand digestion and absorption and a lot of gastrointestinal symptoms that people on or off these GLP1s experience. So I also kind of morphed some of my practice into just optimizing gut health. I have a couple patients, it's definitely few and far between, more so athletes who want to gain weight. So that is a subset of my practice. And then more recently over the past year, it's actually, you know, patients, you know, middle-aged women who are maybe normal weight by all intents and purposes, normal BMIs, they notice changes in their bodies, uh, body composition changes where they have more visceral fat, and now all of a sudden they're pre-diabetic. They don't need to lose 20 pounds. They may want to lose five or 10, but they want to optimize their health. And so we talk about hormones and we can kind of go into how that part of my practice evolved. But it's all the above, but I would say the majority are trying to lose weight.

SPEAKER_06 36:46

Yeah.

SPEAKER_08 36:46

And it's really interesting because I think the two of you see probably very similar patients, right? They don't have a diagnosis, but they want to know how can I eat or work out or optimize my hormones so that when I'm 70 or 80 years old, I'm thriving, but they don't necessarily have a diagnosis. So talk a little bit when you're having, let's say, this comprehensive discussion with someone who let's say wants to lose weight. How do you ask them about what they're eating? Because so often, what do we do when we see someone in clinic? We say, uh, how's your diet? You know, what do you eat? And what do they tell us? Oh, I eat pretty healthy. And then we check the box and we move on. Is that sufficient?

SPEAKER_00 37:18

No.

SPEAKER_07 37:20

Well, it's interesting. I think most healthcare providers would argue that nutrition is an important part of the conversation, right? But if you don't have the expertise, just like testosterone, you oftentimes don't want to open that Pandora's box because you may not have the answers for that person. It also requires a lot of time. Now, you and I are very fortunate, Prime Institute, to have the luxury of time. My conversations range anywhere from an hour and a half to two and a half hours. And I'm really talking about the foundation, lifestyle medicine, as we call it, which is really the foundation for all health and prevention of disease. Um, so it just depends on the person. But yeah, I go into the details and I apologize to my patients. I say, I'm gonna ask really nitpicky questions, and it is totally fine if you don't know the answer. So I say, take me through a typical day on what that looks like for you. So when are you getting up? When are you having your first meal? If you're having coffee, how much coffee? If you say a cup, I want to know how large is that cup. What are you adding to the coffee? If you're adding Fair Life milk, are you doing the chocolate milk? Are you doing the plain? Are you doing the 0% or the 2%? Are you adding sweeteners? What do those sweeteners look like? Are we talking about stevia, aspartines, you bow. Thank you very much.

SPEAKER_00 38:26

I'm out of here.

SPEAKER_07 38:30

You know, so for your breakfast, if you tell me you go to Starbucks, okay, are you getting those egg bites and what are in the egg bites? Um so it's really the devil is in the details when it comes to really all aspects of health, but specifically with nutrition. So I go over their meals, I go over their snacks, but what I've learned is that what is equally as important as what we eat is how we eat, how fast we eat, how much we eat, how we feel when we're eating. Um, are we swallowing a ton of air when we're eating, how late we're eating, like all of these factors. What is equally as important is that is what we eat is the dietary habits, which I think we often ignore. Yeah.

SPEAKER_00 39:04

My primary care, you know, I I paid for this, what is it called? Uh concierge medicine, which they offered at Baylor. And I figured, you know, I really should do it because it's Baylor and it's our institution. So he said, Well, you know, after the regular, you know, things you would expect. He said, Well, I'm gonna have you meet with our dietitian and go over your diet. So I went to another room and this lady came in, a white coat, a little white table. She sat down, she said, Well, here are the healthy snacks I'm gonna give you. That was it. She didn't ask me anything. Yeah. She just gave me these healthy snacks. What kind of snaps? Which I think included skinny pop.

SPEAKER_07 39:35

Seriously, they were probably unhealthy snacks. And I think registered dietitians have a really important role, but if it doesn't come from the healthcare provider like the doctor, then I think oftentimes patients aren't necessarily gonna buy into it, right? So, like I saw a patient recently who pays probably four or five thousand dollars for an annual executive health visit. And this guy has pre-diabetes and other chronic conditions. And in the letter that he got at the end of the visit, it said, start a healthful diet.

SPEAKER_00 40:00

Oh, that's and go see Michelle.

SPEAKER_07 40:04

No, he didn't refer the patient to me. But I'm just like, well, a healthful diet, people may think that's skinny pocket.

SPEAKER_00 40:10

Yeah, they just changed the pyramid, right? The new pyramid.

SPEAKER_07 40:12

Yeah. So everyone has a different perception on what healthy is. You can all do better, including myself. But really, the devil's in the details when it comes to nutrition. And that's Well, let me ask you, why is the devil in the details?

SPEAKER_08 40:23

Because a lot of people say I'm eating healthy and I'm not reaching my goals. What are we missing? What is the most important thing though? Is it macros? Well, it's interesting. That's what I thought.

SPEAKER_07 40:32

It's a combination of things. So I think it starts with okay, what is the person's goal, right? Because the recommendations are gonna change whether someone wants to maintain their weight, gain weight, or lose weight. Um, it depends on what their chronic conditions are. If they have diabetes, my recommendations are probably gonna be slightly different from someone who is an endurance athlete who probably needs more simple sugars, okay? Um, but when it comes to macros, I think part of the problem is we get with obviously the digital age, we get so much information online. And there's a lot of influencers or self-made nutritionists who have actually no formal training. And a lot of people in the gym who say, you know, this is what I look like. Follow my diet and follow my macros, and you'll have a six-pack like me. Their full-time job is being in the gym, right? Um, so it really just depends. Macros, well, what are macros? Okay, are macronutrients, right? So fat, protein, carbohydrates. Um, but what we've learned is that there actually is no magical macro ratio.

SPEAKER_08 41:25

You heard it, folks. There is no magical macro ratio.

SPEAKER_00 41:28

And I thought, wait, wait, wait, wait. So what I thought that was the whole thing of the food triangle was it tells you what percentages, right?

SPEAKER_07 41:35

Yeah, so they tell you like how many servings of certain foods. Is that what it says?

SPEAKER_00 41:38

I mean, can you tell the audience and me what this food triangle is that they've just changed? Well food pyramid.

SPEAKER_07 41:45

Yeah, it's saying obviously. And what was it?

SPEAKER_00 41:47

What was it when we were younger?

SPEAKER_07 41:48

Oh, when we were younger, I remember looking at that food pyramid on every cereal box. It's telling us to have six to eleven servings of like whole grains, like breads and pastas per day. So I can't blame my patient if for every meal they're having a sandwich, like potatoes, pasta, because that's literally what we told them. But I think we have to go back and say, well, who funded this, right? It's agriculture, and there's a lot of money obviously in food. And you know, is that true?

SPEAKER_00 42:12

Was it funded by agriculture?

SPEAKER_07 42:13

Oh, 100%. Yeah, yeah. The the USDA and and just our government, right? That's they're all these subsidies and everything for corn and soy, and it's all pushing all out of these carbs. Um, so so that was part of it. It was actually not based on evidence on any evidence. But if you look at the diet trials, it doesn't matter if you're low carb, if you're keto, if you're more Adkins style, as long as you are calorically restricting. So if you're burning more than you're taking in, um, calories do matter. It doesn't necessarily matter if someone's trying to lose weight, if they eat 100 grams of carbs versus 200, you don't see actually a big difference in in weight loss. Now, obviously, we're going to talk about the importance of protein. So protein does matter, but I think people focus way too much. I mentioned the devils in the details. People sometimes put too much into counting macros and then stress themselves about that.

unknown 43:01

Yeah.

SPEAKER_08 43:01

So when someone is doing their dietary recall and walking you through a day of what they're putting in their mouths, what triggers like, oh, I need to address that? That might be problematic.

SPEAKER_07 43:12

Well, it just depends on what they're telling me. If they're saying that they crave a lot of sugar, then obviously I'm really honing in on where are those little bits and pieces of sugar that they're getting in that I know are triggering more cravings for sugar. Oftentimes we say, okay, if I have a piece of candy, that will get rid of the craving. The reality is food manufacturers are much smarter than we are. They spend millions upon millions of dollars to create concoctions and chemicals to put in our food to drive more hunger and cravings. So Larry, you've heard of that really true. Oh, yeah, you've heard of like natural flavors. Like what? Natural flavors. Natural flavors contain upwards of 50 to 100 chemical compounds that are created to drive more hunger and cravings.

SPEAKER_08 43:51

But it just shows up as natural flavors, and anything that has natural in front of it sounds awesome.

SPEAKER_00 43:56

So, you know, what what makes me want to eat? Like, give me an example of Something that would trigger hunger.

SPEAKER_07 44:02

So anything that's highly processed, right? Because they're adding chemicals that stimulate certain neurotransmitters in our brain that want us wanting more. So for instance, high fructose corn syrup, right? If we have like a Snickers bar, it may satisfy us in the short term, but it may be triggering us to then crave ice cream at 10 o'clock at night. So it's high fructose corn syrup or anything that's like highly processed and with natural flavors and other sorts of ingredients. So that's a big thing, right?

SPEAKER_08 44:23

And it's crazy because some of these ingredient labels will have like five ingredients. So it looks like it's not an ultra-processed food. But if one of those ingredients is natural flavors, that could be 55 ingredients.

SPEAKER_00 44:33

So this is like a bu a buzzword for you better watch out whenever you see.

SPEAKER_07 44:37

You better watch out. You better not cry. So these are proprietary blends that no manufacturer will actually disclose what's in it. Um it's interesting that finally people are talking more and more about it. So yes, macros are important, calories are important, but ingredients are actually what I look at the most because if someone's putting in artificial sweeteners in their coffee, that's not driving.

SPEAKER_00 44:57

So should I, as a consumer, be looking at ingredients? Yes. And if the answer is yes, how do I know without going to someone like you what I should be looking for? I don't know intuitively.

SPEAKER_07 45:07

Yeah, we can make it as simple or as complex as we want it. Oftentimes the ingredients label is written so small in like four, four-point font that most people can't even read it. Okay. It starts pretty simple. Um, you look at an item and you say, Can I identify, can I identify where this product came from? That's simple. I don't even need you to look at the ingredients list. If you look at a slice of bologna, Larry, where did that baloney come from?

