Obesity may be the most misunderstood chronic disease in medicine. For decades we told people to eat less and move more, but the science says our weight is regulated by biology we don't control, in the same brain region that runs our reproductive cycles. Dr. Angela Fitch, past president of the Obesity Medicine Association and one of the country's leading experts in obesity medicine, joins me to separate what's real from what's myth in the world of GLP-1s.

Angela's fascination with metabolism started back in her chemical engineering days and carried her through residency, ten years of primary care, and eventually board certification in obesity medicine, where she's spent the past fifteen years building non-stigmatizing, comprehensive care for patients, including her current clinic, Knownwell.

We start with the question I hear constantly: why does obesity carry so much stigma when we treat it as a chronic disease like diabetes or hypertension? Angela traces it all the way back to Hippocrates prescribing treatment for "gluttony and sloth," through insurance systems that carved out obesity treatment as cosmetic, to the willpower myth that still shapes how patients are treated in exam rooms today.

The science behind why weight loss is so hard is more interesting than most people realize, and Angela is one of the few people in this field who can explain it without making you feel like you're being lectured.

We get into how these medications work, what they do in your brain, and why the conversation around them has become so loud. We also answer the questions that come up most frequently in my office and online, around muscle loss, microdosing, and whether compounded versions are safe, and Angela is refreshingly direct about all of it.

For the women in perimenopause and menopause who feel like their bodies stopped responding to everything that used to work, this episode puts language to what you're experiencing and gives you something real to bring to your next appointment.

Highlights:

• Obesity is a chronic disease, not a willpower problem.
• Why your body actively fights weight loss.
• What GLP-1s actually do and how they evolved.
• The truth about muscle loss on these medications.
• Compounded GLP-1s: what you need to know.
• Why access and coverage still fall short.

Get in Touch with Dr. Fitch:

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Get in Touch with Me:

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Hey y'all, it's me, Dr. Same Ramon Gyno Girl. Welcome back to another episode of Gyno Girl Presents Sex, Drugs, and Hormones. I'm Dr. Same Rahman.

today I'm super excited to talk about an such an important issue, such a trending issue, I think. I wanna say that obesity is probably one of the most misunderstood chronic diseases in medicine. I think that for decades we tell people to eat less, move more, but we know it's more biologically complex than that. And when you add menopause or hormonal dysregulation into the equation with changes of estrogen and your muscle mass and sleep and insulin resistance, all the things.

Women might feel like their bodies just stop responding to their normal thing that would work in the past. I've patients tell me every day I used to be able to eat this and and work out this way and my body will always respond the same way. but today we're we're talking to one of the country's leading experts on obesity medicine, Dr. Angela Fitch, who is going to tell us what the science says and what what women should be doing and what's the latest with when it comes to GLPs. So thank you, Dr. Angela Fitch. Thank you, Angela, for joining us today.

Yeah, thank you for having me. It's a pleasure.

I'm excited for this conversation. I I like, you know, my tag name is Gyno Girl, so I love a good backstory. So I want to know what is your backstory? How did you come into the field of obesity medicine and you know why did you decide to like really hone in and become the, you know, one of the leading experts in the world on this? So

Yeah, it's a good question. I always, even in medical school residency, I just always was fascinated by metabolism. You know, like how does this work? You know, like we eat food and then we, you know, use it for energy and we store it for energy. And, you know, I just I think my undergrad was in chemical engineering. So I, you know, was always sort of interested in those processes that happen, right? And

You know, one of my sort of that you'll appreciate, you know, like my favorite conditions during residency was PCOS, now PMOS, right? and I was always just fascinated by it. Like, this doesn't seem right. Like, why is this happening to people? That's not good. Like, you know, and and so again, just I think that love of that drove me, you know, I went into internal medicine and pediatrics. So I'm double boarded in both specialties and I did primary care for 10 years and took care of full service, you know,

Yes.

Yeah. Why is it great?

both men and women, but you know, from birth to death, you know, the whole spectrum. And but out of the during that time of doing primary care, I just like you said, people would come in, they'd be like, How do I lose weight? Well, this was, you know, 25 years ago. We didn't know what we know today about GLP one and and other types of treatments. And we just, you know, we had to just, like you said, we tell people, well, eat less.

Sure. Sure.

