The Truth About Ozempic, Wegovy & Rebound Weight Gain | Obesity Specialist Interview EP. 07

Is obesity a personal failure of willpower, or a chronic disease rooted in biology? 

In this episode of "From the Inside Out", Dr. Cass Nakason and co-host Lehua sit down with double board-certified internal medicine and obesity medicine specialist, Dr. Tui Lau Leo. Together, they break down the complex realities of modern medical weight loss, the science behind viral GLP-1 drugs like Ozempic and Wegovy, and the systematic barriers patients face when trying to access life-changing care.

Dr. Tui shares her personal and professional journey with obesity, offering a compassionate, evidence-based perspective on why lifestyle modification is often not enough on its own. We also dive into the impact of perimenopause on weight gain, the realities of bariatric surgery, the "Ozempic Baby" fertility phenomenon, and the critical importance of proper medical supervision over unregulated med spas.

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Transcript

SPEAKER_04 0:01

How effective is it? So people can expect to lose around 15 to 17 percent of their body weight. But when I see a patient in the clinic, you know, my whole thing is hey, this is not a personal failure. This is not because of a lack of willpower, like obesity itself, that's the disease.

SPEAKER_00 0:21

For Polynesians, being big isn't necessarily like a problem, it's the warrior mentality, too.

SPEAKER_05 0:28

It's like trying to find a tall Okinawan. I challenge you to find me a 100% full-blooded tall Okinawan. If you do, let me know. There's part of the genetic differences of all of us, right? You don't find petite Samoan people, they're the exception, not the rule.

SPEAKER_00 0:44

Except, you know what? I did 23 in me, and it said I was 23% Somewhere. Did you know that?

SPEAKER_05 0:50

I would believe that. Their 70-year-old or 60 or 55-year-old patient is not gonna lose 70 to 100 pounds.

SPEAKER_03 0:59

We need to help them.

SPEAKER_05 1:00

Exactly, right? That's they they're not gonna do it on their own.

SPEAKER_00 1:24

I'm Lehu Perry. Welcome back for another episode. Today we have an amazing guest with us. Um, she's my Polynesian sister from another Mr. Her name is Dr. Tui Lao Ilefwe. Um, she is working in New Ola Health. She's a compassionate and dedicated physician who has had a diverse career in different areas of medicine. She's worked in academic medicine, corporate medicine, and now has a direct primary care physician. Dr. Tui brings a wealth of knowledge and expertise to her practice. She is a TEDx speaker as well, and she's passionate about sharing her medical insights and visions for improved health care delivery. She has a firm belief in the inherent advantages of direct patient care and a genuine commitment to providing patients with exceptional care. She is double board certified in internal medicine and obesity medicine and offers specialized weight loss services via telemedicine to patients in Washington, Hawaii, Utah, Alabama, and Pennsylvania, with license pending in Alaska and Oregon as well. She's also a menopause society certified practitioner. She completed her internship and residential training at the John A. Byrne School of Medicine and University of Hoyamanoa. She is currently residing in Olympia, and Dr. Tui places a great emphasis on personalized care and building strong relationships and fostering an atmosphere of compassion and trust. Little known fact, Tui is also the Kataoke Queen and very, very talented in music. She's the most beautiful angelic voice as well. So welcome, Dr. Tui. We go back very, very, very long. I don't know if you want to tell people about oh yes, yes.

SPEAKER_04 3:09

Oh my gosh. I'm so first off, thank you so much for having me. I'm super, super excited to be here. Me and Miss Le Who are here. We go back what? We were we were just talking about um uh trying to calculate this almost 20 years a year. So can you believe that? We were both at years ago.

SPEAKER_00 3:26

The Imi Hoola program, which is I think we'll talk about it on another um episode about medical school and I think I was Imi Hoolo too.

SPEAKER_05 3:35

Yeah, that's why they were very upset when they decided to go into orthopedics.

SPEAKER_00 3:40

Hey, we need good orthopedics too, yeah. We do, yeah. So Imi Hoola is a post-back program that we um do for a year and then uh enter into the John Bear. Oh no, no, no, don't that.

SPEAKER_05 3:53

That's different then. I did some the other the community one that when you're in, they kind of oh, maybe I maybe I'm thinking of the wrong thing. Don't don't don't my memory for that is not so good. So let's just scratch what I just said there, okay? Because I I didn't do that for a year before. So it must be a different program.

SPEAKER_00 4:13

I think so, maybe, yeah. But Amy has been around for quite some time, and it's actually only I think now it's 12 when we were going, it was 10 students. Um yeah, they increased their number. I hear they did, and it's a great program.

SPEAKER_05 4:27

We should do a a podcast on medical school, getting into medical school, you know, yeah, the things that medical school anyway, we'll we'll do that another time. But um and we'll talk to some students that have been part of the e-me program, yeah, which I think would be great.

SPEAKER_00 4:40

And um, Tui, can you tell us a little bit about like where you grew up and what brought you to where you're at today?

SPEAKER_04 4:46

Sure, sure. So born and raised in American Samoa, um, and then after high school, I then went over to Hawaii, where you know, a lot of um kids growing up in American Samoa, that's kind of where we tend to go as far as the diaspora, Hawaii along the west coast, right, of the US. Um, then I went to the University of Hawaii at Manoa. I did Imi Ho'ola and then Johnny Byrne School of Medicine. You know, that's where I met Lehua and the entire gang. And after that, uh stayed in Hawaii for internal medicine residency. And then I worked at Queens for the first few years after residency, and then I moved to Olympia, Washington with my family back in 2015.

SPEAKER_00 5:30

That long ago? Right?

SPEAKER_05 5:33

Why did you and and um so you also are a certified obesity specialist? Is that correct?

SPEAKER_02 5:42

Yes.

SPEAKER_05 5:42

So was this a separate fellowship or uh uh, you know, like you're for the audience, right? You know, you go through your internal medicine residency, which is typically about three, possibly four years, and then you worked as an internal medicine doctor. And then when did you get interested in specifically helping people with weight loss?

SPEAKER_04 6:00

Yeah, so that that's uh that's a really good question. So as far as when I started to get interested in, and Lehua can attest to this because she's known me for a long time now, but I am someone who has probably lived with obesity most of my adult life, if not my entire adult life. So as we went through um like medical school, through training, as far as our curriculum, I mean, we touched on obesity, I felt like, but um, I also felt like our curriculum was a lot about um like focusing on, you know, giving a lot of lifestyle medicine type of advice, which is great. And we need that when it comes to approaching obesity management. But it was a lot of, you know, you have to eat better, you have to move more, uh, which is still the cornerstone. But you know, it it was always such a struggle for myself personally trying to counsel patients, but it's like looking in the mirror, it's like, well, I mean, I look a certain way, and yet I'm, you know, giving this kind of advice to patients. So it was a lot of um, like, how come I can't do this myself? And if I'm seeing this, you know, um, like what kind of doctor am I to not be able to um, you know, practice what I preach, uh sort of thing. So throughout training, um, it wasn't until like two, three years ago when I actually moved to Washington that I discovered that I could do this obesity medicine track, right? So there is a fellowship that you can do, but I mean, after being in attending, and then I'm I'm I was already practicing, I'm like, I don't think I can go back to, you know, just doing fellowship for this. They actually opened up a separate track where you can do independent study, right? So you can kind of you can still work whatever job you're working as a physician, but you can also um do like CME credits, um, whether that's attending conferences um or doing modules, the obesity society, you know, they have a lot of different educational resources for us to do that. So once you get all the credits, you sit an exam at the end, and then that's how you get your obesity medicine certification. So, and then every year since this has been available, more and more people are applying. And I think that's great because I feel like we need a lot more just looking at the prevalence of obesity in the United States, it's it's really quite high.

SPEAKER_05 8:30

So it sounds like with your training, it was a lot of really more self-um self-directed learning, which actually, as you know, a lot of post-medical training is right. I mean, I guess that's why they they call it practice, where you know, even for surgeons, right? You know, you learn or trained a certain way and then you try to increase your expertise with experience and obviously doing what you need to do to get better or learn more about the topic, et cetera, et cetera. And a lot of times what we're taught is absolutely not what you do in real practice.

SPEAKER_00 9:04

Yes, I know.

SPEAKER_05 9:05

So, um so that's that's very interesting.

SPEAKER_00 9:08

And I feel like culturally, I don't know if you feel this though, Tui, like for Polynesians, being big isn't necessarily like a problem, right? Exactly. We are just known as Polynesians, Hawaiians, Samoans to be bigger people, you know, it's the warrior mentality. Yeah, it's like a sign of status. And our diet now with like things.

SPEAKER_05 9:34

So this is a question that I'm gonna ask you also later is you know how you were saying that you struggled with obesity, right? For most of your adult life. I I I've really come to believe that a lot of it is just is just genetically driven. So you know, Samoan people are not small people, right?

SPEAKER_00 9:51

That's what I was trying to say.

SPEAKER_05 9:53

So whether it's accepted or not, it's because they're just big people. You can't you're not gonna find uh you don't find petite Samoan people, not often. They're they're the exception, not the rule.

SPEAKER_00 10:05

Except you know what? I did 23andMe, and it said I was 23% someone.

SPEAKER_05 10:10

Yeah, but did you know that? But you know, you but yeah, I I would believe that. No, no, no, I would believe that. But you're also what your mom's French or whatever. No, my mom's Japanese, Irish, Irish, Irish, and you're mixed, right? So your your genetic makes it cancels out. It's it's it's a mosaic, it just depends on what's expressed, right?

SPEAKER_00 10:28

It's hard though, because you have to fight against the case.

SPEAKER_05 10:30

I always tell people it's like trying to find but it's like trying to find a tall Okinawan. I challenge you to find me a 100% full-blooded tall Okinawan. If you do, let me know, right? It's just part, that's part of the genetic differences of all of us, right? Yeah, you know, yeah, like I'm lucky, I can eat whatever I like.

SPEAKER_01 10:53

It's very true.