SPEAKER_00 45:29

I don't understand from. I mean, what manufacturing. What's in it? What's in it?

SPEAKER_07 45:33

Yeah. What is it? I have no idea. It's the odds and ends of I don't even know.

SPEAKER_00 45:36

Is that what I was gonna say? These are made from the odds and ends of who knows what.

SPEAKER_07 45:39

No, but that's that's why you don't even need to look at the ingredients list. If you can't figure out what components it came from, it's highly processed, right? So for instance, like these roasted edamame that my sister and I absolutely adore. If I were to open this package, they're literally soybeans. I know they're soybeans. I don't need to look at the ingredients label to tell me the components of that food.

SPEAKER_00 45:58

So edamame are soy.

SPEAKER_07 46:01

Yeah, soybeans. Okay. Versus Cheez-Its. If I were to be favorites.

SPEAKER_00 46:05

How did you need to?

SPEAKER_07 46:07

So we took it for your snack bag. So this is where the numbers matter and maybe don't matter so much, right? This package of edamame has 100 calories. The cheese-its have 140. So if I were only focused on calorie counting, they would actually be pretty similar. Okay. Where do the numbers start to matter? Well, I want to know what they're made of. What are the components? So if I'm looking at fat, they're pretty similar. Four grams of fat, seven grams of fat. But I'm looking at protein. So protein is the only macronutrient our body needs to survive. Now, Larry, we can survive without carbs and we can survive without fat. We tend to not be happy when that's the case. But we can survive without those macronutrients. Without protein, we do not survive. The edamame gets you 11 grams of protein. The cheese-its get you three grams of protein. So that's a big difference. Less calories, more protein. Yeah. And less fat. Exactly. When it comes to fiber, so I'm a gastroenterologist. Fiber is very important for the gut microbiome.

SPEAKER_00 46:58

But is that true? Because I've heard all these debates about fiber.

SPEAKER_07 47:01

Are you following like keto people on Instagram? I'm not following anybody. So fiber is very important. We have so much data to support that. These little edamame beans have four grams of fiber. This has less than one. So these are critical differences.

SPEAKER_00 47:17

But the Cheez Its taste great. These are bland.

SPEAKER_07 47:21

Have you tried them?

SPEAKER_00 47:21

Yes.

SPEAKER_07 47:22

I don't know because these are roasted when they have sea salt on them.

SPEAKER_00 47:24

Do they have sea salt on them?

SPEAKER_07 47:25

Oh yeah, oh yeah. So maybe you may have tried like a different brand. And then when I look at the ingredients list, okay, so I've already this one is clearly winning here. If I look at the ingredients list, it has sea salt and soybeans. Two ingredients. If I look at the Cheez-Its, it has enriched flour, vegetable oil, soybean, palm, and or canola oil, cheese made with skim milk, salt, paprika, yeast, paprika extract color, soy less of them. It's a lot more ingredients.

SPEAKER_00 47:53

It's not bad though. It's not there was no, I didn't see it.

SPEAKER_08 47:55

What is it?

SPEAKER_00 47:56

There was not food color in it.

SPEAKER_08 47:57

It is a cheese-it. And what nutrients are you actually getting out of the cheese-it?

SPEAKER_07 48:02

Exactly. So when you look at the nutrients, 0% vitamin D, 2% calcium, very little iron, no potassium, versus this one, you're getting um much higher percentages of iron and calcium and potassium. So it's you get more bang for your buck, long story short. Okay, so you don't have to have extensive knowledge or 13 years you know worth of medical training to know the little nuances which are.

SPEAKER_00 48:25

Okay, but I've got to get back to this very important thing, which we're glossing over. Yes. And that is in general, to me, healthy food does not taste as good as unhealthy food. And that is that learned? Is that I mean, obviously that's how they make it. Yeah. They make it so you want to eat it. Correct. So, you know, if you're gonna tell me to eat edamame, at least make it taste good. If you're gonna tell me not to eat Cheese Its, give me a substitute that tastes good, right? That's got the same crackling, crunchy, snack-like, you know, that we've grown up with. So what do I take?

SPEAKER_08 48:59

I don't I think you should try an edamame. Yeah. I've tried them.

SPEAKER_00 49:02

No, they're fine. I'm just pulling your leg a little bit. But I'm not on the taste. Yeah. I think that I think it's great to look at all these things, but people are gonna follow it if it tastes good. That's gonna make a big difference.

SPEAKER_07 49:14

I agree.

SPEAKER_00 49:15

So what so what would you recommend to someone who you don't want them to eat Cheez Its, but they can eat what?

SPEAKER_07 49:21

But you can always make your own. So for instance, like I'm not gonna tell someone, um, I'm not gonna tell someone to not have french fries, right? Well, I will. I will tell someone not have french fries. But if they wanted to have french fries, then you could make your own french fries at home. You just cut up some potatoes, you soak them in water, you get rid of some of the superficial starch. So the more that we can make our own food, the better. Um and that way you're in control over the ingredients and you can make it tasty. It's just all these mass-manufactured products have a lot of areas.

SPEAKER_00 49:48

So there is nothing that I can go to that to buy that's going to be comparable to Cheez Its or any of the I'm not sure.

SPEAKER_09 49:55

You can tell he really loves Cheez Its.

SPEAKER_00 49:57

I don't. I'm using it as an example of I just think it's easier to say to somebody, I don't want you eating these Cheez Its. It's okay to eat these uh roast this uh roasted beets or whatever. You know what I'm saying? I mean, what would give, and you know what people what makes them uh taste good and satisfies people's cravings. Yeah. So you know if you have that crazy craving for salty, crunchy snack, I I want a healthy snack.

SPEAKER_07 50:24

Yeah, I mean that's pretty easy. You can do like sea salt almonds, right? So if you're looking for crunchy and savory, like the edamame, you can do roasted chickpeas, you can do roasted nuts, like there are options. Now, obviously, people need to play around with it, right? But the problem is we're groomed starting from when we're babies, when we're infants. Because when we cry and we're upset or something like we're um acting in a in a kind of weird way, what do we do? We're soothed with like juice and sweets. And so that's how juice is high.

SPEAKER_08 50:54

Well, it's like juicy juice. We grew up on juicy juice. Wait, wait, wait.

SPEAKER_00 50:57

So juice is off the table.

SPEAKER_07 50:58

Well, it's it's high fructose corn, you know, it's high fructose. But even the Natalie's orange juice. So I actually saw a patient yesterday who said I have this waiting at my office. So I looked at the nutrition label and it had 36 grams of sugar. That is comparable to having three oranges, but you're extracting all the fiber. Larry, would you ever eat three oranges in one sitting within like a 10-minute period? No. So why is it normal to consume the sugar that's in three oranges?

SPEAKER_00 51:22

But I would I would not eat the oranges only because it's takes time and you know. And I like eating the skin. Yeah. When I eat oranges juice.

SPEAKER_07 51:28

Well, and that has the fiber. So with these juices, you're getting like three times the amount of sugar.

SPEAKER_00 51:32

So is it unhealthy for me to have freshly squeezed orange juice from our market here that has a little has a little bit pulpy, but not that pulpy.

SPEAKER_07 51:40

So it's a healthier alternative to soda.

SPEAKER_00 51:42

Oh, yeah.

SPEAKER_07 51:43

Um, but it's not healthy. No, we should be eating the fruit.

SPEAKER_00 51:47

Oh.

SPEAKER_07 51:48

Yeah. So vastly different. If you're an endurance athlete and you're going for a two-hour run, by all means, that juice is gonna help you. But if someone is just the normal Joe Schmel, and I'm not saying you're normal Joe Schmell, but like typical person, but I'm doctors. The typical person has cardiometabolic disease and other health conditions. So, like juice for them is not really a viable option. So here's a question: Should people drink their calories or eat their calories? So it's not.

SPEAKER_08 52:13

It doesn't make a difference.

SPEAKER_07 52:13

No, absolutely.

SPEAKER_08 52:14

It does make it.

SPEAKER_06 52:15

Tell me why.

SPEAKER_07 52:16

So, you know, a lot of people struggle with hunger, and we know that liquids empty faster from our stomach than solids. So, solid food, if you look at comparable calories, you're gonna feel more satiated or full longer eating 300 calories worth of food versus drinking 300 calories worth.

SPEAKER_00 52:32

And do you have to like chew 30 times each time before you swallow?

SPEAKER_07 52:34

Well, you want to liquefy it, yeah. So it takes about 20 minutes for our brain to get those satiety signals. And I know we're gonna talk about GLP ones and everything, but understanding normal digestion and absorption and physiology of the body, which is critical, I think, with a gastroenterology background, uh, is part of why I'm successful with these GLP1 medications, because you have to understand normal physiology before you disrupt some of that. Um, and it helps me uh definitely counsel patients on the nutritional side when they're on these therapies.

SPEAKER_08 53:01

Yeah, because some people are very gung-ho about going to like Smoothie King and getting, you know, a big uh fruit drink that seems very healthy. What's your take on smoothies?

SPEAKER_07 53:10

Oh, I had a patient a couple years ago who was an undergrad at the University of Miami. She was an architect student. So they would be working until like 10 o'clock at night, and one of the only places open was like some smoothie bar. So she was trying to make that health conscious decision and saying, I'm gonna get the avocado smoothie. I mean, that sounds great. I said, let me pull up the menu. And then I looked up the nutrition facts. How many grams of sugar do you think this girl was consuming at 10 o'clock at night, choosing the healthier option?

SPEAKER_00 53:34

40.

SPEAKER_07 53:34

100. 100 grams of sugar. So they can avocado. They can say that it's avocado.

SPEAKER_00 53:40

Now, is that like a big Miami drink? I mean, that means nothing to me. Avocado. I mean, it sounds fancy, right?

SPEAKER_07 53:46

It has probably some avocado in it, a little bit of spinach, but it probably has like four servings of fruit, yogurt, honey. So too much sugar.

SPEAKER_00 53:53

Are we taking fruit off the table here?