Exercise more, go to Weight Watchers, you know, it's like this this this and I'm like that yeah, I'm like that just can't be the answer like alone. And so I at the time, you know, there were no real fellowships in obesity medicine. Now there are. You can actually do a fellowship. there's multiple fellowships across the country. So there you can do a year, you know, of getting extra training in obesity medicine. But back in my day it was, you know

Yeah. Yeah.

Right, right, right.

train on your own and go to conferences and shadow people. And so I shadowed some of the experts in the field and and then got board certified. And then when I got board certified in twenty twelve, I then shifted and spent the the vast majority of my recent career, you know, the past 10, 15 years, you know, really sort of focusing on obesity, you know, building comprehensive places where people can come and get

unbiased, non-stigmatizing care. And then the other piece of me is really all about education. So, you know, I love educating people. I was the president of the Obesity Medicine Association, which is our scientific, you know, physician, you know, community organization to support each other and make guidelines, etc. So I'm really passionate about education, about advocacy, and about

Yeah.

you know, doing research as well. We're doing, you know, clinical trials right now at my clinics. So I mean, I'm just really passionate about advancing the field and getting people the help they need.

Wonderful, I love that. why do you think like when we think about obesity as a chronic disease, but yet there's so much stigma around it, like compared to diabetes or hypertension, you know, chronic diseases, no cure for these things, right? We know it's a something you have to live the rest of your life with. but it's just there's so much stigma and negativity around it. Why do you think that it's had such it's viewed been viewed so differently?

Yeah, well, it comes out of the right, even so I use this in a lot of my lectures in 500 BC, which was before Christ, you know, not before COVID, right? It's 500 BC. It was a long time ago, you know? it was a long time ago. And Hippocrates, who's considered the first sort of physician, you know, right, of of the times, you know, he said the way you treat obesity, so they even had obesity in 500 BC.

Right.

And he's it's written down in his books or tablets or whatever. It's written in, you know, that in that you the way you treat obesity is by treating the gluttony and the sloth, right? So you stop eating and you move more, right? And so there was just always this for centuries, we've had this mantra and we've just never spent the time until recently.

Yeah, yeah.

To really, you know, look at the scientific causes behind it. It was always just a calories in and calories out. But if you look at calories in and calories out, I mean they're still important, but they're not just that, and they're not controlled by us. Like just like we can't control our reproductive competence, we can't decide that we're going to be fertile or not, right? I mean, it's there are cycles and we go through them and we as women can't say, I want my cycle to be today, right? I mean, with

Yeah. Yeah. That's true.

With pharmaceuticals we can, but you know, but but but by nature we can't. And that's it's very similar because you know, these things are controlled in our hypothalamus, which is an area of our brain that we don't have control over, you know, by you know, willing it so, right? And and that is very much the truth, you know, of of our weight as well, and and the control of that and how it's affected by

Yeah, yeah, exactly.

our genetics and the environment around us and and all of these things. So it's just it hasn't we haven't put the scientific resources and energy and and research into it. So because of that, it has become this, it's you know really I think what's fundamentally wrong, and I say this a lot and we'd we do a lot of advocacy,

Yeah.

Yeah. Yeah.

s and if they want treatment for it, something like surgery at the time, for example, barech surgery, you know, that's a that's elective for them, just like having a facelift. You know, you can choose to have cosmetic surgery, but you're doing it cosmetically. And that was always the thought is that, you know, losing weight was a cosmetic problem, not actually a medical problem. That the that and so now that we know that obesity puts us at risk for all these other conditions, type two diabetes, hypertension,

All right.

Heart disease, you know, all of these sleep apnea, fatty liver disease, you know, all of these conditions are really driven by this excess adiposity. Odiposity is the, you know, fancy word for fat, right? So that we don't have to say that word. But, you know, our excess body fat is what leads to this these other metabolic diseases that you're hearing about now.

Yeah. Right.

Yeah. And I think for so long we're like, it's a willpower issue. That person doesn't have the willpower to like b stay skinny or you know, whatever the case.

Yeah.