SPEAKER_05 10:54

I I can eat whatever I like as much as I like, and I I don't gain weight. I mean, I'm I actually have to force myself to take extra protein, you know, maybe because he's a man too, uh no, but some of my friends they just eat a little bit and they get big, right? Everybody's different.

SPEAKER_00 11:10

I think women I wonder if though all women, you don't really find women who are like anything after like 40. Wow, you know, and like hormone fluctuation.

SPEAKER_04 11:21

It's hormonal.

SPEAKER_05 11:24

No, but like, you know, like for example, like my auntie, right? She's from Japan. My my uncle. Yeah, you're right. I swear to God, she can eat more than me. That's not saying much, because I've never been a big yeah, and she is like thin, thin, thin. Like I always think like, oh my god, you must have tapeworms. Right? Because how can you eat that much and stay stay so skinny?

SPEAKER_00 11:45

It is genetic, though. It's highly genetic. You're right.

SPEAKER_05 11:48

The other thing that I wanna I'm impressed about is that you said, as a physician, right, you're trying to counsel people on how to lose weight with diet, exercise, lifestyle, all of these things. But you yourself realize how difficult that is. Right?

SPEAKER_04 12:05

Exactly.

SPEAKER_05 12:06

And so this is where we bring up this topic of OZEMPIC as a weight loss drug or these types of medications that have come onto the market and seem to have uh I I would say sort of exploded and a little bit uh revolutionized how people are losing weight, right? Um because it's it is I don't know, I think as a as a you know, we're all doctors. We we all talk to our patients. But I also realize that it's you know, in in my situation where a grandma comes to me with an arthritic knee and she's uh 70 pounds overweight, right? And she's 70 years old, she is not gonna exercise and diet herself to lose 50 pounds.

SPEAKER_00 12:55

Yeah.

SPEAKER_05 12:56

I'm sorry, she's not, she has a sore knee, she's 70 years old. There's no way, and the thing that used to really upset me is that whenever I ask them, is your primary care doctor helping you lose weight? Right? Have they referred you to a bariatric surgeon, which we should have on at another program? Because I've never seen people lose weight, or it's the exception with just diet and lifestyle changes. I mean the younger, the younger, maybe younger ones, but it's it's still the exception.

SPEAKER_00 13:27

Well, Tui, can you kind of go through maybe like a stepwise approach of how you would uh approach somebody who comes to you with, you know, they're overweight or obese and they want help. What what do you I mean we always start with the diet nutrition?

SPEAKER_04 13:42

Yeah, exactly.

SPEAKER_00 13:43

I love nutrition, that's my thing, but yes, no nutrition.

SPEAKER_04 13:48

Um, so the approach really is um as far as the different pillars with um like when I was doing my study for the obesity medicine certification, it's four main pillars, right? So you've got the nutrition portion, of course, which is huge, yep, physical activity, behavioral modification, which I feel like plays a really big part. And then the final pillar, um, it's the medical treatment, right? And that includes things like medications, um, the different procedures, such as, you know, the different bariatric bariatric surgeries. So, but when I see a patient in the clinic, you know, my whole thing is I really try to emphasize to them that hey, this is not a personal failure. This is not because of a lack of willpower, like obesity itself, that's the disease. Like, I think that's big, right? Is the first realization that it's not just not you, yeah, and it's not your fault. And and like you had mentioned earlier, Cass, about this being like having some kind of genetic predisposition. Oh, for sure, for sure. We see that a lot. Um, um, especially like with the Pacific Islander Polynesian community. Um, and then there is a pyramid type of approach that we use uh when we offer um like different medication options for patients or just an approach, right? So when patients come in at the root of it, we always have ongoing, if they can, like physical activity and nutrition, right? The lifestyle modifications that we do. But but like you had said, you know, not everyone can do like, you know, running or or like intense exercise. So it really, we really have to kind of meet patients where they are. So that's kind of at the root of everything. And then afterwards, we have um different medication options, um, not just medications, but we even have a lot of different like structured medically supervised nutrition programs, whether it's calorie restricted, low carb, low fat. Um, then we start getting into the oral medications, um, injectable medications. And I'm just thinking in terms of the amount of weight loss that people can achieve with each um with each of these approaches, right? So as you go up higher on the pyramid, you know, the medication option or medical option, it gets more expensive, it's more complex, but it also there's also a greater payoff as far as far as weight loss. So and then at the top of that pyramid, we have the bariatric surgeries, and that's probably where we see um the most success.

SPEAKER_00 16:25

Is that safe now for like last resort or not necessarily depends?

SPEAKER_04 16:31

Yeah, it really just depends. And especially for our patients who come in and their BMI is already so high, um, then we we we don't, you know, and and that's something that I see other um, you know, clinicians do. It's like, well, we're we'll we'll withhold this, we'll have you start this first, and then we'll kind of reassess. And but that's just prolonging the treatment because we know obesity is a chronic disease, and we know that when it comes to lifestyle intervention, there's only a small amount of patients that can actually do strict lifestyle changes and stick to it and be able to have like some kind of sustainable weight loss for the rest of us, myself included, like that is not realistic, it's not doable. So if patients come in and they meet the criteria to start either a medication or or for certain to be considered for surgery, then I always let them know these are all the options, but bariatric surgery is actually indicated right now given the high BMI. And it's not as high as you think. Like for to start medications, for example, you need a BMI of at least 30 and without any comorbidities, um, or a BMI of 27.

SPEAKER_05 17:45

I'm sorry, repeat that. You said to be to have an indication for weight loss medications, you have to have a BMI of 30. And you do not have to have any other comorbidities.

SPEAKER_03 17:58

Nope.

SPEAKER_05 17:58

Why then is it so difficult to get patients on these medications?

SPEAKER_04 18:04

Yeah. Oh, that's a loaded question.

SPEAKER_05 18:07

Okay, wait, wait, wait, wait. You know what? Before we get into that, I want to just say how much how refreshing it is for me to hear you say, and maybe we need more specialists like you in Hawaii, because what really gets me upset is I, you know, from again, I'm as a hip and knee replacement surgeon, right? I get all of these patients come in. I have we had a patient with a BMI of 50 something, 52, right?

SPEAKER_01 18:34

Oh yeah.

SPEAKER_05 18:36

And I I'm saying, why haven't you been referred to a bariatric surgeon? And and the patients tell me, and you know, patients might might lie, so I don't know, but I've heard this on many occasions. Their primary care physician tells them, Oh, that's too dangerous, the complications are too high. And I'm thinking, yeah, but if you don't have anything done, you're gonna you're gonna die early anyway because your BMI is 52.

SPEAKER_01 19:01

Yes, right?

SPEAKER_05 19:01

So I'm thinking like these whoever these primary care physicians are that are discouraging their patients from having or being referred to. And we have in Hawaii, we have some excellent bariatric surgeons. And the patients that we've had in common, meaning the patients actually did take my advice, went to the bariatric surgeon, lost like nearly a hundred pounds. Yeah, they come back, they get their hip or their knee replaced, and they are like new people because they have this new freedom where they can walk, hike, go traveling. Yeah, for God's sake, they can fit into a bathroom stall, you know, a public bathroom stall. I mean, they're it and they've kept it off because you know we've at least gotten rid of their hip and knee pain, but they've had this weight loss and they don't want to lose it.

SPEAKER_00 19:47

So But I'm wondering if people hesitate to now that there's all these like medications that are.

SPEAKER_05 19:52

No, no, but before Ozempic came onto the market, right? There was really not a lot of options.

SPEAKER_00 19:58

That's true, right?

SPEAKER_05 19:58

There was fenfen and some of those other yeah, that was dangerous, apparently. Um, so that's been taken off the market, correct?

SPEAKER_04 20:06

Oh, I'll I'll address that. Yeah, so let's address that. Fenfen, it's like a different one, but fentramine itself, fentramine is still out there, right? Okay, FDA approved. Yeah, okay, great. Yeah, so that's still on the table.

SPEAKER_05 20:18

Yeah, but I I'm glad to hear you say that because I I think a lot of primary care physicians need to understand that their 70-year-old or 60 or 55-year-old patient is not gonna lose 70 to 100 pounds.

SPEAKER_03 20:33

We need to help them, yeah.

SPEAKER_05 20:35

Exactly, right? That's they they're not gonna do it on their own. Like, I'm like, come on, let's get real people, you know.

SPEAKER_00 20:42

Especially your specialty, right? Obesity and arthritis go hand in hand. Oh, yeah.

SPEAKER_05 20:48

And you know, the the thing, um, like you know, the people that I work with, they're always they sometimes they get a little upset. They're like, why did you agree to do surgery on this BMI 52 lady? And and I always tell them, like, well, you know, who else is gonna help them? If we don't take away their pain, for God's sake, this lady is not gonna walk more, right? We have to do something. So, yes, her risks are higher, but her risk of death is even higher if we don't do anything. Because she's gonna have pain, she's gonna be more lethargic, she's gonna gain more weight, and then do you find they lose more weight after you do the studies don't necessarily show that they do, but you would think more mobile, right?

SPEAKER_00 21:32

Feeling better, but that's their quality of life.

SPEAKER_05 21:34

Yeah, their quality of life is better. In orthopedics, there's a bad joke that we say that having a hip or knee replacement only allows them to get to the refrigerator with less pain.

SPEAKER_01 21:45

Do you know what I mean?

SPEAKER_05 21:46

That's why the studies don't necessarily show that people lose a lot of weight. However, the the removal of the pain is only one part of the solution. The other part is like what you're talking about is this multimodal attack on the This problem of obesity. So they need the help with um, you know, whatever m diet and modifications, exercise, etc. But I still believe they need uh further help medically because I just don't see it being realistic, you know.

SPEAKER_00 22:18

Um do you guys use any um any outside resources for like the behavioral modification part of everything too? Like psychiatry or psychology and trying to help that part too.

SPEAKER_04 22:31

Because part of it, um, and especially not just for medications, but even before patients get considered for bariatric surgery, right? So even if you meet the criteria, and I think for bariatric surgery, you just need like a BMI of 40 and then that's it. Wow. BMI of 40, and then that's it, and then you meet the criteria or 35 with comorbidity.