SPEAKER_07 53:55

Fruit's very healthy. But you can't. Thank you. You wouldn't eat like a whole pineapple and an orange and a cup of strawberries and pour honey on top of it. For some reason, we think that's normal to pulverize and then to drink it as a snack. So I so that's kind of.

SPEAKER_00 54:09

I have trouble eating the pineapple rind.

SPEAKER_07 54:11

Wait, I don't think you're supposed to.

SPEAKER_00 54:14

Okay.

SPEAKER_07 54:14

I was about to start an intervention here from this webcast. But yeah, I think part of the issue here, it's not that people don't care about their health. It's not that people are naive. It's that just, you know, I'm in the fitness industry industry. So even within the fitness industry and the diet food culture, most of what is being poured into us is healthy behaviors and healthy dietary intake. It's not. It's just they're packaging it in a really nice little package and saying, high protein, but I'm not going to tell you the hundred other ingredients that we have in this protein.

SPEAKER_00 54:40

Yeah, that's the problem.

SPEAKER_07 54:41

So it's very misleading.

SPEAKER_08 54:43

Talk a little bit about your role in the fitness industry because you compete in fitness competitions and you've trained yourself in a lot of different ways. What have you learned from being a fitness competitor, even outside of being a gastroenterologist?

SPEAKER_07 54:53

Oh, yeah, it's it's very fascinating. Now, one is I don't tell my patients to eat the way I do because it's just not realistic. Um, if they ask me, I tell them what I eat, but by no means do I expect people to live the life that I my next question is gonna be walk us through a day with what you eat because Larry wants to know.

SPEAKER_08 55:08

Yeah.

SPEAKER_00 55:09

I just don't think people who are in the fitness industry and competing are healthy. Yeah. I think a lot of the stuff they do to their bodies is unhealthy. The rapid weight loss and the, you know, just the dieting, dieting and the restriction of calories. That's not healthy.

SPEAKER_07 55:25

Yeah. So I've been there. I I am happy to say I have learned my lesson, hopefully along the way. But I started competing back in undergrad um when I was a personal trainer, and I lost like 30 pounds in like three months. So that was not the healthy way to do it. I was also taking a bunch of diuretics, and I think probably gave myself um compartment syndrome of the legs. I couldn't walk for about two weeks. I mean, it's kind of funny now, but I think I gave myself renal failure. Yeah.

SPEAKER_08 55:47

Because you were what were you doing?

SPEAKER_07 55:49

Well, taking a bunch of diuretics. And I literally wouldn't drink water for two days before getting on stage. I mean, the vascularity was insane. I'm not gonna lie. Um, I think it's a terrible look. Yeah. So that is a woman who's vascular?

SPEAKER_00 56:01

What is nice about that? I had no clue what I was doing to my body. I think you look good.

SPEAKER_09 56:04

I like the vascularity.

SPEAKER_07 56:06

And a woman?

SPEAKER_00 56:07

Oh, come on.

SPEAKER_07 56:09

So, okay, so that was back in like 2008 when I started. And I for years would do a couple shows every couple of years, like put on the weight. I was still a normal weight, but then I would drop about 20, 30 pounds in like a three or four month period. That is not healthy. That wrecked havoc on my metabolism. That is probably one of the reasons why I have osteoporosis today.

SPEAKER_00 56:27

Yeah, but she has it and she didn't drop it. Right.

SPEAKER_07 56:28

So part of it's genetic, but part of it is the female athlete triad, which I don't think we talk enough about. Yeah. Especially in Miami and probably Houston too. A big, you know, push for a lot of women specifically is to stay thin.

SPEAKER_06 56:40

Yes.

SPEAKER_07 56:40

And when we stay thin and we are overtraining and underfueling, that wrecks havoc on our ovulatory cycles. And so, but we thin is healthy, or so we think, right? And a lot of times, especially as women, we're not really paying attention to our periods. Or, you know, Dr. Amy and I have had the IUD for probably 20 years, and if we don't menstruate, you have no clue what's going on in the background. And then you find out when you're 39 that you have low bone density, even though you've been lifting your whole life and eating tons of. Is that crazy? So the effects on our hormones are really, really important.

SPEAKER_00 57:08

And I think the message they are underlying it is you can't change genetics. You can't. You can't. You can't.

SPEAKER_07 57:14

Um, but but we do have modifiable things exactly. Exactly. Yeah. Exactly. Um, so I think, you know, I was overtraining, I was doing two hours of cardio every single day. They'd have to kick her out of the gym. They would literally have to kick me out. I was doing two days in medical school, going before and after class. I would literally take nasty my car growing up.

SPEAKER_00 57:30

Do you have body dysmorphia?

SPEAKER_07 57:32

Before before like a competition.

SPEAKER_00 57:33

Yeah.

SPEAKER_07 57:34

Um yeah, I probably have that. I would say a lot of people probably and a lot of people probably have it. I think I am just a perfectionist and I want to look a certain way. And um it is what it is.

SPEAKER_06 57:44

Yes.

SPEAKER_07 57:44

Um, but yeah. Well, you look very nice.

SPEAKER_06 57:46

I mean, it looks terrible.

unknown 57:49

You look good.

SPEAKER_07 57:50

So I've gone up and down in my way, that's for sure, over the years. But I think more and more now, and and we will probably talk about, you know, uh the risk of frailty and fracture, is understanding the importance of nutrition, irrespective of like what number we're seeing on the scale, making sure we are fueling correctly, especially for the amount of activity we're doing, is really critical.

SPEAKER_00 58:09

So, what percentage roughly are your patients male versus female?

SPEAKER_08 58:12

It's probably about 50-50.

SPEAKER_00 58:14

That's good. Yeah.

SPEAKER_08 58:14

And just to go back really quick on Larry's comment, would you say that the fitness industry is one of the most unhealthy industries around? I would say, I mean, compared to what other industries, you know. Um Well, I think a lot of people think what a lot of the fitness industry is promoting is super healthy, but a lot of it is protein shakes and protein bars.

SPEAKER_00 58:32

But you know, it's it's let's let's, for the sake of discussion, call it a sport. Look at football. Are those guys healthy? 350, 450 pounds? I mean, they're not healthy. Yeah, yeah.

SPEAKER_08 58:42

Well, you see a lot of different types of athletes. Yeah. What are some of their concerns coming in?

SPEAKER_00 58:47

And what are the healthiest athletes? What sport? Baseball, maybe?

SPEAKER_07 58:52

Oh, I I probably wouldn't say that. It's hard to say. I would say if you're playing at a competitive level, that's probably not healthy, right? Because you're overtraining. Definition. Um, when it comes to the fuel, like I've worked with many athletes from the you know, the collegiate level to professional. Just because they're very athletic and playing at a high level doesn't mean that they're fueling correctly. A lot of times we are looking at our coaches for advice and thinking that that's the way to do it, but I've also taken care of many of the coaches, and they also don't have much background in nutrition. At one of the institutions that I was at, I actually went to the nutrition room that the athletes would go to, and it was just a glorified 7-Eleven, and they could go there and get three snacks a day. They were getting, you know, Uber Eats. So I think, you know, even though you are playing at such a high level, it doesn't necessarily mean that people are getting the nutrition they need. And they could probably play at an even higher level. Oh, of course. If they actually had good nutritional guidance.

SPEAKER_06 59:41

Yeah.

SPEAKER_07 59:41

But I think at any level, if you are competitive, we see overuse injuries, we see concussions. Like just because you're an athlete doesn't mean you're the picture of health. And I've experienced it myself, and I see that in a lot of patients. And I see that decades beyond that, even though they're still maintaining a healthy weight, now they have terrible knee issues. So, you know, there's a lot of things that play into it where I think we look at athletes and we say they're the picture of health. How can they have any problems? They're making good money, they have all this exposure, they seem so happy, they are like any other person, right? They still have their struggles.

SPEAKER_06 1:00:11

Yeah.

SPEAKER_08 1:00:12

So let's go back to you had uh brought up before fiber. Yes. And you were saying is fiber good or bad. I'm hearing mixed messages.

SPEAKER_00 1:00:17

Yeah, I have had recently um I have a relative who suffers from, you know, serious constipation. And the whole thing about fiber versus no fiber, and you know, came up. And I thought, yeah, lots of fiber. And the doctor he went to said, no, not a lot of fiber. So what is the real story? Well, I was gonna say the real poop. I decided that was a bad choice.

SPEAKER_07 1:00:40

I said it anyway. I'm gonna say, just like with probably the dis the testosterone discussion, it depends who you ask. If you ask five different providers, you're probably gonna be given five different answers. Now, we know, um, especially like as a gastroenterologist and in the GI literature, fiber is really important. Okay, our gut microbiome is truly our second brain. Our gut is our largest immune organ. Okay, so what we feed it several times a day has a profound impact on our immune system. And so we have these billions of bacteria in our gut. We have more bacteria in our gut than we do actual human cells. Isn't that crazy?

SPEAKER_00 1:01:14

It's scary.

SPEAKER_07 1:01:15

It is well, it's a beautiful thing. It's a beautiful thing.

SPEAKER_00 1:01:18

Bugs?

SPEAKER_07 1:01:19

Bugs, yes. So these organisms help protect us. Now, if we don't eat right, if we're eating the cheeses and the ice cream and the Snickers bar, that promotes an unhealthy gut microbiome or what we call dysbiosis. That increases inflammation. It increases chronic conditions. Our gut microbiome, when we talk about weight management, also has a profound effect on our metabolism, on the way that we take care of hormones like estrogen. Um, it also has a profound impact on the amount of calories we extract from our food. So this is quite interesting. If you eat bread, it's better actually to put the bread like in the fridge or the freezer and then you can toast it. That actually changes the molecular structure into what we call a resistant starch. So you actually absorb less of those calories. Is that interesting? Same thing for pasta. That one thing alone. So if you wanted French fries, at least freeze them and then reheat them. Seriously? But don't do it for rice. Rice is uh you gotta be careful with it.

SPEAKER_00 1:02:15

I'm getting so confused. How about I'm supposed to freeze my pasta?

SPEAKER_07 1:02:18

Or refrigerate it. So you cook the pasta, then you make it cold, and then you can either reheat it or eat it cold, and and actually it turns into a resistant starch. Now I'm not saying everyone should be eating pasta forever.