And and people feel that way, right? I mean, as as humans, you know, because we hear this constantly, you know, and

You know, people will even say, for example, that they went to a doctor, a well-meaning doctor, and that person just told them, no, you don't need medication, you can just do this. But the in people might say, Well, why do the doctors still say this if it's not true? Well, because again, the doctors are part of society. And so unless they get specific education and understand that this, and that's what we're working on more and more, is educating everyone, not just the public, but also all of the healthcare system, that this really is, you know, not a

Willpower problem that it is a complicated condition, like other complicated conditions that we have, where we treat them with surgery, with medication, and with lifestyle intervention, right? It's not that you you don't do lifestyle intervention, but you shouldn't do lifestyle intervention for the intention of necessarily losing a lot of weight. It just doesn't work that well for weight loss.

for a few people it will. And if you are able to make enough changes in your lifestyle, if you're really going from zero to a hundred, like you know, you're you're not doing any physical activity and now you're running marathons, but it takes that level of of increase, unfortunately. And for a lot of us, we can't fit that into our daily lives for various reasons. I mean.

Right, right. And I kind of feel like even within bias in medicine, like some of the frontiers that we haven't really conquered yet are around ableism or around, you know, obesity and how we treat, you know, people that suffer from obesity and overweight conditions. So I do think that it with even even that stigma is so much ingrained in the medical community, right? We're product of our culture, right? So

Right.

Which is why we of our own culture. Yeah, exactly. And that's why we built known well as a clinic was to really enforce that, you know, we are going to be a non-stigmatizing, unbiased place where you can come and get care, all types of care, right? Because we also know there's data to show that women with obesity don't get their mammograms as often as they should, or they don't get their GYN exams as often as they should because they are embarrassed by their weight or that the gown doesn't fit or that

they almost like tip the table over because they're trying to, you know, in those these old tables we used to have. I remember distinctly when I was in primary care. I mean, these old exam tables were not necessarily, you know, designed to hold people of size. And, you know, you would get yourself in those stirrups in that certain position and, you know, the table would start to like turn, you know, right. And and it's that's not the way it is today, thankfully, with some of our new equipment. But

Yeah. Yeah.

Right.

Yeah.

I know.

you know, we made it specifically in our clinics that we have equipment and chairs and everything that that don't make people feel like that they're trying to squeeze into them or you know that that make them feel comfortable in their body, you know, and the other thing that, you know, people with that live in larger bodies, you know, get a lot is they get blamed for their other conditions around their obesity inappropriately, right? And so that's the other thing is they might, you know, people might say to them,

Yeah.

Well, your knee just hurts because you have obesity when they just were, you know, maybe they've lost already a hundred pounds. They're still living in a larger body, and nobody looked at that data and they just think, your knee just hurts because you have obesity. Well, no, I was actually playing pickleball and I actually like hurt my knee. Like it's not because I have obesity. So can you please like check it out? Right. And we shouldn't have to like

No.

All right. Yeah.

Yeah. Yeah. Yeah. Yeah.

do that, right, as patients, 'cause you know, we people shouldn't assume that just because we have some sort of condition that that it's that it's necessarily because of our weight.

Absolutely, absolutely. And just like sex, obesity starts in the brain, right? Like I think that like that's something we should think about, like what's happening let's talk about what happens in our brain that makes long term weight loss so difficult for people.

Yeah.

Right.

Yeah, well it's you know a mixture between not only our brain but our gut. You know, so there's this I idea. I can't remember who said this recently, but I thought, that was profound. But, you know, maybe it was even at our conference we were at recently. Someone said that, you know, like that that like there's our our, you know, we have like two brains, right? One of our brains is in our head and the other one's in our gut. Because our gut does do a lot of stuff neurologically, right? I mean, it has nerve endings and we know there's a lot of other sort of

yeah, this is an idea. Yeah.

Sure, yeah.

you know, s significant things people get relative, yeah, the hormones that get released by the liver, et cetera. So the idea is there's this intricate relationship between our brain and our gut that therefore together really try to maintain our weight, right? Meaning what I tell people all the time is the issue is with with losing weight

hormones in our

intentionally, you know, because you want to, is that it's not normal to do that. Just like it's not normal to sort of for us to sit here and look at each other and try not to blink, right? We cannot do that. Like we would just like one of us has to start blinking because the human body blinks its eyes in order to protect, you know, the surface of our eyes and keep it from drying out, right? It's a protective mechanism. The human body has a protective mechanism in which it wants to maintain its weight, right? It wants to put its weight back on.

Yeah. Yeah. Yeah.

Yeah.