SPEAKER_02 22:51

Comorbidity.

SPEAKER_04 22:52

Yeah, and for medications, it's a BMI of 30 or 27 with comorbidity. 27. Um yeah, but before, so let's say, okay, step one, you have to meet the criteria. Step two, you then have to enroll into a program where you have to meet with a psychologist, you know, because they want to make sure that you're doing it for um not just for the right reasons, but you're of you know, you're in a good place as far as your mindset. Yeah. Because if you're going in and you're doing it because you have body image issues, for example, um, they end up losing a lot of weight. But if if that body image issue is still there, it'll still be there no matter if your BMI is 50 or if your BMI is like 20.

SPEAKER_00 23:32

You know, and it's a long-term change, right?

SPEAKER_04 23:35

It's not just long-term, yeah, yeah. And a lot of the programs and even like insurance requirements, they say you can't like we won't cover for it until you complete like six months of counseling and seeing a dietitian. And so it's pretty regimented.

SPEAKER_00 23:51

Maybe that is a barrier for some people not going for bariatric surgery.

SPEAKER_05 23:55

If it's if it has these no, no, and and and I would agree that maybe some people fail those pre um those those required assessments, right? Like maybe maybe they do have a body because this actually brings me to another question. Really morbid obesity, people with morbid obesity, I mean like BMI is 40 and above, right? I've heard from other doctors that they say, you know, it actually takes work to get that heavy. Meaning, you know, like if you were just eating sort of a normal diet, you wouldn't be able to eat yourself into that kind of a weight. Therefore, or and the reason is it usually is accompanied by some kind of psychiatric or psychological issue with, you know, body image, depression, for example, right? You might be just eat trying to eat your way out of depression, right? Like I really believe that these morbidly obese people have an a true element of depression and this a sense of helplessness. That's why they keep I there's something driving them to eat that much till you get to a BMI of 55. You know what I mean?

SPEAKER_04 25:05

Yeah, and psychologically that that makes sense too, if that's a contributing factor, but also if you think about obesity as a disease, it's chronic, it's relapsing, it's progressive. Um, but it's also like neural, it's like rooted in a lot of neurobehavioral pathways. Yeah, you know, for example, um, there's there's so many different hormones, and then not just psychologically, but things like your satiety hormones, your um um appetite stimulating hormones, all of those levels, exactly. Lept engram and all of those levels are affected. So it's it's like biology working against you. So you can even if you have like a good mindset, no depression, no anxiety, none of those issues, um, a lot of people will still struggle just because of that metabolic um metabolic adaptation. Yeah, it's hard, it is hard, it is hard. And and I'm the other thing is um, you know, like you said, it's when when patients or as a society, when you think about obesity, you know, a lot of um misconceptions, right? It's just a big misunderstanding. I know that people have biases, there's a lot of what do you mean uh misunderstanding? Missunderstanding that um I was not a disease, yeah, that it's not a disease, right? That it's a choice. Yep, it's a choice. It's like I didn't wake up today and choose this, right? Right. But it's not easy. Um, but I did want to want to point out when you have said, you know, just the primary care doctors, why isn't everybody helping them? I wouldn't necessarily say it's entirely their fault. I feel like it's the system that we've been trained in, right? Because the way that we practice, I mean, this we are a product of our education system. And if these things were not taught, and I'm not saying that it was wrong, it was just not widely known at the time.

SPEAKER_05 27:07

So I you know, I I would agree with that. I also would say that the constraints on our primary care physicians in terms of you know the number of patients they have to see and the time that they can spend with each patient, yeah, is so limited because of our the uh the payment system, right? Yes, like you know, in this day and age you in Hawaii we're constantly dealing with a doctor shortage, right? And it a lot of it is because we live in a ridiculously expensive place and the even Medicare payments are lower in Hawaii for reasons that I still don't fully understand, right? So like you know, like you you you moved away. I'm not sure what what you moved away for, what reasons, but financially it's probably better to live somewhere else, right? And you can come on vacation in Hawaii, yes, right? We can always visit, you can always visit, but you could make way more money on the mainland or in some other environment, right?

SPEAKER_04 28:16

Yeah, your butt goes a lot further here exactly to Hawaii.

SPEAKER_05 28:20

Yeah, and it's I always say this that Hawaii's lucky we have good doctors because a lot of the ones that have come back are from here, right? Family and friends, everybody's here, so they've come back.

SPEAKER_04 28:32

You're already rooted there, but but you're right, every year it's Medicare reimbursements get cut, it's you know, it's it's insurance, even even coverage for for a lot of things. I think most insurances they don't see obesity as a disease. So if you look at like your plan, your formulary, it's like all these medications are covered, but yeah, sorry, obesity medicine that weight loss medications are not covered because that's not considered necessary.

SPEAKER_05 28:57

Yeah, and that's uh well, I think these are And it's so it's so multimodal, right?

SPEAKER_00 29:02

Like even OBGYNs, we see it, right? But we don't have how am I gonna address all your hormones, your postmenopause, plus the obesity, plus right, weight gain. Um, so it's this whole discussion that takes a very long time because you have to talk about all of those pillars, plus whatever, you know, and and primary care physicians like like us, if somebody sees me about their knee, I I don't have I can't talk to them about exercise and diet, right?

SPEAKER_05 29:34

I I'm like saying, hey, you need to talk to your primary care physician, or and the primary care physicians don't have time for that either, right? It's just it is just not feasible to spend that much time with your patient. It's just not, people don't realize this. But you know, maybe before we get into all of that, let's um I just wanted to ask you maybe basic things. Like, first of all, what are your recommendations on example diet? Like, if if you were to just give a simple advice, simple advice to people who are listening, what would you say, or how would you say they should change their diet or what they should be eating or not eating?

SPEAKER_01 30:12

I know that's a really, really big question, but like you know, should they be eating more than more rice?

SPEAKER_05 30:20

Should they be eating more of just vegetables? You know what I mean?

SPEAKER_04 30:25

It's hard to give like a blanket statement because as we know, every patient is unique in their own. That's the other problem.

SPEAKER_00 30:31

And also access, right? Like people have different levels of access to food and healthy food and not canned foods, you know, it's really fast foods are cheaper. Like, I feel like access is the hugest part of nutrition because if you have access to good healthy foods, you're gonna eat that. But this is a good thing. But if you don't have that in your wallet, right, or a person.

SPEAKER_05 30:57

Yeah, but it's also choices, right? Like every people behaviorally, like for me, you know, just hanging out with different people. I noticed that some people they they'll they like to snack. I never snack. I hardly ever eat any, I just don't crave it.

SPEAKER_00 31:14

Really? Yeah, you know the only thing. I love to do it.

SPEAKER_05 31:18

Oh, wait, wait, but but why is that, right? That's that's something just in my brain.

SPEAKER_00 31:22

I don't really But do you eat a big meal? Because I don't eat like huge meals. I love to snack, snack, snack, snack, snack, snack, snack.

SPEAKER_05 31:28

I don't hardly eat anything because surgery days.

SPEAKER_00 31:31

Oh, yeah.

SPEAKER_05 31:31

I I just take I take some protein shakes.

SPEAKER_00 31:34

You just don't have the time.

SPEAKER_04 31:37

Oh the protein helping you.

SPEAKER_05 31:41

I I found a bag of sharp cheddar cheese individually wrapped sticks from I think I got it from Costco, and I'll just have that in between cases just to keep my energy up. But I don't like when I go to Safeway, I never buy cookies or you don't crave like a melanol or like a minorial. Oh the only thing I do crave is the only thing I do crave once in a while is uh the Pop Tarts, the cinnamon uh brown sugar cinnamon.

SPEAKER_00 32:12

I know, but I've never had a Pop Tart in my life. But I don't have that all the time on the never had a Pop Tart in my life.

SPEAKER_05 32:23

But I'm just gonna say that that's one of my you know things that I like to I like to eat once in a while.

SPEAKER_00 32:29

But you know, I feel like the biggest thing, again, is like if you have the means to eat well or to eat protein shakes or to buy the you know how much protein powder is? It's for like people who can like if you come from a family and you you get protein powder, or you can get seven Big Macs for dinner, right, for the entire family. Which one are you gonna do? And it's cheaper, yeah, right. So that's my thing is like I feel like they always have deals, they always have the family deal now, right? You can get huge amounts of food for cheap. But you know, I feel like it's a big a big issue in nutrition is access. Yeah.

SPEAKER_05 33:11

So anyway, what what do you recommend if you just had to make just a couple of big simple, yeah, general recommendations?

SPEAKER_04 33:18

Yeah, so um protein. Protein is such it, it makes such a big difference. Um, and for most of us, we are severely undereating our protein, right? So we don't realize that, and and usually when I have patients first start, I'm like, okay, we're gonna have you track, but don't get overwhelmed. I'm not gonna have you do this every single day. Just choose maybe at least three days where you're tracking every single thing that you're eating, and then we'll have a good idea of how much exactly, you know, as far as protein you're taking in, how much carbs you're taking in. And most of the time, my patients are severely under-eating protein, right? So that looks different for different people depending on their body weight. Usually we try to, um, if you want to do the actual calculation, I try to do like one to 1.2 grams of protein for every like kilogram in body weight. So for example, um, if someone needs like a hundred grams of protein a day, um, and then they figure out, okay, here's my tracking, here's my log. It's like, oh, you're only getting in like an average of 30 a day. Like, no wonder you're you're having cravings, you know, throughout the day, because we know that um if you think about the protein effect, um, protein gets you full faster, it keeps you full longer. So when you said, Cass, that you were kind of just snacking on protein throughout the day, I'm like, oh, maybe that's why, you know, it kind of does keep your cravings at bay. Um, and our bodies, we actually have to burn a lot more calories or we have to work a lot harder at breaking down protein compared to something like carbs. And that's why when we eat carbs and just carbs, it's like after an hour, it's like, I'm famished again, I'm starving. Like, did I just eat? You know, my appetite, it's like it's it just kind of goes through us. So the protein is a big thing that I try to emphasize. And there's so many different sources sources of for protein and not just animal protein. You can do like more lean meats, you could do um um like more plant-based protein, like beans, lentils, tofu, for example. Um, but just helping patients realize that hey, so throughout the day you're only eating this much, but you really need to be on this end. And protein builds muscle, and we know that muscle is metabolically active. So the more muscle we have, the better our metabolism is.