SPEAKER_00 1:02:27

And a resistant starch means it's not going to be degraded to sugar or exactly.

SPEAKER_07 1:02:30

So you absorb most of those calories. So some of it probably still will, but it's less basically digested. Okay, very important. So that you can check on your you have a CGM. Yeah. So you could actually.

SPEAKER_00 1:02:38

So you could check, but you know, nothing changes with my CGM.

SPEAKER_07 1:02:41

Yeah, but you could check if you're eating warm pasta or cooled pasta and then we're pairing it with protein. So we also know that food pairing and order of eating has a profound impact on blood sugar control, right? So it goes way beyond just what we're eating and the macros and the calories. Because we know data shows that if we eat the protein and fiber first, we will get less of a blood sugar spike than if we had bread first, like we get at restaurants. You get the bread first. And that's crazy. Um if we eat the protein and the fiber.

SPEAKER_00 1:03:10

This is all very important.

SPEAKER_07 1:03:12

And then you have the potato, and then you have the pasta, you'll get less of a blood sugar spike. So I was gonna say, and then if you go for a walk, like five or ten minutes after eating, that has even more effects on blood sugar control and digestion. So it's really interesting. We're walking tonight, and these details matter.

SPEAKER_00 1:03:28

So here's an important question.

SPEAKER_07 1:03:29

Yes.

SPEAKER_00 1:03:30

If I am not if I'm kind of sloppy with my diet and worrying about a microbiome, is taking that probiotic gonna solve my problems?

SPEAKER_07 1:03:39

So there is no quick fix.

SPEAKER_00 1:03:40

I'm just yeah.

SPEAKER_07 1:03:41

So probiotics. I know the answer. I'm just kind of So it's a you know, obviously, the supplement industry when it comes to hormones and testosterone boosters and probiotics, billion-dollar industry. Um, the reality is we don't have much data. One of the things that's very interesting is a lot of the probiotics on the market are the ones that are just easy to grow, not necessarily the ones that show the most health benefit. So if they're easy to grow, they're easy to manufacture.

SPEAKER_00 1:04:02

So two important questions. Do you recommend a probiotic? And if you do, which one?

SPEAKER_07 1:04:07

So, no, no. Um I recommend, so probiotics are basically bacteria that have been shown to have health benefits.

SPEAKER_06 1:04:14

Right.

SPEAKER_07 1:04:14

Prebiotics is just dietary fiber. It's just a fancy name for dietary fiber. We know that if people give themselves prebiotics, dietary fiber, specifically in food form, is ideal, that helps promote a gut, a healthy gut microbiome to the point that you wouldn't need probiotics because you would have the healthy mix of bacteria.

SPEAKER_06 1:04:32

Right.

SPEAKER_07 1:04:32

Um, so that's really the short answer. We also don't know, you know, for you, let's say, for example, do you need more lactobacillus or more bifidobacteria?

SPEAKER_05 1:04:42

I think the lactobacillus.

SPEAKER_07 1:04:43

Maybe, maybe not. We know that stress and sleep and hormones and our food impact our gut microbiome. If you get a pet like a dog, your microbiome is going to shift within that two-week period. It's a very dynamic process. So if I were to get a stool test on your microbiome today and say, this is what you need to eat, and then I check it, you know, two years from now, it may be vastly different. So you may or may not benefit from lactobacillus long term, it's hard to say. Plus, these products are not regulated. So if I'm saying, you know, this product has 50 billion colony forming units, okay, it may have 50 billion colony forming units. Are those units actually viable? We don't know. We're not testing it. For some of the bacteria, if they're anaerobic bacteria and they got exposed to one molecule of oxygen during the manufacturing process, they are no longer viable.

SPEAKER_00 1:05:27

So the probiotic that you buy has never been tested to show that it's going to end up as bacteria in your gut?

SPEAKER_07 1:05:34

So they do trials, but the problem is probiotics are not regulated. So unless you're doing independent testing and testing a bunch of products that are on the market, um, people aren't really doing that. And that's why they've gone into the supplement route and not the pharmaceutical route, because it requires obviously a lot less testing. So let's, I want you to finish answering the question about fiber.

SPEAKER_08 1:05:53

Yeah. Because you had mentioned that do you know that getting enough fiber can be good for promoting a good gut microbiome and probiotics. But is all fiber created equal? Like, is it enough for us to say eat more fiber?

SPEAKER_07 1:06:04

Well, a lot of people don't know what fiber is, right? And so we have two types of fiber. We have soluble fiber and insoluble fiber. Typically, foods that are high in fiber are gonna have a good mixture of both. Um, we should be getting around 25 to 35 grams of dietary fiber per day. Now, if you're going from no fiber and just eating like white toast, you know, and I don't and what else? Like steak or something, right? If you're going from no fiber, and I were to say you should be having 35 grams of dietary fiber a day, you're not gonna feel well because a lot of that fiber is indigestible. And people, if you're reintroducing it at a rapid rate, you're gonna not feel well. You may have abdominal pain, bloating, cramping, diarrhea or constipation. So you need to do a slow introduction.

SPEAKER_00 1:06:41

Diarrhea or constipation. Yeah, I mean I know.

SPEAKER_07 1:06:43

It could be all over the place because it depends on the type of fiber. So celery. Celery. So that could give you, let's say, diarrhea. If you're eating a lot of greens, that could give you diarrhea, depending on the components of what sort of dietary fiber is in there. People who take a lot of metamucil, that's a supplement. There's a lot of soluble fiber in there. That's a stool bulker. If if I were to just tell my patient, eat a ton of fiber, and they go, Oh, I don't like eating veggies, I'm just gonna drink a massive metamucil bomb with a lot of water, what happens? They may give themselves a bowel obstruction. I had that with a patient who was on Zetbound, um, was constipated, drank way too much metamucil, literally ended up in the hospital with a bowel obstruction because it basically absorbs a lot of the water with that, bulks up the stool, and then basically causes an intestinal plug.

SPEAKER_05 1:07:25

Yes.

SPEAKER_07 1:07:26

So that's where the devil is in the details. Not all dietary fiber is equal. We as providers, we need to be more um informative with our patients or at least give them the resources so they know where to go. So it's the slow introduction. So usually what I tell people is if you're having three meals a day, then each meal should have, you know, five to ten grams of fiber. What does that look like? Nuts, seeds, you know, fruits, veggies, uh, beans, chickpeas, all of those things, Ezekiel bread will get you a couple grams of fiber. So there are ways, as long as you're thinking about it. It could be a simple change from going from wonder bread to Ezekiel bread. A simple change from going to, you know, mashed potatoes with no fiber versus a sweet potato or a regular potato with the skin with the skin.

SPEAKER_00 1:08:10

You know, every time you say something, I think of a question. This is terrible.

SPEAKER_07 1:08:12

I'm gonna have to And then Amy's gonna have to keep really attracting.

SPEAKER_00 1:08:15

I'm gonna have to come for my two, my two-hour appointment. But are potatoes, I mean, can are potatoes healthy?

SPEAKER_07 1:08:21

Potatoes are great. They have some protein in there, they have fiber.

SPEAKER_00 1:08:25

Why is the word on the street? Don't eat potatoes.

SPEAKER_07 1:08:27

Because who just eats potatoes? Plain.

SPEAKER_00 1:08:28

Me.

SPEAKER_08 1:08:29

Plain?

SPEAKER_00 1:08:30

I mean, I could eat a sweet potato plain. I could, I could, you know, ketchup on my white potatoes. Oh, let's talk ketchup. Oh, I'm sorry. I'm sorry, I didn't say ketchup. I said that, but I didn't I didn't say it.

SPEAKER_07 1:08:42

So potatoes are great, but it also depends on how are they being made, right? If it's like mashed potatoes with cream and butter, no, I know that, but we're talking about just potatoes. Just a potato, great. But we have to go back to what else is important. Protein is really critical. So if our meal is just based on potatoes, then we're not getting our protein. But it's a great side as long as we're hitting our fiber and protein goals.

SPEAKER_08 1:09:03

But there's also the serving component, right? And there are a lot of like big potatoes that we think, oh, just one potato is one serving. One potato is not one serving. Well, you asked me the other day.

SPEAKER_00 1:09:11

You said it depends how much of how big it is. Yeah.

SPEAKER_08 1:09:13

Well, I said to my sister, I said, I cut up an entire sweet potato, I cut it up like so it looks like french fries, I put it in the air fryer, put some olive oil on, salt and pepper. And my goal was to eat just half of it, but I ate the entire thing because it was so delicious. And I said, Do you eat an entire sweet potato when you're, you know, making the sweet potato french fries? And I said, Amy, how big was the potato? Like I can't eat it. And I said, I don't know, a normal size from the grocery store. And she said, That's not helpful. I weigh my food.

SPEAKER_07 1:09:36

So I weigh, let's say, four ounces of sweet potatoes because most people don't quite understand what a true portion is. So if I were to have 16 ounces of a sweet potato, that would be pretty heavy in carbs. But I should have the caveat here.

SPEAKER_00 1:09:47

And the caveat is if you want people to eat healthy, you've got to make it easy. Correct. I mean, you can't. I don't tell my patients to weigh food. You know, it's just they'll go the opposite direction, I think.

SPEAKER_07 1:10:00

So um I, like I mentioned, am different from what I tell my patients. Now, if I have a patient coming to see me and we start with very basic recommendations and we're not seeing the results we anticipate, then I will ask them, okay, if you're losing muscle and you're telling me you're eating 140 grams of protein a day, something doesn't make sense to me. Get a food scale and just weigh a portion of your typical chicken and let's see, are you eating four ounces, two ounces, or six? Because otherwise, like it's really hard for me to give feedback if we don't anticipate the results. Or you don't get the results even anticipate. Exactly.

SPEAKER_08 1:10:31

But the thing is, it's not like you're asking someone to weigh their food every single time. People eat similar things on, you know, a daily basis, typically, right? So if they do it a couple times, they get a sense for what they're actually eating.

SPEAKER_07 1:10:40

And I have tougher wear containers at home. So if I know I'm using a specific container and the chicken fills to the top, I know it's four ounces. I don't need to weigh it every time. So that's very easy. So talk about ketchup.