SPEAKER_05 35:43

Okay, so that actually is brings up another point, right? So you're saying that a good strategy for first of all is to increase your protein intake for about to about one to two grams per kilo.

SPEAKER_04 35:54

Yes, right?

SPEAKER_05 35:55

And for obviously for the audience, one kilo is 2.2 pounds.

SPEAKER_04 36:00

Yes.

SPEAKER_05 36:01

So whatever your body weight is, you divide it by 2.2, and that you get your weight in kilos.

SPEAKER_04 36:06

And then two grams is so hard to get though. So I start like maybe at least one, one, one gram per kilo, and then work your way up.

SPEAKER_05 36:13

Yeah, but you know, uh, actually, like you were talking about cost, right? Like I I seriously I think I drink like two of those um uh it's a lactate milk, you know, milkshake that you can buy from Costco. Oh, yeah. I only have one meal a day, so my food cost is actually probably pretty low.

SPEAKER_04 36:31

Yeah, right?

SPEAKER_05 36:32

Like I just like what 30 grams?

SPEAKER_04 36:34

So when you come home, you don't eat.

SPEAKER_05 36:36

No, no, when I eat dinner because I I have time to eat dinner. But throughout the day, I don't know that's all you drink. That's like I'll have the two, maybe three, because I'm you know, I need about 90 to 100. Yeah, and of course I eat dinner.

SPEAKER_04 36:52

Oh, on top of that, you're getting more than, yeah.

SPEAKER_05 36:54

Yeah, because I'm lifting too, right? So I'm trying to make sure that I increase my protein so that I can anyway. But when you think about it, I've only eaten one meal a day.

SPEAKER_00 37:03

Yeah, right.

SPEAKER_05 37:04

So it's actually probably yeah, I don't I don't spend money on buying lunch or breakfast or wow.

SPEAKER_00 37:10

You don't go to the cafe and eat no, I don't have time, right?

SPEAKER_05 37:14

We don't have we don't have lunch breaks. Even in clinic, I don't have time to eat.

SPEAKER_00 37:17

Yeah, clinic no. Eat through lunch, right?

SPEAKER_05 37:20

Yeah, but your other thing about the muscle thing, so the thing that I recommend to my patients are is the one of the things I recommend to my patients is is that lifting weights is probably one of the best forms of exercise.

SPEAKER_02 37:33

Oh yeah.

SPEAKER_05 37:33

You know, you've you and I and everybody have seen the guy on the treadmill or on the stationary bike, and they never lose weight.

SPEAKER_01 37:42

Right?

SPEAKER_05 37:43

And I I tell them because it's it's I'm not sure what it is, but with lifting weights, when you're breaking down your muscle, even when you're at rest, your body is metabolically very active, trying to heal right the the things that you've the the micro damage that you've done with the lifting weights. So you you're burning calories even when you're just sitting down, right? Even when you're sleeping. What are your thoughts on types of exercises to do that you you feel are probably best bang for your buck?

SPEAKER_04 38:16

Yeah, I do, I do like to promote, you know, the strength training, resistance training, even at least twice a week. You don't even have to do it daily. Um, and especially for my population, because I am internal medicine, a lot of it's more a geriatric population. So I have patients who have osteopenia, osteoporosis, and I tell them, come on, you gotta, if you fall down, you live alone, Grammy. We gotta make sure that you can, you know, lift yourself yourself back up, or or if not, then have one of those devices where you can press or you know, alert somebody if you've fallen. Um, so strength training is so big. Um, and I try not to, like with every recommendation, try not to overwhelm people, tell them, you know, you don't need a gym membership. There's so many things you can just do at home. Like even if you're not mobile, you can just do seated exercises, you can just use your own body weight, even if you have like dumbbells. I mean, it's it's not a huge investment, but that is enough for you to get started. That way, we just as far as barriers go, there there really shouldn't be that much.

SPEAKER_05 39:15

You know, I I try to also tell patients that um exactly the investment is small. You could just get two two and a half pound kettlebells, yeah. And I tell you, you can work you could you could get a really, really full body weight. We should do an experiment.

SPEAKER_00 39:34

I want to try. You think I would get two weeks if I do kettle bells?

SPEAKER_05 39:39

I'm telling you, if you came to Captain Sony, I guarantee you you'll feel better.

SPEAKER_00 39:43

But like mom life, you gotta make it like super.

SPEAKER_05 39:45

No, no, I know, but like easy. Yeah, you could do it at home for real. Yeah, or in the office between the office, absolutely.

SPEAKER_00 39:51

Yeah, yeah, you know.

SPEAKER_05 39:52

Um, what else was gonna say? Oh, the other thing too is I think I always try to tell my patients that YouTube has been a great resource for because people ask me, oh, what kind of exercise? And I tell them, you know, just look up kettlebell exercises on YouTube, and there are great videos that can show you very simple exercises which have almost zero investment in terms of cost. Yeah, right? It's amazing, it's amazing what you can do with just body weight.

SPEAKER_00 40:21

Tui, I'm gonna ask, oh, sorry, go ahead, go ahead.

SPEAKER_05 40:23

No, no.

SPEAKER_00 40:23

I'm gonna ask you a selfish question because I get this every single day. And okay, all the ladies out there after 40. There's everybody comes in and says, you know what? I don't, I can look at a donut and it goes straight to my butt. You know, I I've always been thin, but now I'm like 10 pounds heavier. I can't keep the weight off. I'm doing the exercises, it just seems like nothing is working. Do you get that a lot? Because I get that a lot in my tip clinic.

SPEAKER_04 40:54

That's the perimenopause. The perimenopause time we see, you know, the fat redistribution. Right. And it's so sad because like we're still eating the same, we're still eating activities, it's a different change. Like it's our body is not responding the same way.

SPEAKER_00 41:09

It doesn't respond, and that's why.

SPEAKER_04 41:11

That's why, and I think they've been looking at these medications like the GLP ones, you know, also for perimenopause weight gain, because we know that during perimenopause as estrogen, you know, there's so much fluctuation. Yeah, as it declines though, it's like insulin, um, in insulin sensitivity, all of that gets worse. Like people are at higher risk of prediabetes. And I feel like during perimenopause, there's such a huge metabolic shift that goes on that affects not just body composition, but also the way the brain works, the way that our appetites regulated. So um, and it's off label use, but I've used it for some patients like um who've experienced perimenopause weight gain. Yeah.

SPEAKER_00 41:52

And um where you're just doing everything. You're you know, I have patients working out five times a week, they're doing resistance training, cardio, they're eating right, they're trying to increase protein and it's still not enough. And it's just a you're kind of like paddling up the the stream, you know, it's bizarre.

SPEAKER_05 42:10

That that's a good segue. So, what I'm hearing you saying is increase your protein intake.

SPEAKER_04 42:14

Yes, hydration is another big one. Stay hydrated, okay.

SPEAKER_05 42:18

Hydration, uh increase your protein intake, maybe focus a little bit more on strength training.

SPEAKER_04 42:25

Yep, strength training for sure. Aerobics is still good. I mean, it's great for the heart, but as long as you get your yeah, cardio is still good, right?

SPEAKER_05 42:32

And that's the other thing, too, is I think people don't realize that weight training does train your heart too. I think they're finding that out too. So even with kettlebells, right? Or or you just do push-ups and you know uh body weight squats, you you try to do 50 at one time. It's you know what I mean? It's you're gonna get a good workout.

SPEAKER_03 42:50

Yeah, yeah, you'll be out of breath.

SPEAKER_05 42:52

Now we've gone through um exercise a little bit with um strength training, so that's something people can focus on. But what Lehoua was talking about was that you know, even though people are doing all of these things, they still need a little bit of maybe how should I say scientific or medical help. And this is where a product like Ozempic or those types of medications have come into uh use now, correct?

SPEAKER_03 43:17

Yes.

SPEAKER_05 43:18

So maybe because I I think our audience, every everybody wants to get on Ozempic, right? I mean, I I hear so many, even our nurse, I mean, nurses to you know, MAs, everybody was like, Oh god, I wish I could get on Ozempic. Maybe you can just kind of start with the very basics and tell us what is Ozempic? What what is this medication and what was it originally?

SPEAKER_00 43:40

Yeah, or like maybe the different classes, right? Because there's GOP and there's so many different ones.