SPEAKER_09 1:10:50

You brought it up, Larry.

SPEAKER_00 1:10:52

I don't very often use ketchup. I was just thinking of something to put on a potato to make it more interesting.

SPEAKER_09 1:10:56

So I think it's a really salsa. Yeah.

SPEAKER_00 1:10:58

There you go. Salsa, that's what's the same. But let's talk about better. Much better.

SPEAKER_07 1:11:00

But let's talk about ketchup because you and I used to be ketchup haulets.

SPEAKER_00 1:11:04

I know it's terrible. I know it's got a million different things in it.

SPEAKER_07 1:11:06

Straight high fructose corn syrup. Yeah. And the serving is like two tablespoons. And like most people are putting a full tablespoon on like one French fry. Yeah. So the serving also does matter. Oh, we used to put ketchup on everything. I'm sorry to say it. Dressings, marinades, that stuff also. I go into the details. I want to know, okay, you're, you know, putting seasoning on your chicken. As a gastroenterologist, a lot of my patients suffer from heartburn, bloating, diarrhea, constipation. They may blame the potato. It may have nothing to do with the potato. It may have everything to do with the fact that they put a ton of garlic and onion seasoning on it. So that's again where the details do matter, especially as a gastroenterologist. Yeah.

SPEAKER_08 1:11:38

Okay, so now, like on the topic of ketchup. Okay, okay. So there are some items that are healthier items because they have less sugar and they're sweetened with artificial sweeteners. Talk to us about artificial sweeteners.

SPEAKER_07 1:11:51

So that was actually my grand rounds when I first started at the University of Miami, was talking about artificial sweeteners. And Amy and I used to be splendoholics.

SPEAKER_09 1:11:58

We were ketchup olives and splenohics.

SPEAKER_07 1:12:00

I know, and gumaholics, right? So, like as a gastroenterologist, I have a ton of patients, like I mentioned, with reflux and bloating and like gum, for instance. A lot of people chew gum, well, for the minty, fresh breath, but also to try to help curb their appetite. And then they're wondering why they're always bloated. The constant chewing is actually causing a lot of air swallowing called aerophagia. If you look at any packaging of gum, there's like six ingredients in there, like four of which are every different type of sweetener you can imagine, including sugar alcohols. So sugar alcohols like erythritol or sorbitol can cause massive GI issues like diarrhea and bloating. So it's those simple things. Yeah, but as a gastroenterologist, what did I used to do? I'd order them an endoscopy, right? So Bob would wake up from his endoscopy, he'd say, Doc, what's wrong with me? I feel terrible. He'd say, Bob, great news. Everything's normal. And Bob would look at me and be like, but I don't feel normal. I need a diagnosis, what's wrong with me? And so what I realized, and one of the reasons why I transitioned more into nutrition weight management is because, listen, I'm a I'm a pretty good endoscopist, but I wasn't moving the field in any regard when it came to being a proceduralist. But really, what my secret sauce pun intended was was I had the nuanced conversations about nutrition, right? Because we can do these fancy procedures and be very innovative when it comes to these technologies. But if I'm not talking about the basics, I'm never gonna help Bob feel better. No endoscopy is gonna change that. And that's where I think, honestly, in the whole gastroenterology field, we are missing the boat. Yeah. Skipping the foundation. Yeah, getting a little too technological.

SPEAKER_08 1:13:19

So talk to us more about artificial sweetness. How does that even come about?

SPEAKER_00 1:13:22

If I want to, yeah, and I I would go, I'm more savory than I am sweet. So that's not a big thing.

SPEAKER_09 1:13:26

Oh, you seem pretty sweet to me, Lila.

SPEAKER_00 1:13:27

What? What did you say? What?

SPEAKER_09 1:13:29

You sound pretty sweet to her.

SPEAKER_00 1:13:31

That's so nice. No, but seriously, if I want to put a sweetener in something, which are there any monk fruit?

SPEAKER_07 1:13:38

I mean, are there any So those are gonna be better because they're natural alternative sweeteners as opposed to artificial sweeteners? So like monk fruit, stevia, those are gonna be better. I mean, the ideal scenario, what I do all the time is I'll add cinnamon to like Greek yogurt and apples, or I'll use obviously you're not gonna put fruit in your coffee, but things, let's say you're having like a plain Greek yogurt and you want to sweeten it up, like adding berries or a banana would be a great option, or cinnamon, or I'll use just like a natural, like no alcohol um vanilla extract type of thing. So those are all ways. Another thing is like these little fruit bars. So this is they're literally like candy, but it's literally just mashed fruit. There's no added sugar, it's all natural. I'll cut this up and I'll put it in a yogurt. So there's still ways to sweeten food that are not adding a bunch of high-fruit coins here. No, you can. Stevia, truvia, that is a natural sweetener. Now, there is a lot of conflicting data. Some studies will say it helps people lose weight and it helps with diabetes control. I just, I don't believe it, okay? Because what I see and what I experience myself as well is these sweeteners, whether it's natural or an artificial sweetener, they are anywhere from 300 to 600 times sweeter than natural sugar. So it trains our brain to make us need something super sweet to feel satisfied. So that when we have a Greek yogurt that has natural sugar in it, most people tell me it tastes super bitter. And that's because our brain doesn't even sense the natural sugar. We need something super sweet. And then you mentioned that you eat things because they taste good, but there's a fine line.

SPEAKER_00 1:15:02

Is that unusual? No, no, no.

SPEAKER_07 1:15:03

That's very normal. But the problem is things taste too good, right? To the point that we can literally not stop eating it, to the point that we are full and we can't stop when we're satisfied. So that drives a lot of the overeating habits, right? I want people to enjoy their food, but not really enjoy their food. And that's where a lot of the seasonings, the extra salt, the added sugars, it drives more hunger, more cravings, more overeating. It's harder to put the rest of the food away. So is a diet soda better than a regular soda? They're all bad. They're all bad, unfortunately. Um, we're seeing more and more data actually on artificial sweeteners and the gut microbiome. So again, I'm gonna keep going back to the gut because that is truly our second brain and has such an important role in overall health and disease. And things like artificial sweeteners, components like emulsifiers. So we're seeing more and more data on emulsifiers, caragenine, xanthom gum, guargum, all these things, they're basically acting as detergents, okay? When you process items in like a dressing, oil and water don't like each other. So you have to add detergents so they meld together and don't separate out. We're seeing more and more data actually showing disruption of the gut microbiome and increased risk of colorectal cancer.

SPEAKER_00 1:16:10

I'm not gonna eat it anymore. That's the easiest way. So you have to look at the labor.

SPEAKER_09 1:16:14

Well, no, like no, no, no, no, eat anymore in general. No, it's just um listen.

SPEAKER_07 1:16:20

But you see patients that come in that are like, I don't know what to eat. Yeah. And so they become very food averse. Correct. So my goal is actually to get them to experiment with more foods, right? So I have people that say, Oh, I've never had tofu. Okay, well, why don't we try it, right? Cube up some tofu, pat it dry, put in the air, you know, air fryer with some seasoning on top, and it tastes delicious. Or to mask it, you can do like a veggie puree where you steam cauliflower, you put silk in tofu and just blend it, and you don't even taste it.

SPEAKER_00 1:16:45

I have a very, very, very basic question. And it's gonna sound stupid. Yeah. But I don't care. How does the air fryer fry? I mean, does it fry, or is that a euphemism for the fact that it superheats it? I mean, what does it do?

SPEAKER_07 1:16:57

Yeah, it's not frying anything, and I honestly couldn't tell you.

SPEAKER_00 1:17:00

But why is it called an air fryer?

SPEAKER_07 1:17:02

Because it makes things crispy.

SPEAKER_00 1:17:03

So if you put your potatoes in there as French fries and they come out, do they taste like regular French fries?

SPEAKER_07 1:17:09

Oh, they're amazing. You'll have to look at my Instagram for the recipe.

SPEAKER_08 1:17:12

I would these sweet potato french fries you couldn't stop eating, were delicious. I put tofu on the air fryer, divine. You get a crunchy taste and you feel like you feel good when you're eating it because you know that you're eating something healthy and it honestly tastes good.

SPEAKER_07 1:17:27

I put some salt and pepper on it. And better, you f and and the other thing is that's even better, is you feel great after eating. I hate going to a restaurant.

SPEAKER_00 1:17:35

But doesn't it bother you don't know how it's working?

SPEAKER_08 1:17:37

Not really. No, and we can delve into that, but on an air fryer. Um, no, it tastes good. It tastes good and it's super easy. And it you put it in the air fryer for 10 or 20 minutes. I mean, you can't get any easier than that.

SPEAKER_07 1:17:47

So, you know, I think a lot of things when it comes to just men's health in general and a lot of what I do within the gut health realm and GLP ones, nutrition is the foundation. As you can tell so far with our conversation, it's a little bit more complicated. So I think as providers, if we don't have the expertise, we can't just tell our patients to eat healthy and that will improve your testosterone. Like it does require, you know, more detailed conversations or at least resources.

SPEAKER_00 1:18:10

But I mean, I see a lot of athletes and you know, they all, and a lot of them are from the gym and they all have coaches. And the coaches tell them what to eat. I mean, it's outrageous. Yeah, right.

SPEAKER_07 1:18:22

Well, and I've hired coaches in the past, and one of them told me to eat a bunch of tilapia and white rice. And I say, listen, I don't eat either of those. I actually just want more like broccoli and cauliflower. And she goes, just stick to the plan. And I was like, okay, well, this is not working out well. You know, so I think I think a lot of times just because we hire someone who looks great on stage doesn't mean that they actually have any sort of background whatever in nutrition just because they know how to get someone ripped. Yes. And I think, you know, it can be dangerous for sure. Yeah.

SPEAKER_08 1:18:46

What are some of the common foods that athletes might be told that are good to eat that are actually terrible to eat? Like let's say long distance running.

SPEAKER_07 1:18:53

Well, I think a lot of the pre-made items, like the gels, the goose. Have you ever had any of those? There's like waffles like that. The goose.

SPEAKER_00 1:19:00

The goose, yeah.