SPEAKER_04 43:44

Yeah, so many different ones. But but I just want to make one more point. Sorry, I was supposed to bring it up when we were talking about the the exercise. So another thing that I tell my patients is exercise is great for you. You know, depending on the exercise, you build muscle, it's just great for overall health, but That if it's weight loss that you are after, exercise is better for weight maintenance, but it actually doesn't lead to a significant amount of weight loss. Interesting. So that's why when people start talking about like, oh, I get my my um you know cheat meal, or I start rewarding myself, you know, um by like, oh, but but it's it's it's is it mostly like calorie in out? Is that what makes and that's the thing too? Like I try not to to focus too much on calories in, calories out, because that's if you really look at the science of it, it's so nuanced and because there's so many different kinds of calories, right? Yeah, it's like 500 calories worth of something considered healthy is not necessarily equivalent to 500 calories of something not so healthy. Uh, but I still tell them exercise is great, but don't get overwhelmed by trying to incorporate exercise in, you know, um if if you're just trying to focus on a nutrition, um, because it doesn't necessarily lead to uh like a high amount of weight loss, it's more it's great for preventing weight gain or weight regain. So yeah, it's interesting. It's interesting. Um, but as far as the medications go, so you had mentioned Ozempic. Um so Ozempic, the other it's semaglutide, and now it's in two different forms, right? So semaglutide, we have Ozempic and then vigobic. So Ozempic came out. Um, the indication right now is mainly for you know type 2 diabetes when it first came out. So when the patients were being treated with not just Ozempic, even before Ozempic, um, it's actually been around for like 20 plus years, right? We've had things like Vietta, Bigurian. These injections have been, or GLP1 agonists have been around for decades, really, but it's only recently that it's really exploded in like social media or hearing about it because we see that there's also a significant amount of weight loss using these medications. So OSempic and you know other similar GLP1 agonists, the main way that it works is um it really helps to delay gastric emptying or it slows down gastric emptying. So that just means that food will sit in your GI tract longer and it just takes longer for that food to start moving through your GI tract. So that gets people full longer and people full faster. So naturally that means that their appetite will go down because they already feel so full. Um, and then if they try to overeat, it's like you already have a lot of stomach already in your in your or have a lot of food already in your stomach. So people tend to experience things like nausea, vomiting as far as GI side effects go. So for um, but that's olzempic, um, but we also have a newer one, which is terzepatite, right? And that one is um zetbound as well as um uh zetbound, the FDA indication is for obesity, but Mongerel, Mongeral, that one came out for diabetes. So it's essentially like the same medication if you think about like WeGovi and then Ozempic, and then you have Zetbound and Mongerol, same medication, but just they just basically put the same solution in different packaging. And then, you know, this one is FDA indicator for this, but it works the exact same way, and a lot of people kind of get confused about that, and I think that has just something to do with the manufacturers and the way insurance works when they when we have to do like prior authorizations to get this approved for a certain indication uh versus something else.

SPEAKER_05 47:47

But so uh my understanding is the Ozempic is an injectable form, yes, right? But there is a there is an oral form of the medication. Is that is that what WeGovi is?

SPEAKER_04 48:01

Yes, so so we go when it first came out, we govi um is a weekly injectable, but they just released the oral Weigovi just this past January. Okay, um the pen. Oh, ooh, you brought samples.

SPEAKER_00 48:20

I got sampled because I was shocked when I talked to the Ozempic person that like your first pen is different. I don't know. The injectables can stay good for a long time.

SPEAKER_04 48:33

Um they can, it can stay out of the fridge for you know, like even a couple of weeks, like up to three weeks. But yeah, but the injectable Wigovi versus oral Wigovi, the efficacy is actually about the same.

SPEAKER_05 48:45

Oh, really? I was just gonna ask which was better. So it's about the same. And how often is the dosing of the Wigovi, the oral, the pink, the oral is daily, daily, okay.

SPEAKER_04 48:55

Yeah, so you have to take it in the morning, but it's pretty strict how you're supposed to take it. It's once once every morning, has to be on an empty stomach. You have to drink it with no more than four ounces of water, and then you have to wait at least 30 to 60 minutes before you eat anything. You can't mix it with any of your meds. So for patients who have to take something like levothyroxine already on an empty stomach, it's it's really hard for them to kind of time it. But um, yeah, but um, it's a lot, it's a lot easier for people to choose the oral, especially for those who you know can't stand needles because not everybody will want to inject themselves, even if it's once a week. We have these things in here, all the needles.

SPEAKER_05 49:39

I wouldn't want to inject myself.

SPEAKER_00 49:41

Really?

SPEAKER_05 49:41

I'm such a I would be I I tell you I'm a surgeon, but I I wouldn't want to, I wouldn't want to inject myself.

SPEAKER_00 49:47

Even like a boop.

SPEAKER_05 49:49

Well, I I I I could have somebody else do it for me, but I wouldn't want to inject myself.

SPEAKER_04 49:53

Tiny, tiny needle, and it's a subcutaneous injection. So for people who are already used to taking insulin, it's like, oh yeah, it's very similar. It is, yeah. You can barely feel it, you know. But um how effective is it? So people can expect to lose around 15 to 17 percent um of their body weight. Um, if if you take either, you know, Wigovy or Ozempic. Um, and that's the average, right? So the only other medication on the market right now that's more effective than um semeglutide or you know, Wigovi or Ozempic is terzepatide. So that's the Mongero and Zet bound. So this is a little bit different as far as the mechanism of action because the um the semeglutide or osempic, that is a GLP1 agonist, but the terzepatide is a dual um mechanism, right? So it's GLP1 agonist and a GIP, and then because of its dual mechanism, um, there are actually less GI side effects. So not only is it better tolerated, but terzepatide is also more effective. So on average, people lose about 21 to 23% of their body weight if they do the terzepatide compared to the compared to the ozentics. But those are probably like the top two um FDA approved medications for weight loss um right now on the market. They're more coming down the pipeline exciting time for obesity medicine, right?

SPEAKER_05 51:24

A common um question I get from patients and you know, just family members, friends, etc., who want to lose just a little bit extra weight, you know. Um, they were saying that they cannot get the medication, uh, meaning that their the insurance won't be a lot of my ladies go to um the med spas to get it, right?

SPEAKER_00 51:45

And they might have to do that.

SPEAKER_04 51:46

That way they can get like a compounded one.

SPEAKER_00 51:48

Yeah, what is your feeling on that?

SPEAKER_05 51:50

Well, yeah, so how do because I I heard you say your BMI just has to be over 30.

SPEAKER_00 51:56

Yeah, 30 or higher. 30 or higher. And then you meet the criteria, but Ozempic, I know you can get out of pocket too for like $200 or something, right? It's a little known Ozempic, yeah.

SPEAKER_04 52:08

So the oral, yeah, the Oral We Govi, you can get it for $149 to $299 a month, depending on the dose. And there are four doses for the oral we govi pill for the Ozempic, you can get it for a couple hundred. Um, you know, they you have to use a coupon for it.

SPEAKER_05 52:26

But so this is uh a true out-of-pocket not going through insurance because I think a lot of people are trying to get it trying to get it prescribed, and they're saying that, oh my doctor will not prescribe it for me because it won't be covered. So if they're willing to just pay.

SPEAKER_04 52:42

Yeah, yeah, you can do cash pay options. So even if if your doctor is not prescribing, if that is the reason, and then um it's just a matter of of the prescriber knowing what the resources are, where to get it, got it, um, that kind of thing, like how to get that information to their patients, because we have manufacturers' keep on too.

SPEAKER_05 53:02

Um I also heard that or you know, read that these these medications can have some serious side effects, right?

SPEAKER_04 53:11

Like uh pancreatitis, I think is yes, is one of those eye pancreatitis, you have the eye findings that um that has been coming up.

SPEAKER_05 53:20

Yeah, so blindness sometimes. Oh, I didn't hear I didn't read about that. What's tell us about those things?

SPEAKER_04 53:26

I hear most times it's reversible, but sometimes there's like yeah, I forget the exact name of the disease, but I feel like if you if you go back and you look at the studies, like the people that they looked at already had they're already predisposed, like they already had diabetes, and you know, we're already um you know meant to have these complications. But it's super rare. Like if you think about all the rare, like pretty severe but side effects, like a lot of the percentage of people getting it, it was pretty comparable to like even placebo. So it does happen, and those are the big ones that I talk to people about. It's pancreatitis, um, you know, any kind of gallstone-related thing. Um, gastroparesis is another one, which makes sense if you think about the delayed gastric emptying.

SPEAKER_05 54:12

You know, but I know um I have a family member, one of my cousins is uh was on it, and he's not really big, but I guess he was maybe maybe a little bit you know overweight. But he said that what it's really killed his appetite, so he doesn't he just doesn't eat as much, and that's part of the thing.

SPEAKER_00 54:28

I heard it's the food noise, right? Because you know the food noise.

SPEAKER_02 54:32

What do you mean the food noise?

SPEAKER_00 54:33

Like because you're not a snacker, but like when you're if you're a snacker, you're like, oh chocolate sounds great right now. Oh, I'll just have like a couple MMs. Oh, I'm a little hungry. Let me, I just want a little bit of this, some of this, you know, so it's this noise constantly saying, like, oh, can I have a cheese stick now? Oh, can I have some nuts? You know, I don't know. It's like this noise that goes on in your brain. Like I'm always on the mind. Yeah, okay.

SPEAKER_05 55:01

Okay, the my other, I have to say, the only thing that I would say I've had to stop myself or try to stop myself is those stupid copico coffee candies.

SPEAKER_00 55:10

You like those? Oh man, I'm a coffee drinker.

SPEAKER_05 55:15

Yeah, snack. I guess it's not a snack.

SPEAKER_00 55:18

I guess it's got it.

SPEAKER_05 55:20

Man, I gotta that that darn thing is like addicting. Copico.

SPEAKER_04 55:25

It's addicting, man.

SPEAKER_05 55:26

Yeah, it's like it's like uh anyway. I don't know. For me it's sweet tea. But I I really try not to salty, I don't know.

SPEAKER_00 55:34

I'm gonna make a selfish PSA, or we can touch on it. But this is very selfish because a lot of my patients are on these types of medicines, right? Yeah, and we're learning more about them. We don't have a lot of evidence quite yet long term, but we've been seeing as OBGYNs the fertility rates have been going so high when you're on one of these guys. Wait, why would that be a baby? Yes, we've been seeing tons of. Why?

SPEAKER_05 56:04

Does it make women more horny?

SPEAKER_00 56:06

No, it's I don't know, but what's what's what fertility? It does. So with weight loss, that will increase your fertility. So people who have like PCOS or other sort of hormonal metabolic syndromes.

SPEAKER_05 56:25

You know, I again I I probably don't recall this, but it is it true that obesity does negatively in fact impact your fertility, right?

SPEAKER_00 56:34

100%. That is one of the first things we have.

SPEAKER_05 56:37

And that's because of that's because of a a hormonal thing, correct?

SPEAKER_00 56:41

Yes. Uh because adipose tissue is actually a hormonal um entity.

SPEAKER_05 56:47

So the adipose tissue, what what does it do? It increases your estrogen? Yes. Right? It increases your estrogen, and that actually makes you it just throws off your whole uh so everything. Your whole hormonal balance is disrupted and therefore you're less fertile.