SPEAKER_07 1:19:02

They're just like they're like gel packets that have a lot of these preservatives and other components like emulsifiers. So I see a lot of people with GI distress. Oh, for energy, right? So if you're an endurance athlete.

SPEAKER_00 1:19:12

Yeah.

SPEAKER_07 1:19:12

So any sort of endurance athlete, if you're training for more than like an hour, uh, typically you're not you're gonna need to fuel during your workout because your body needs some simple sugars. Yeah, exactly.

SPEAKER_00 1:19:22

Yeah, I see that.

SPEAKER_07 1:19:22

Um, but a lot of them actually, you would think because they have a six-pack and they're doing great, that they don't have any issues. Um, upwards of 60% of endurance athletes actually have GI distress. I actually gave a talk in Boston at an orthopedic surgery conference on GI distress in athletes. Um, and what we see is that moderate exercise actually improves gut function. But when you take it to the next level, when you become, let's say, you know, on the extreme or a very high-level performance athlete, that stress on the body can actually have the opposite effect. And if you're not well hydrated before or during your workout, if you're not fueling properly, that has big impacts on the gut, on the gut microbiome. Where actually a recent study came out showing increased risk of colorectal cancer in marathon runners because of the changes in blood flow to the gut. When you are doing endurance sorts of activities, your blood flow is being shunted to your muscles and away from your gut. And that's actually we're potentially seeing disruptions in the cells. Yeah. Well, talk about runner's trot. Have you ever heard of runner trot? Runner's trot?

SPEAKER_00 1:20:18

Runner's trot. Trot.

SPEAKER_07 1:20:20

Yeah. So we've a lot of people have heard these terms. They don't quite know what it means. So runner's trot is when you have someone who's underfueling or not or dehydrated. And when they're running or they're not eating properly, you get this shunting, obviously, of the blood to the muscles and away from the gut. You actually get ball ischemia. So they'll have diarrhea. That's why you see all these portapodies. You have diarrhea, sometimes bloody diarrhea, to the point I've seen patients in the hospital that needed to be admitted because of bloody diarrhea, because of the shunting of the blood. So it's not just about like drinking a bunch of protein shakes, eating protein, you know, all that stuff. It's it's the hydration component. And just drinking a bunch of water, that's not hydration. You got to make sure it has the appropriate electrolytes.

SPEAKER_00 1:20:56

So let's talk about water.

SPEAKER_07 1:20:57

Source nutrition is a whole nother world.

SPEAKER_00 1:21:00

How about water for the average person? What is recommended?

SPEAKER_07 1:21:03

Well, the average person, the average person in America is unhealthy.

SPEAKER_00 1:21:06

Okay.

SPEAKER_07 1:21:06

So you.

SPEAKER_00 1:21:08

Me. What should I? I'm healthy. What should I be drinking?

SPEAKER_07 1:21:10

Well, I mean, I'd see at least 64 ounces of water a day. 64. At least 64. So that would be eight cups. I don't know if we have a magical answer.

SPEAKER_00 1:21:17

What is the what are the regular bottles? Usually 60 o'clock.

SPEAKER_07 1:21:20

But it also depends on, you know, the size of someone. So that is taken into account. It depends on where you're living. So it's very humid in Houston. It's, you know, it can get obviously very hot in Miami. So even if you're not sweating, you're still losing a lot of insensible water losses through your skin. So it depends on what your activity looks like.

SPEAKER_08 1:21:35

Well, and then a lot of foods have some water in them too.

SPEAKER_07 1:21:38

Yeah. Yeah. But then also things that we do that dehydrate us. Like a lot of people drink coffee. Yes, it's water, but the caffeine can act as a diuretic. So many things that play into it. But I think specifically as proceduralists and surgeons, we are kind of taught not to drink water because we're stuck in the OR, right? And we've trained our bladder to, you know, basically exactly. So I remember when I at my prior job, we couldn't even have water in the workroom, even though it wasn't even patient-facing. So we are, we're walking around all today, I think, just chronically dehydrated.

SPEAKER_08 1:22:06

Yeah.

SPEAKER_07 1:22:06

When we're thirsty, it's a little bit too late. Yeah. Yeah.

SPEAKER_08 1:22:08

Um, do you have any like top recommendations for someone who, let's say, is an athlete in terms of electrolytes or like how to fuel? Just I know it gets very complex, but like anything that like are top of mind.

SPEAKER_07 1:22:18

Well, the nice thing is it's the recommendations are all the same. It's more of a Mediterranean type diet.

SPEAKER_00 1:22:21

It doesn't matter whether you're an athlete or have to define Mediterranean because people are watching. And so what do you?

SPEAKER_07 1:22:26

Yeah. So nuts, seeds, fruits, veggies, lean protein, olive oil. I'm not going to push the wine because I think that's a little bit outdated now, but it's, you know, those typical foods. Um a Mediterranean type diet. And what you and I have discussed. And what you mentioned, that's athlete or no athlete. Exactly. What we've mentioned before is whatever's good for the brain is good for the heart, is good for the gut, is good for the bone and muscles. So it's kind of all the same. And the genitals and hormone health. Exactly. So where my nuanced conversations come in is a lot of my patients have GI symptoms at baseline. So that's where, again, the devil's in the details. If someone has a lot of constipation, then I'm really going to focus more on protein and hydration and getting their bowels more regular.

SPEAKER_00 1:23:01

So protein helps with GI with gut health?

SPEAKER_07 1:23:05

Oh, absolutely. But if you're only eating protein, then that can be constipated. So that's where I want to make sure, okay, if the goal is they're on a GLP one, that's already going to increase their risk of constipation. They have constipation at baseline, right? Those are where the nuanced discussions come in because I want to get them fiber and protein, knowing that they're not going to be able to eat that much. What are things we can do? Edamame is great because edamame, you're killing two birds with one stone. You're getting protein and fiber. So that's, you know, the nutrition recommendations can really help in that regard. Chickpeas, beans, they get you both protein and fiber. Now, if someone has chronic diarrhea, I'm not going to tell them to eat tons of salads, even if they're trying to lose weight, because that's going to worsen the diarrhea. So it depends on what their baseline gut function is. So let's delve into GLP ones.

SPEAKER_00 1:23:49

Can I ask you a question?

SPEAKER_07 1:23:49

Yes, you can, Larry.

SPEAKER_00 1:23:52

So uh coffee, uh-huh. Dehydrates, right? So every morning I get this is all about me. I hope I love this.

SPEAKER_09 1:23:59

Clearly.

SPEAKER_00 1:24:00

This is my doctor's visit. So every morning I have forever now four shots of espresso on ice. That's what I have every morning. Why how why is that bad?

SPEAKER_07 1:24:12

Well, there's a couple things. Um, the half-life of caffeine is six hours. Now, luckily, it's all in the morning unless you're doing four more shots in the afternoon.

SPEAKER_00 1:24:19

That's it. Never any other.

SPEAKER_07 1:24:20

Yeah. So I see a lot of patients who have like bladder irritative symptoms, right? So if they're doing that and they're urinating all the time or having nighttime urination, caffeine will definitely affect that. Now, are you putting anything in the coffee? So no milk, no sugar. So a lot of people, especially in Miami, will have like the Cuban coffee or the cafe con leche. And so they're adding a ton of other things. So if you're strictly just having like black coffee, then for some people that's fine. Now, if you're struggling with constipation, so sometimes that can make it worse. No, some people it can make them go. It depends on the person. So I have some people that say if I'm constipated, I have a shot of coffee and I do fine. It really depends. Everyone reacts differently. So if you're doing your four shots of coffee and you're feeling great, by all means, I would continue doing that. I'm not going to tell you not. But typically the people coming to see me have other quality of life concerns that they're worried about, for which I think coffee is probably making it.

SPEAKER_00 1:25:06

Well, that's my only concern. Yeah. I'm done.

SPEAKER_08 1:25:08

Yeah.

SPEAKER_00 1:25:08

Next.

SPEAKER_08 1:25:09

Well, I was looking into this about a year ago, talking about brain health and caffeine, and they mentioned that caffeine is a vasoconstrictor to the blood vessels in the brain, that it reduced blood flow to the brain. And I used to take two caffeine pills every morning for probably the last 15 years. And cold turkey, I said, I'm done with it. Really? Yeah.

SPEAKER_00 1:25:28

Because I think so. You don't think you feel more alert when you drink coffee?

SPEAKER_08 1:25:31

Well, I was so used to it at some point that I needed it just to be at my baseline. And I thought coming off of it was going to be absolutely terrible. And I actually did okay. So I drink coffee because I kind of just, it's kind of like a little bit of a habit. And I might drink like a quarter of a cup to sometimes like a full cup. But with the two caffeine pills, I was taking like two cups of coffee like immediate, like at one time, you know? So I think there is some interesting data looking at um blood flow to the brain and caffeine, which is just kind of something to think about.

SPEAKER_07 1:25:56

Well, I think what I've seen too is people will drink a couple of um a couple cups of coffee in the morning because they use it kind of as an appetite suppressant or not that hungry. But and we'll dive into the GLP ones. When you're on a GLP one, you need to hit a certain protein requirement. So I have a ton of patients that say, Oh, I'm drinking coffee all morning, I'm kind of doing like intermittent fasting, my first meal is at noon. And I'm like, then there's no way you're gonna hit your protein targets if your eating window is, let's say, noon to 6 p.m. So I need you to actually eat something in the morning and drink less coffee. So it does play into the GLP ones as well in protein intake.

SPEAKER_08 1:26:26

But I would probably say, and you would know this better than I do, is that usually it's not just coffee. It's what they're putting in their coffee and maybe what they're eating with their coffee. Yeah. Absolutely.

SPEAKER_00 1:26:33

So we need to go to the GLPs.

SPEAKER_08 1:26:35

Yeah, let's go into the GLP ones.

SPEAKER_00 1:26:36

Well, the whole class.

SPEAKER_08 1:26:37

Yeah, yeah. And you had started your career at the University of Miami and now we're in practice together. And you've um kind of been in this space during this time period where the medical weight management space has drastically like revolutionized in terms of medical weight management. Can you talk to us about how that has changed throughout the course of your career?

SPEAKER_00 1:26:55

It's been amazing to actually bariatric surgeon. All right.