SPEAKER_00 57:00

Yes, and so with every at least every five pounds of the body.

SPEAKER_05 57:03

So I guess if it goes weight up, you're feeling like you're feeling yourself, right?

SPEAKER_00 57:07

You're like, oh, I look good. Now maybe your husband notices. I don't know. My boyfriend. Anyway, but we've been seeing a lot of babies and pregnancies on these. So now we are actually recommending that you do two types of birth control if you do not want to get pregnant on these. So you know, pills and a concept. The efficacy, right?

SPEAKER_05 57:32

When you first think wait, wait, decreases the efficacy of what?

SPEAKER_00 57:36

Of like different sorts of birth control.

SPEAKER_05 57:38

You're talking about uh like birth control pills, pills, things like that.

SPEAKER_00 57:42

So if you're on the pill and you're on Ozambic or anything like that, it decreases the efficacy of the we're not sure. See, we don't have solid evidence yet.

SPEAKER_05 57:51

Or if it's just maybe increased sexual drive or better hormonal balance, and it's all it's multifactorial.

SPEAKER_00 57:58

You're more fertile.

SPEAKER_05 57:58

Yeah, that's the problem.

SPEAKER_00 58:00

So we if you haven't heard increased in libido, I haven't heard the increased in libido thing. It's just like I'm pregnant, I'm pregnant, yeah. And a lot of people are like, I'm not losing weight anymore. What's going on? I'm like, what's your period? Oh, I haven't had my period in like six months. Like, oh no, did you take a pregnancy test? No, guaranteed they're like three, four months along, you know. But if you are do not want to be pregnant and you're on one of these things, usually we would say, hey, if you're on the pill, please use condoms too, or please use a second method of birth control because your fertility goes way up. And we don't exactly know the exact mechanisms yet. And like I said, we're still studying things, but there's a and even CVS will send us, hey, your patient is on the pill. She's on Zip bound, she needs to be on a secondary medication if she does not want to be pregnant.

SPEAKER_04 58:52

Wow, CVS. I know.

SPEAKER_00 58:54

So guys, that's what we've been seeing.

SPEAKER_05 58:57

Hear that. Yeah. Might be more activity on Wagovi.

SPEAKER_00 59:02

So that's a secondary side effect that is actually a desirable side effect for some ladies. Now we don't want you to be on these when you are pregnant or find out you're pregnant or trying to be pregnant.

SPEAKER_05 59:14

Well, actually, uh, I haven't uh read about that those effects on what what are the dangers of being on this if you happen to be pregnant?

SPEAKER_00 59:24

Again, they're still studying it.

SPEAKER_05 59:25

Yeah, that that's I think the audience needs to fully understand that we as doctors don't have all the answers.

SPEAKER_04 59:31

Yeah, and a lot of them, like even after they give they give birth, they want to restart it. Yeah, but we're recommending even if you're breastfeeding, we don't recommend because we just don't have the studies for it, you know, because we're not gonna um willingly enroll pregnant women as far as like this new medication. Uh but like from my experience, and I don't know if there's an ongoing study now, uh, I think they are, right? Like whoa, they're looking back at at all these like Ozempic babies, Mongero babies, just trying to see if they have developed any kind of complications since their mom was on. But I haven't heard of any, and even just with my own practice, I had two patients who were trying to get pregnant. Um, they were on like GLP ones, not for that reason, but they ended up um um getting pregnant and giving birth. And as far as you know, their babies, they're they're both, you know, doing my LV, but that's just the sample size of N2. So right.

SPEAKER_00 1:00:25

I know they're doing some retrospective studies, but yeah, it would be interesting to see. Bigger scale.

SPEAKER_05 1:00:30

Okay, so bigger scale. So this issue about um un being unable to get on these types of medications.

SPEAKER_00 1:00:38

That's a big barrier, yeah.

SPEAKER_05 1:00:39

Yeah, if you're not if like it is, I would say BMI of 30 is already in the obese range, but if your BMI was say 29, right? Right, for women like like so like like for for like this is the common thing that I get, these um mothers that are still relatively young. But you know, you're in your late 30s, maybe early 40s, you really want to get rid of that little extra weight. You're not obese, right? They just want a little bit of help. They are exercising, they're doing all of this. They just gonna have to pay out of pocket, I guess, right? If they really want their Wagovier to get on it.

SPEAKER_04 1:01:15

But even if they do meet the criteria, I mean, that's just the guideline. And you know how insurance, even though there are things that are guidelines, they don't necessarily insurance might be different, right? Oh, yes, yeah. Because I have some Hawaii patients who I manage just via telehealth or BC medicine. Not once have I been able to get it covered.

SPEAKER_05 1:01:37

That's the problem with having so few insurance companies in in Hawaii, right? I mean, you know, I mean, there's um some big things going on, um, which I I probably can't speak about. But I mean, you know, that's the complaint in Hawaii, right?

SPEAKER_03 1:01:52

Is that uh the access.

SPEAKER_05 1:01:56

Oh well, it's just the the insurance may not cover this, that, or the other, right?

SPEAKER_00 1:02:01

Um and it's hard because the doctors know that patient so well, right? And you know what would work for them and you know kind of what they need, and it's just so frustrating when you're like it's not covered and they can't get what they need. It's really frustrating, exactly.

SPEAKER_04 1:02:17

And it's expensive, even the cash pay options, you know, that's like extra couple hundred uh a month.

SPEAKER_05 1:02:22

And for a lot of people, but maybe that'll offset your food, uh, your your food bill because if you don't if you're not eating as much, it's that's true, right? It's true.

SPEAKER_00 1:02:31

It's like smoking, right? Like the smokers will stop. Like, I didn't realize one pack of cigarettes is so expensive.

SPEAKER_05 1:02:37

I tell you, if if you stop smoking, yeah, you could save a lot of money, right?

SPEAKER_00 1:02:42

Yeah, I was like, what? How much is a cartoon?

SPEAKER_04 1:02:45

That's crazy.

SPEAKER_00 1:02:47

Expensive.

SPEAKER_04 1:02:47

And I try to tell them, like, hey, this is really, I mean, it is an expense, but it's more than expense. Like, this is an investment in your health. No, because we know if obesity is not is not um treated, like people are at increased risk for like 13 different cancers, like 40% of all cancers, it's all weight related. And you know, there's other there are other things that are affected, like osteoarthritis and hypertension, hypertension, there's gout, fatty liver disease, cardiovascular disease. And like, if you look at it long term, this will probably save you a lot more money down the line. You're not getting dialysis, you don't need surgeries, you know, or cabbage or whatever it is, the cost of medications that you have to keep taking, yeah, all of that stuff really adds up, you know. So this is more like an investment. So you end up saving money down the line.

SPEAKER_00 1:03:34

That's true.

SPEAKER_04 1:03:35

And that's kind of an approach for people who are kind of like, I don't know, but there are people who truly can't afford it.

SPEAKER_00 1:03:40

So do you feel like if you're on these medicines? Because a lot of my patients get them because they the insurance doesn't cover from the med spas. Do you think though, even if you're on a medication from one of those places, a compounded medication, that you should be under the kind of eye of your own doctor and your PCP, or is it safe to just like, can I just take this and just kind of see what happens? Or should you be monitored?

SPEAKER_04 1:04:04

Like with any medication, you definitely need to be monitored. And and I get scared when I hear about people getting it from a med spa because you know, we don't know what's in it. Who is yet what's in it, first of all, who is is supervising them, what are they checking? Are they being followed closely? Are they, you know, is their medical history being considered? Are they doing labs if necessary? Um, or if there are any complications, would the prescriber be able to pick up on all the different nuances? Like when would they know, like, hey, this is an emergency, these are the red flags to look out for. Because for I can speak for what's going on locally here, uh, as far as the med spots that are doing it, I ooh, we have heard some stories about patients just not being followed, they're just showing up or things are just getting shipped to them, but nobody's checking up on these things right, you know, and yeah, that's the danger in that.

SPEAKER_05 1:04:54

But I guess if you're if you're paying for it out of pocket, the smart thing to do would be to tell your primary care physician so that they can follow you and just say, hey, look, if you're if you are paying for this out of pocket and you are on it, maybe you should get these blood tests every, you know, whatever, every couple months, or check in with me about um, you know, any stomach issues or whatnot. How things are gone.

SPEAKER_04 1:05:16

Yeah. Yeah. Um, but unfortunately, so many patients won't do that. Like if they don't have a PCP or if there's somebody who's been trying to get their PCP to prescribe it for them, and their PCP is just not, you know, either not a believer of it or just not willing to do that. That is for whatever reason.

SPEAKER_00 1:05:31

Huge problem, too. I don't know if you get this, but well, no, because PCPs send their patients to you. But everybody I know who comes in to see us, there's been so many PCPs retiring. Nobody's taking patients anymore. Um, it's just it's out of control. We just have nobody who is willing to take a lot of these patients as primary care docs. I think it's just so hard to yeah. I think we're so short.

SPEAKER_05 1:05:54

I think in Hawaii where we have a and the doctor shortage is anticipated to get worse, right?

SPEAKER_00 1:05:59

Yeah, especially primary. Primary care though. Like I feel like OBG buy ends were kind of overrepresented here. Are you? I think so. I think per capita we're kind of okay. But I know that the primary care, family medicine, internal medicine is very and it's very hard to get in with them. They have either a long wait list. Yeah. And then most of the guys are retiring who are in that older generation. And then a lot of them are going to concierge medicine. Um, so you know, I get like MD V IP. Yes. That's what I hear. Yeah, a lot are going to concierge. So it's uh pay, you pay into the practice to be a patient, and then um you still have to pay out of pocket though for lab work and things like that.

SPEAKER_04 1:06:43

And or they can still use their insurance for it for the application.

SPEAKER_00 1:06:48

I think for those kinds of things, yeah. So I don't know. I feel like it's so hard because the PCPs take the brunt of most of this, and it's we have such a shortage here. I can't even give a recommendation. Oh, like about who to see. Yeah, I'll give one this week and the next week I'll get a call. Hey, we're not taking any more or they're gone. Oh yeah, yeah, that's hard.

SPEAKER_04 1:07:11

That's hard to do.

SPEAKER_05 1:07:12

So sorry, another question. So when should patients actually talk, when would you recommend patients talk or ask about these medications and the appropriateness of these medications for themselves with their primary care physician?

SPEAKER_04 1:07:26

Oh, as far as um, so whenever patients come in, um, and that's that's a discussion because if people come in and it's not addressed, because we always do weight, we do height, right? But people can just go in and see their primary care, even if their BMI is 50, it doesn't mean it'll necessarily get addressed, right? So can you imagine like BMI 50, the you know, the class of obesity, that's very, very high. Um, but can you imagine going in as a patient and then your blood pressure is like 190 over 120, um, and then the doctor never mentions it, you end up leaving no plan. So that's kind of what is happening now, you know, as far as people going in to see their doctor, it's like, oh, if if it's just it's just the approach to the obesity that is a big discrepancy compared to all the other chronic diseases. Um, so I feel like as for myself, I can speak for myself as a primary care provider. If patients come in and they meet that criteria, um, we don't, it's the approach that the obesity, you know, society recommends, it's like a 5A approach where they come first, you have to, you know, it's kind of like the approach to smoking. You have to ask permission, you have to then assess their risk factors, and then you kind of um um advise them like, hey, this is what's going on, and and these are the different options, and and assess their readiness too, as far as, you know, is this something that you want to address that you want to talk about today? Um, and if they do, then you kind of come up with a plan, you assist them, um, and then you raise it.

SPEAKER_00 1:09:00

It's a hard topic to broach, like even for because I work mostly with women, right? And it's hard to be like, hey, by the way, you're being mine, right? It's like it's a very hard to gain because I don't want to talk about my muffin top, right? Like I don't want to talk about, yeah, I've gained five pounds since I was last year, but it's a hard thing for physicians too too.

SPEAKER_05 1:09:24

I wonder if it's harder with um, I wonder if it's harder with uh uh a woman woman interaction because I I don't know. I I've I've been I've brought it up with my patients and most of them have been very uh But the men are more, right? Like, hey like everybody's gaining a little bit of weight.

SPEAKER_00 1:09:42

The men are kind of I feel more like oh yeah.

SPEAKER_05 1:09:44

I mean I I guess I talked to it in in in relation to the hip or knee replacement, right? Like, hey, you know, I think it's a good idea to make it.

SPEAKER_00 1:09:52

It's not like a body image discussion, right?

SPEAKER_05 1:09:56

Like with women, I feel like you bring weight up and it just has all these other but but the body weight has an effect on the the 190 over 120 blood pressure, right? Is it might have to do with the fact that your BMI is 42, right? You know what I mean? So I I I think but I wonder if maybe that's it's a little different. You know, like I I'm I feel bad saying this, but in my practice, I haven't really limited my BMI in terms of surgery indications because we haven't been able to show some surgeons do yacht. They do, but they do, surgeons, they do, but be but a lot of it use that as um, and you know, I'm thinking about doing it myself, but I always feel bad because I'm like, if nobody does it for this person, they they are just gonna get worse because obviously arthritis is not gonna get better, right? You're not gonna get better. There's nothing that's gonna cure it, miraculously get better. Yeah, it's not gonna get better.

SPEAKER_04 1:10:53

I mean, I wish more surgeons were like you.

SPEAKER_05 1:10:55

I don't know.

SPEAKER_00 1:10:56

That's what we really need. But but it comes with a lot more risk too, right?

SPEAKER_05 1:10:59

But it's it also it also um it depends on the on the surgeon, right? Because there are there that there are a lot of studies that show that the complication rates are definitely increased with obesity, right? But it's surgeon dependent. Oh right. So like when we looked at our data, we really can't, we don't have a statistically significant difference, right? The the complication rates are low, which thankfully, so it's hard for me to hide behind the fact that, oh, I'm sorry, your complication rates are gonna be too high. I can't do this for you. Now it's really a matter of I'm I'm getting it's it's harder to do surgery on very obese people. And there's no there's no the rear the reimbursements are exactly the same.

SPEAKER_00 1:11:47

Yes, right? So even though it takes twice as much energy and longer.

SPEAKER_05 1:11:53

It's harder. It's harder. We we have to spend more money because the 300 pound lady is not going to be able to discharge from the hospital on the same day like the 120 or 130 pound lady who's in in shape, right? Because regardless of the arthritis, if you're 300 pounds and five, two, it's hard to get off the toilet. Yes, right, even if your knees were good. So you know, it it just costs the medical system so much more. And you know, I'm I'm kind of I I've been debating, at least in my practice, of just making a say, hey, if your BMI is over 35, I'm uh we're just not gonna do your surgery. First of all, you need to see your primary care physician, get that down, because that will be better for you anyway. And I'm just it's just it's tiring for um us to have to work those put considerab you know considerably more energy into doing your surgery and taking care of you postoperatively, right?

SPEAKER_00 1:12:52

Without any I mean, even with a modifier 22, it's not they're not gonna pay you more, right? I don't blame you. Yeah, right.

SPEAKER_05 1:12:59

And it's like, but I feel bad for doing that because I'm like, you know, yeah, no, it's hard.

SPEAKER_04 1:13:05

That's that's not on you, though. I feel like that's like a systems problem. You know, like reimbursements really should be higher. They should be able to do that.

SPEAKER_05 1:13:12

They should be higher, but it's also too, it's it's kind of the responsibility of each individual person, right? To try to seek that help, you know, from their from their own. That's true, too. A lot of people don't want a lot of people are just resistant, you know. They they don't I've had many patients say I'm you know, I mean they they clearly so usually usually what I do is I make a deal with the really heavy ones. I'm like, if you can show me that you can lose, I'm not I'm not ridiculously unreasonable. I'm just saying, if you can show me that you you can lose about 20 to 30 pounds, if they're depending on size too, right? Because if they're 120 pounds overweight, I hope they can move at lose at least 30 to 40 pounds. And if they can meet me there, at least I know that they're really trying.

unknown 1:13:54

Uh uh.

SPEAKER_03 1:13:55

Yeah, right.

SPEAKER_05 1:13:56

Then then I'll do my part to help you along this journey.

SPEAKER_03 1:13:59

Yeah.

SPEAKER_05 1:14:00

But if they if you can't lose any weight, that means I kind of feel like you you really haven't, you know, put any effort into this at all. Right? I mean, even if it if even if as much as even if it entails just speaking with your primary care physician about, hey, help me, help me do this because I want this surgery, you know. But you know, I I've been most, I mean, I've been looking at most of my patients, they do at least meet some of that criteria, and then I'm like, okay.

SPEAKER_04 1:14:31

You know, but then it's like a matter of patients knowing like who to ask, what to ask to advocate for themselves, right? What's available? Yeah. So many people they don't realize.

SPEAKER_05 1:14:41

But I think I I think uh, you know, you you mentioned or Lehua mentioned earlier in our discussion that there are weight certified weight specialists in Hawaii. Uh who who are they?

SPEAKER_04 1:14:53

Yeah, do you so um you're looking at one? Yeah, I still have my Hawaii medical. Oh, that's cool.

SPEAKER_00 1:14:59

Well, can you tell people how to get in touch with you? Or because just on my website, uh New Ola. New Ola H. New Ola H.

SPEAKER_05 1:15:08

You know what? We'll we'll check posted uh for you because I I think that sometimes, like you like we said, it's not the fault of the primary care physicians, but that's not what they're there to do, right? They're trying to manage everything.

SPEAKER_00 1:15:21

But part of this podcast is our goal is to really help people. Yeah, help people and show that they're doctors.

SPEAKER_05 1:15:27

Maybe we can refer them to you as a telemedicine, as it as a separate, you know what I mean? Um to see you as uh just specifically for weight, because um I think a lot of people it's very difficult to manage all of that, right?

SPEAKER_04 1:15:41

And a good resource um would be if you go on the obesity, um like the OMA obesity medical association website, there is a section where you can just punch in your zip code and it'll pull up all the uh ABOM certified. So that's American Board of Obesity Medicine, A B O M certified like diplomats or people who have gone through the training like that.

SPEAKER_05 1:16:07

That's awesome. I think it's sorry, can you repeat that again? The obesity.

SPEAKER_04 1:16:11

Oh yeah. So um I think you go on the um OMA website, so obesity medical association, and I can text over the link that you'll do a search, right? Yeah, you just do a local search and it'll show you, oh, all these people from your zip code are that's perfect, yeah. Zip code, like these people are certified, and and if they have a practice, usually they'll have a phone number listed or their website that way if they want to see somebody um who's local, because a lot of patients do you know would prefer that to see somebody in person or or if they're there in Hawaii, you know, for the the face to the name, and they're like, Oh, so I can go in and see you physically, right? Yeah, because I know some some colleagues who have just gotten their certification. I think one person just started their practice, and and he should be listed on that website too. So that'll be a great resource for your listeners.

SPEAKER_05 1:16:57

Oh, okay, great.

SPEAKER_00 1:16:58

That's so good. Yeah, so we have one more question um about these guys. Sorry, all the medication. Is this a lifelong thing that you're gonna be on these? Or and if you do get off of them, I heard about the rebound weight gain. And is that something that's a big concern? Or is this like you what is your plan for maybe long-term health regarding these sort of types of medications for like long-term success?

SPEAKER_04 1:17:27

So because we know that obesity is a chronic disease, treatment of that chronic disease is also long-term, right? It's like chronic diseases that deserve chronic treatment. Because I feel like a lot of people think, oh, I'll go on this and then I'll stop, and then I'll be not something that's like cured, it's not something like, oh, I have a UTI or pneumonia, and then antibiotics, and then it goes and it goes away. Yeah, it's not like that at all.

SPEAKER_00 1:17:51

So it is a long term, even though you're taking the long term, even if you're taking it.