SPEAKER_07 1:26:58

It's been amazing to actually practice throughout this whole transition. Um, it's like people who um, you know, I mean, when we were growing up, we didn't have cell phones. Right. So to kind of live through that transition.

SPEAKER_08 1:27:08

We have to live through the transition of like organ trail and then Nintendo and cell phones and AI.

SPEAKER_07 1:27:14

So it's cool to experience all of that, versus people a couple years from now will never know what it was that there was life before GLP wants, right? So when I first started practicing, um, we basically had like fentramine, we had ally, we had Contrave, we had, you know, basically five FDA-approved medications on the market, and they were pills. Um, and they were not that effective. People would lose anywhere from maybe five to eight percent of their weight, but a lot of side effects. So things like fentramine is a stimulant, a controlled substance. It would cause potentially arrhythmias, high blood pressure, insomnia, constipation, dry mouth. So a lot of my patients that were seeing me for weight management had cardiovascular disease, these medications were off the table. And you could only put them on fentramine for a certain period of time. FD approved for only three months, which is so crazy. If we know that obesity is a chronic condition and weight regain is very common, why would it make sense to only have an FDA approved medication? For three months, why was it? Huh?

SPEAKER_00 1:28:02

Why did they do that?

SPEAKER_07 1:28:03

Who knows? I mean, people would prescribe it for longer, but that's what they did the clinical trials with. So why are we surprised when people lose a bunch of weight and then gain it all back? That's crazy. And then HCG. So I don't know. I mean, you you all use it for a different purpose, but you had these HCG shot clinics, just like we do peptide and testosterone clinics, is people would go in and be put on 500 calorie per day restriction diets, given HCG, and basically told don't exercise. How crazy is that?

SPEAKER_00 1:28:26

Well, I think the HCG part of it was crazy because it was just the diet. They were not losing weight from the HCG.

SPEAKER_07 1:28:31

Well, it was an appetite suppressant. Yeah. So they were able to just consume 500 calories a day and feel fine. But they were actually told do not exercise.

SPEAKER_00 1:28:38

So is HCG an appetite suppressant? Yeah. Significant.

SPEAKER_07 1:28:42

But it's never been endorsed by any obesity society. You just had a lot of these like medispa, you know, do you think it does?

SPEAKER_08 1:28:48

Um Well, you've never used it for that. I've never used it for patients. But but people used it. And we use a lot of HCG, but oftentimes we're using dosing is different. We're using HCG also in combination with testosterone, and sometimes testosterone can drive up hunger.

SPEAKER_00 1:29:00

Yeah.

SPEAKER_08 1:29:00

But I So I think it's probably hard to tease out.

SPEAKER_00 1:29:02

I just have never never thought that. I thought it was just a placebo so that they could get a shot, but it was really the 500%.

SPEAKER_07 1:29:09

Well, it's also hard to know what else they were getting because none of these things were regulated. So they were getting the medications like kind of in-house. So they were also getting polythyroid hormone, they were getting other stimulants. It was basically a whole cocktail.

SPEAKER_06 1:29:18

Yeah.

SPEAKER_07 1:29:19

Um, so those were the days back then. I'm sure people are still doing it, although less so now. So then um around, so so actually the first medication that came out for weight loss was Sixenda. So that's the raglotide. Okay. So let me actually go back before then. These medications, although people think they're pretty new, have been bad ones for two decades. Okay. Early 2000s is these medications first came out. So l'heraglotide was the first injectable GLP1. Um, and that was for uh FDA approved for type 2 diabetics. And we saw people were losing weight. So we did additional clinical trials and then came out sixenda. It was just a higher dose version. It was a daily injection. Now, those injections are effective, but you only get about 6% weight loss. Then came Ozempic. So Ozempic, so basically it's semaglitide. So you have Ozempic for type 2 diabetics, that came out around 2018, and then Wagovi, which is also semaglitide, just different dosing, came out, I believe, in 2020 or 2021 for non-diabetics for weight loss. Okay. And then more recently, we have terzepatide. So terzepatide is Mongioro for diabetics and Zeppound for non-diabetics for weight loss. So these medications have been around for quite a long time, a lot of clinical trials. So I've been around during that whole evolution. Now, what's fascinating is we probably have at least 15 medications in the pipeline. So the pill version of Wagovi, just FDA approved. We have um, or um, there's another medication by Lily. It's another pill option that's coming out, I believe, in March. Um, retadrutide, Reditrite, Reditrutide. Thank you, Amy.

SPEAKER_08 1:30:41

Which you have a lot of, you've seen a lot of people on Reditrine.

SPEAKER_00 1:30:44

I am willing to predict right now, I would say over 50% of my uh gym guys are on that. Yeah, Reditrine.

SPEAKER_07 1:30:53

I'm not quite sure.

SPEAKER_00 1:30:53

No, no, no, they're not, it's not being sold locally. They're getting it online.

SPEAKER_07 1:30:57

No, correct, exactly. Yeah. So they're getting it, some chemist is making it, we have no clue because it's not, it's in phase three clinical trials, right? It's probably going to come out hopefully in December or early next year. So, I mean, Amy and I had a patient, this guy in his 80s, who said he was on this medication like two years ago. I go, I don't even know what that is. I haven't heard of it, right? It's it's really interesting and a little bit scary on what's going on. Um, but a lot of medications in the pipeline.

SPEAKER_00 1:31:25

So that's delaying the phase three studies. Have you heard anything?

SPEAKER_07 1:31:28

No, I haven't. I haven't.

SPEAKER_00 1:31:29

I heard that from two people.

SPEAKER_07 1:31:30

Yeah. But it's it's fascinating. And so what's gonna happen is obviously one of the um barriers to these medications initially was access. Access has become um better now, although you have all these virtual platforms that are basically weight loss commerce and just selling scripts, which is crazy with no supervision. And we see that with you know testosterone as well. Um so better access, the price has gone down. So initially, I would have patients spending$1,500 per month, which gets very expensive. Now, depending on where you're getting it, we can get it for as cheap as, let's say,$250 a month for the low dose. So And this is the commercially available product, this is not a compound formulation. Yeah. So the price is, yeah, still expensive for a lot of people, but at least it's a little bit more reasonable. But the nice thing is that because there's more competition, that is going to continue to drive down the prices. So when Ozempic or Rugovi were the only game in town, yeah, they could do whatever they wanted with the pricing. Now it's really, you know, competing for market share.

SPEAKER_00 1:32:22

And do you personally think that there was a big advantage with trusepatide?

SPEAKER_07 1:32:26

Oh, 100%. Yeah, if you look at the data, head-to-head trials, trisepatide versus semaglitite, you get more weight loss. So at 72 weeks, with semaglitide, we see, you know, around 14, 16% total body weight loss with trisepatite is 15 to 22%. So as more of the of these medications come out, we're seeing more weight loss. Now, is it too good to be true? With more weight loss comes more potential complications. These drugs are now similar weight loss than we're seeing with bariatric surgery. People have to be monitored. And we'll talk about the concerns for lean tissue losses. If you're losing upwards of 22 or 25% of your body weight, yeah, you're gonna have lean tissue loss. Whether you're on GLP ones or not, there are some concerns there.

SPEAKER_08 1:33:05

Yeah. And that's what people are talking about is this profound amount of muscle loss, right? Or let's say they're on a GLP one and they stop the medicine, they gain more weight than when they started. Why does that happen? And what do you mean by the importance of a monitored program? What are so many clinics missing?

SPEAKER_07 1:33:20

Well, it's interesting. I'll I'll talk on that last point first, is with bariatric surgery, right? You had to call to make the appointment, you would see the bariatric surgeon, you would probably see there were certain things you had to do before you got surgery. You oftentimes had to see a psychologist. I think it's like a year-long process. Yeah. Depending on the insurance, you had to see a psychologist to be cleared, you had to see a dietitian, usually like monthly for at least like six months. You had to show that you could lose, you know, some sort of weight or at least not gain weight while you were on the program. You would have a bunch of baseline labs. There was a whole protocol. Then you'd obviously have the surgery, and then you may not see the surgeon after, but typically you would still be enrolled in some sort of follow-up program. So that took a lot of work and time investment. Now with these medications, if all I have to do is create some random profile online and get the drug, I could have similar weight loss, but have literally no barrier, no supervision. So that's part of the issue here is yes, I think it's phenomenal we're improving access, but we're still not providing the value that I think really comes with adequate training, not just signing a script. So what are you worried about when someone has no supervision? What's at risk? Well, a couple things. So we know that with any of these medications, really they're all about the same in the drug class. Upwards of 6% of patients are gonna stop the medication because of a side effect. And you know, 3% of those patients, um, or 3% of patients have gastrointestinal related symptoms, which is why they stop the medication. But upwards of 60 to 80% on these medications have symptoms. Okay, so side effects are very common. And the typical symptoms because of how the medications work are gastrointestinal nausea, reflux, bloating, diarrhea, constipation. So you mentioned earlier diarrhea and constipation. Yes, it could be both. Okay. And especially if someone already has. Right. And when people are, you know, pushed to go, you know, eat more protein, which is very important. If all you're doing then is eating protein and no fiber, yeah, you're gonna get constipated. These medications also have diuretic effects. So yeah, you can get dehydrated. Um, they also will kind of shut down your thirst. So if they have a diuretic effect and then you're not drinking as much and you're vomiting, of course, you're gonna run into issues. This is where the conversations are very important with that supervision piece. Now let's hit on the lean tissue losses. So I actually gave a um quick talk at the Florida Urological Association meeting this year on lean tissue losses or GLP1 specifically in men's health and the role of testosterone. Um, and if you actually look at the data, if you compare diet and exercise, GLP1 therapy, and bariatric surgery, the percent of lean tissue loss with any of these is actually very similar, believe it or not. It's about 25 to 40% of what you're gonna lose could be lean tissue. Isn't that crazy? So that's bone, that's cartilage, that's muscle, it's not just muscle. But it's similar between all three groups, okay? Now, the absolute numbers, though, are gonna be much higher, obviously, for bariatric surgery and for GLP ones because people are losing much more weight on these therapies than they were with diet and exercise alone. So, yes, the absolute numbers are gonna be higher, but the percentages are actually pretty similar. But when you look at the data, people on GLP1 therapy, even though they're losing lean tissue, their body fat still drops more significantly. So they're still losing more visceral fat and they're healthier. Now, I brought this dynometer to also talk about something when it comes to lean tissue. In my clinic, right, we're checking uh muscle mass on a Seca bioimpedance scale, which is a uh medical grade bioimpedance device. So that is only showing me muscle mass. So at least I can track on a month-to-month, month-to-month basis what that muscle mass trends look like. But what's really important is the performance, is your strength, right? Because you can have someone with a lot of mass. If you're not using the muscle and it's non-functional, why does it matter? Okay. So incorporating things like dynometers to measure hand grip strength can be very important, or like a six-minute walk test or a get up and go test. These are performance measures that actually look at what is someone's obviously performance capabilities, which is going to reduce your risk of fracture and frailty, not just how much mass someone has. Um, so that's really important. But just squeeze that and it gives you a number of number and then it can, it will tell you, you know, how low or high you are. And this can definitely be linked to risk of frailty and fracture. So I think incorporating more of these sorts of measures in our um clinical kind of toolbox can be very helpful. But yes, lean tissue losses can happen with any sort of weight loss. We need to stop blaming GLP ones. The GLP ones do not inherently cause um ozempic butt, right? The reality is our glutes are like our largest muscle. So, yes, if you lose weight and you're not doing resistance training, you're gonna see it in your butt. And that's just the reality.