SPEAKER_04 1:17:56

And there's some people who take it and they say, Oh, it'll kickstart things and then I'll lose the weight. But we do know, like from the studies, that after you stop the medication, um, people end up gaining back up to um on average, up to like 70 or 70, 80 percent of their body weight back. Wow. Yeah. And then sometimes, like I think a smaller percentage, you know, end up gaining back more or all their weight and then some, and then some. And then that's why like I've heard some pen some patients say that, well, I don't want to like be dependent on it. And then, you know, that means if I, you know, and then it's gonna cause me to gain all the weight back if I lose it. So I'm like, well, it's not, it's not necessarily because of the medication, like with any approach that you have to weight loss. If you don't do all the things that you need it to do in order to lose the weight, which I think that's diet exercise.

SPEAKER_00 1:18:48

The biggest point.

SPEAKER_04 1:18:49

Yeah, like once you stop whatever was effective for you, the weight's gonna come back. Same thing with the medications. The medication we know doesn't just help with appetite, it helps with um, you know, like with cravings and there are a lot of off-label uses now too, right? So we see that there's like a huge anti-inflammatory effect. So people who have things like rheumatoid arthritis who are on pain meds, you know, the quality of life has improved because they're not needing as much. Um, even with like alcohol use, right? So we've seen people aren't drinking as much on it and and it affects the mood, and so just a lot of different things or benefits other than just the weight loss. But there is, you know, um a weight rebound or weight regain that happens. And I think just a couple of months ago, was it the NIH? They just announced that that not only do they think that obesity is a chronic disease, but it also deserves long-term treatment, long-term management. Yes. And the analogy that I like to use, I was using blood pressure a lot, and then I am like, well, that's not a really accurate analogy, where you know, like you put somebody on blood pressure medication, then they're well controlled. It's like, congratulations, and now we're gonna remove the blood pressure medication. We don't do that, boom, right? We don't do that. Um and it's kind of like a better analogy would be something like somebody who needs glasses, right? So if somebody has myopia, we know that that is the problem, right? And and we give them these tools like contact lenses, glasses, and then the symptoms go away and they do much better, but it's not like they're cured. We still they still have to continue to wear that or use that tool because once we take it away, it's like, ah, the problem is that so it's kind of like that, but then the issue is insurance companies don't understand that concept, right? Society as a whole doesn't understand that we're still out here shaming people for trying to get help so they can live longer, so they can spend more time with their families, so they can just have a better quality of life. And we're not out here shaming people for wearing glasses, we're not out here shaming people type one diabetics for taking insulin. I mean, it's just understood that yes, that's a disease, yes, that needs long-term treatment.

SPEAKER_05 1:20:59

So I think um so I I I kind of like the alcohol, the alcoholic uh because alcoholics have to be, it's a multifactory, right? There has to be a behavioral genetic. You have to if genetic is behavioral, you have to understand what your specific problem is, right? Yeah, like you said, if you are a snacker, you gotta understand that and you gotta realize that okay, there are some behaviors I have to try to decrease, right? Yeah, you know, and all of these kinds of things.

SPEAKER_04 1:21:29

Um they're really looking at it for addiction medicine.

SPEAKER_05 1:21:32

No, I was just gonna say, I just I read also that they are using it or they're finding new uses for addiction and things like that, which is really interesting. But so to recap, I think this idea of managing it long term, right? It's diet, uh trying to increase protein and not eating so much of the other things, right? Trying to stop it. Maybe, maybe in including strength training into your um into your activity, you know, or exercise regimen, right? And then I think too for the listener to also understand that this is a multifactorial problem, meaning there is a behavioral issue, there is a psychological issue, you cannot change your genetics necessarily. Right, there is a genetic issue, there's no doubt about it. But you can't change that, right? You can't change your genetics necessarily, although I, you know, anyway, we won't discuss that too much. But so I think you know, some lifestyle changes and realizing that this is this is a disease that you have to manage long term with constant vigilance on your life in terms of diet, exercise, right, food choices, etc. And and you know, if you need the help of some medications, right, you need the help of some medications like that. Nothing wrong with that, there's nothing wrong with that. Just like high.

SPEAKER_04 1:22:57

Or if you need surgery, as long as you're a good candidate and you know you don't have any big contraindications, that those are very, very um useful tools.

SPEAKER_05 1:23:07

Well, I think that was pretty good. Yeah, that was very good. Thank you very much.

SPEAKER_00 1:23:14

Oh, you're very welcome. I I enjoyed chatting.

SPEAKER_05 1:23:17

Oh, I so glad thanks, thanks for agreeing to do this. Yeah, we really appreciate it.

SPEAKER_02 1:23:23

No problem.

SPEAKER_00 1:23:24

Is there anything more that you wanted to like let everybody know?

SPEAKER_04 1:23:28

Or no, I think um, well, there's so many things that I get on my soapbox and then I won't stop. That's good. But I think that's that's the main, that's the main thing that I, you know, if if people are out there, if if you're someone who's struggling with your weight, just know that it is not a personal failure. Um, and we're we really are trying, like as a medical community, I feel like we really are trying to make that um have that be different, where it's less about blame and it's more about focusing on um on the treatment, right? And making sure that patients are aware of those options, um, and then making sure that we're offering it to them too, without all the the blame and right unnecessary fluff that comes with.

SPEAKER_00 1:24:14

And a collaborative effort, I feel. Because look, it touched all three of us and we're all in different specialties.

SPEAKER_05 1:24:20

You know, and you know, I always I always tell tell patients who are overweight, you gotta always look on the bright side, right? You can change your weight. Unfortunately, you kind of change your height.

SPEAKER_00 1:24:31

Oh okay.

SPEAKER_05 1:24:34

When uh medication that's gonna make me taller, you know, let me know.

SPEAKER_04 1:24:38

Okay, high platform shoes.

SPEAKER_05 1:24:42

So you know, there's always always you gotta always look on the bright side.

SPEAKER_04 1:24:45

That's true. That's true, right? That's true, yeah. Silver lining to everything.

SPEAKER_00 1:24:49

So well but it's what's the in on the inside that counts, right? That's true from the inside out.

unknown 1:24:56

That's right.

SPEAKER_05 1:24:56

Well, anyway, thank you for being with us. This is really yeah, and they said that you you did do a TED talk as well, correct?

SPEAKER_04 1:25:04

Yes, yes, yeah. Um, it was um, I don't know, can I oh very briefly it was it was all about the importance of disaggregating data, and it's a concept that's not new to us. Like in Hawaii, we know that because we have so many populations, yes, um, and I focus more on like Pacific Islander populations, how if we are being lumped under the you know Asian Pacific Islanders all the problems and the issues that we have as Pacific Islanders, and then that way if there's no spotlight, we don't get resources, we don't get, you know, unfortunately, it's such a small percentage of the population that you know actually we we've actually done.

SPEAKER_05 1:25:43

Pacific Islanders, yeah, yeah, Pacific Islanders. It's a very small proportion. I actually we actually did some studies looking specifically at outcomes for hip and knee replacements regarding um native Hawaiian Pacific Islanders, right? Because it's a very poorly uh reported on population because on the mainland that there's it's so small.

SPEAKER_00 1:26:02

Hawaii so tiny, but I hear a lot more, yeah.

SPEAKER_05 1:26:05

A lot more, obviously. Um so but anyway, uh I think we're supposed to say for our viewers, I always hate this, I feel like we gotta but you know if you can um subscribe like and subscribe um to this station. Uh you know, I I guess it helps with the algorithm.

SPEAKER_00 1:26:23

Yes. Um so and go and find Tuna.

SPEAKER_05 1:26:26

Yes, and you can we'll we'll try to get help those resources posted like send it to um to Ryan.

SPEAKER_00 1:26:34

Okay, great. Sounds great. Well, thank you very much. Thank you so much for having us with you today. Thank you. I hope they get to meet you in person sometime.

SPEAKER_04 1:26:43

I know, I know, like come back there and what we gotta catch up and we have to hang out because you have to hear her kada okay.

SPEAKER_00 1:26:50

Oh, she is the kada okay queen of all time. Let's do it. She has the best new she has the best voice. That's that's awesome. She can treat, but thank you.

SPEAKER_04 1:26:59

She can say, We just like to have fun, you know. We gotta do it in medicine as doctors.

SPEAKER_05 1:27:05

You know what it's the funnest.

SPEAKER_00 1:27:07

I mean, she's fun now.

SPEAKER_05 1:27:09

We can do it at my dad's office. My dad has an office building, he has a conference room. I can set it up, it's completely private with mics and everything, and it's fun because you know, I don't know, maybe the rest of you are not so embarrassed about singing, but I don't want to go through the show. Oh, no shame here.

SPEAKER_00 1:27:23

You don't go. I wouldn't know. No shame.

SPEAKER_05 1:27:26

She can sing, but I just I hate singing in front of other people that I don't know. If it's friends, then it's fun, right?

SPEAKER_00 1:27:32

Of course. What's your what's your kata go-to, Tui? What's your like number one?

SPEAKER_04 1:27:38

So many. Oh so many lately, it's been purple rain. Oh purple rain is back. I mean, it never went away.

SPEAKER_00 1:27:48

That's not an easy song. I like um Edith's Piaf. What is it? No regrets. You gotta sing it in French because if you don't speak French, it's even better. And you just yell.

unknown 1:28:01

Yeah.

SPEAKER_04 1:28:02

Oh, you gotta do it like well. No, yeah.

SPEAKER_00 1:28:05

And then Kleiner, his number one is Stroken. Have you ever heard that song? Stroken. It's the funniest strong. It's the funniest. Claren somebody sings it. I'll be stroken. Oh it's so funny. Oh my gosh, Kleiner. Oh, we gotta have to have Kleiner there too. Gotta gotta. That'll be fun. Thanks so much, Tui. Thanks for we took a lot of your time. I'm sorry, but thank you. No, no, no, no.

SPEAKER_04 1:28:30

I've enjoyed it so much. Thank you for having me. Appreciate you.

SPEAKER_05 1:28:35

Bye bye.

SPEAKER_04 1:28:37

Bye.