SPEAKER_08 1:37:52

So then what do people know if they're on a GLP one? Like, what are the most important things that they need to keep in mind to make sure they are successful with not only their weight loss journey, but minimizing GI side effects and lean tissue loss and helping them maintain that weight loss over the long term, which perhaps could be one of the most significant questions we need to address.

SPEAKER_07 1:38:11

Yeah, absolutely. So the the easier part is losing the weight. The harder part is maintaining that weight loss as our life happens because you nor I are getting any younger and it only gets harder as we get older. And that's what's called metabolic adaptation, right? So when we lose weight, our metabolism drops. So if I'm burning 1500 calories a day now and I lose 20 pounds, that may drop to 1200 calories a day. So when I get to my weight loss goal, I'm gonna have to eat less and move more just to maintain. How do we maximize long-term success? It's by maintaining as much muscle as possible during that process. So that even though I'm losing weight and I and I recognize my metabolism may go down, the more lean tissue I have, the higher my metabolic rate is gonna be. So it's preserving that metabolic rate with preserving as much lean tissue as possible. Now, how do you do that? It requires three things. So we've talked about just like in men's health, it's hormone optimization. So making sure that my women are getting their normal menstrual periods or if they're peri or postmenopausal, potentially supporting them through it with hormone replacement therapy. So it's optimizing hormones not only with estrogen, but I use a lot of testosterone in my women. The other thing is enough protein. So these lean tissue losses are not inevitable. They can be mitigated if people are eating enough protein. And the old recommendations that the kind of RDA recommended was like 0.8 grams of protein per kilogram of body weight. I basically double that for my patients. And to make the math simple, I say aim for about a gram of protein per pound of ideal body weight. So for me, that would be at least 120 grams of protein a day. Now that's pretty hard because most people underestimate their calories that they get in and overestimate the protein. A standard chicken breast gets you probably 25 grams of protein. So if I need to hit 120, that means I need to have my chicken breast plus some edamame to get me to 35 in that meal, plus maybe a side of, you know, Greek yogurt with fruit for a snack. Then maybe I do my little ninja creamy that gets me 40 grams of protein, some more tofu. Like it requires a conscious, daily, consistent effort to make sure I'm hitting my fiber and protein goals. So that's the critical piece. And then stimulating the muscle resistance training. So let's see those muscles. There's a no-gun policy in this podcast studio. So stimulating the muscle. And that means as we get older, not only do we get um metabolic adaptation um and insulin resistance a lot of times, we get anabolic resistance. And I'm sure you all see this all the time as well, where we need more protein. We need to do more strength training, heavier weights when we're in our 40s, 50s, 60s, and beyond than we would have had to do at 20, 30, 40 to help uh minimize some of those lean tissue losses.

SPEAKER_00 1:40:34

I have an important question. And that is I see a lot of my patients come back from whoever has been writing their GLPs and they've lost a considerable amount of weight. And part of this is to feel better, but a big part is to look better. Yeah. And they look terrible because they get this and they get these sunken faces and they look like they've aged 20 years. Is there any way to lose weight and not lose it in your face?

SPEAKER_07 1:40:57

Well, we have fat pads in our face. And the reality is that we don't really have control where that fat's gonna come off, you know. So you can't spot reduce, unfortunately. Yeah. So people will, you know, oftentimes they're gonna lose it in their face, you know, their kind of their chest area first, and the last place it's gonna come off is really the midsection, which is where we'd really like for it to come off first. So you cannot um kind of determine where the fat's gonna come off. Some of it is hormonally driven as well. But minimizing the rate at which you lose, right? So we shouldn't be losing 20 pounds in a month. But that's what people love, especially on these medications, is I want to lose the quickest amount of weight or the most amount of weight in a quick period of time.

SPEAKER_00 1:41:30

Slower, you will not get that fascice.

SPEAKER_07 1:41:32

Well, I'm not saying that, but you'll maintain more lean tissue, right?

SPEAKER_00 1:41:35

But that's not lean tissue, it's fat.

SPEAKER_07 1:41:38

No, that is fat. But if people are losing pretty rapidly, then in general, they're just they're not gonna do as well. But they tend to, you know, if someone's on these medications and they're not getting enough protein or they're just underfueling, then yeah, they're gonna look gauntly. Now, if you're starting out in your 70s, you know, in your 80s and you're on a GLP1, there's not a whole lot I can do, right? You have loss of elasticity and loss of collagen and your hormones are less. So like there's a lot of things that play in cellars. Exactly. Yeah. But um, but the interesting thing is like people are getting like the BBLs and everything to like help, you know, the azepic butt. Oh, they do it all in South Florida, where they basically inject a bunch of the butt. But the reality is, we know data shows thick thighs save lives like that. We know that the larger your quad circumference, the longer you're gonna live. Muscle strength, bone and muscle, what Dr. Vonda Wright talks so much about is bone and muscle are incredible metabolic endocrine organs.

SPEAKER_00 1:42:28

So they And I'm sure we're gonna hear about that when we speak to Gabrielle Lyons. Yeah.

SPEAKER_07 1:42:33

So very important to preserve lean tissue, way beyond just having a six-pack. But when we talk about longevity, like muscle is the longevity organ.

SPEAKER_08 1:42:40

And my last question is this what do people know in terms of eating on the GLP ones? What do you mean? Like a lot of people think that if I just eat less crap, then I will be successful.

SPEAKER_07 1:42:50

Is that right? So that will work at least initially to help you lose weight. But the reality is for long-term success, you still need to eat whole foods, right? Because if you're just eating pizza, yeah, you're gonna lose weight if you have one slice instead of three. But if you're not getting your protein, you're not getting your fiber, these medications only to do so much. What I tell people all the time is these medications, they are not magical, right? They are not the magical pill or the magical jab. They will not make losing or maintaining weight easy or painless. They make it a little bit easier and a little bit less painful. Um, and so it's really the foundation, right? We have all this technology and medical innovation. We have more obesity, more chronic diseases, more metastatic colorectal cancer today than we've ever had. So medications are amazing, but without the foundation, they will not help people expand their health span and lifespan.

SPEAKER_08 1:43:34

And with that, what a beautiful and inspiring way to end our podcast.

SPEAKER_00 1:43:37

No, we're not ending because I am going to call and get an appointment to come see you. That's the only way this is going to work.

SPEAKER_08 1:43:44

Michelle, good to see you as always.

SPEAKER_00 1:43:46

Yes, thank you so much. That was really, really important. Thank you. Liked it a lot.

SPEAKER_08 1:43:51

Well, as always, I love talking to my sister. And I know you learned a lot today.

SPEAKER_00 1:43:55

I did. It was like going to a super, super doctor and getting a really extensive evaluation. As noted in my very carefully planned lunch.

SPEAKER_08 1:44:05

You know, I think so often in medicine we forget the foundation. We skip right over it. We spend billions and billions of dollars on all of this high-level research in medicine. And I'm not saying that's not important, but I'm saying the foundations are the most critical, teaching people how to eat and move their bodies in ways that promotes health over their lifespan.

SPEAKER_00 1:44:24

Yes, but Michelle went into much more depth than just the fundamentals. I mean, I learned a tremendous amount about things I thought I knew about.

SPEAKER_04 1:44:33

Yeah.

SPEAKER_00 1:44:33

And I'm sure the uh the viewers will appreciate the great expertise she brings to this area because how many times do you get to speak to somebody who knows so much about the very, very inhibit details uh about eating and not eating and drinking and not drinking? Yeah, it was uh I'm I have a lot to think about having sat and uh interviewed her.

SPEAKER_08 1:44:55

And sometimes it's not about being perfect, it's just about making that next better decision, which when we were ordering lunch, so the last time we recorded, you got a sandwich. And so today, when I asked you what you wanted to order, you got the salad and we added protein with chicken. I did. So you made your next better decision.

SPEAKER_00 1:45:12

I did, but I did mention that I felt like I was eating my backyard.

SPEAKER_08 1:45:16

There was a lot of um strange greens. Strange greens in there. So, Larry, what do you think today's final F-word is?

SPEAKER_00 1:45:23

I think it easily is food as medicine.

SPEAKER_08 1:45:26

Yeah, I love that. Okay. Food as medicine is awesome. All right, Larry, why don't you give us some foreplay for our next episode?

SPEAKER_00 1:45:33

Okay, foreplay. Uh, at our next episode, we will be sitting down with Dr. Gabrielle Lyon, a leading voice redefining how we think about muscle, strength, and long term health. This is an episode you won't want to miss.

SPEAKER_08 1:45:47

Thank you for joining us today on Fertility and Other F words.

SPEAKER_00 1:45:51

And please don't forget to like, subscribe, and leave a comment.

SPEAKER_08 1:45:55

Until next time.