So the minute you intentionally start to change that and you intentionally start to lose weight, the human body fights back with all sorts of biological neurotransmitters back and forth in order to promote you to eat more, to promote you to move less, actually. There's data to show that when people are losing weight and they're even like working out and and you know

doing lifestyle interventions, that then they move less other times of the day because the body's trying to conserve its energy, right? It's trying to, you know, stop itself from expending more energy. So you have to, you know, it's it's very challenging to get past that with just sort of your your own willpower, if you will, right? Because you just can't, it's very challenging to override these, these basic biological survival mechanisms, right? and

Yeah, yeah, yeah.

Hundred percent, yeah.

And so when those things change, it makes it harder to maintain that weight loss even, right? There's data to show that most weight is regained within two years of losing it if you're not having some sort of medication, et cetera. You know, to to help you, just like, you know, your, you know, period would come back if you weren't taking medication to make it stop, right? and and so, you know.

Good night.

Yeah, yeah.

that's fine if you want it to come back, you know, if you want your weight to come back, but not fine if that's what, you know, what you're trying to prevent. Yeah.

Yeah, yeah. Yeah.

their goals are. Yeah, exactly. and so, you know

Right.

Or something that I would that that I would use Ocemvic with them and actually it was interestingly covered for a short period of time. Like it was weird. It was like, Okay, they failed metaphor and and they got on it. But Yeah. I was like, wait, it was I remember it was so cheap for those patients back then. But

It was a go we we we call it the golden years because it was like it was a very good time.

Yeah, and I was just so it was such an impressive thing. And so let's I wanna talk and transition, you know, talk about GLP ones because obviously that's what everyone talks about when it comes to obesity, because I think it's the mainstay in management now, right? It's like such an effective, like almost like it's I always say it's like a really a next level medication for so many reasons. But can you talk to us about, you know, what are what is GLP one, like what are what are the combination medications that we have and why are they so eff effective?

Right.

Well, you know, there are multiple of what we would call these incretins. So the the bigger name for all of these, GLP1, GIP, glucagon, amylen, all of these neuroendocrine hormones, we call them incretins. That's a the fancy word for that group. Cause GLP1 is is one of those types of of hormones in our body, and that's glucagon like peptide one.

Yeah.

And then, you know, again, we have GIP, which is gastric inhibitory polypeptide, which again, now it, you know, as far as we have all of these things in our body ourselves, right? We make them naturally. And then nowadays pharmaceuticals companies have been able to reproduce that, but in a way that really gives us longer lasting effects of those medications. Because your own GLP1, what happens is, you know, when I when I eat something, let's say,

Yes.

For example, Thanksgiving. This is a classic example I give people. You eat Thanksgiving dinner. It's usually very, you know, lots of food, right? Because it's a celebratory thing and we're celebrating and together with family and it's social and it's a thing to do. And we're having this big Thanksgiving meal.

And so you're sitting there and you've ate your meal and everything, and then you're like, Should I have a piece of pie? Right. And you're like, I should of course have a piece of pie because it's Thanksgiving. You know, that's what we do is we have pie. And you're not like super hungry, but you're not like overly full. But then, you know, you have this piece of pie, and 20 minutes later you go sit down on the couch to watch football or hang out or whatever. And then you're like, my gosh, I shouldn't have had that piece of pie. Because you're like way too full, right? Because that because your GLP one, your own GLP one, kicked.

Yeah.

Right.

In because it takes about 20 minutes for our own GLP1. That's why we used to tell people behaviorally, we'd say, you know, wait 20 minutes until you have a second helping. Like if you're still hungry after your first helping, you know, wait 20 minutes and then if you're still hungry, go ahead and have another helping. But you know, you because it takes time for that GLP one to be made by our stomach. So when that food hits our stomach, our stomach makes GLP1, it goes back up to our brain. Our brain then tells our stomach, you're full, slow down. Like, you know.

Yeah. Yeah.

it slows down the emptying of our stomach and then we feel full. But that process takes a a that that period of time. And then it also, our GLP one in our own natural conditions, only lasts for a few minutes. So it doesn't last for like a whole week like the medications we have today. So it's very challenging to sort of you'll see a lot of these things being sold on

different supplements and things saying it'll increase your own GLP one, you know, and that just doesn't work, unfortunately. I mean, we wish it did, but it just doesn't work because it your own GLP one is only around for a few minutes. And so it doesn't, you know, help you longitudinally across the whole day or hot across the whole week. but

Right, right.

Now, you know, because we know this science of how all these biological hormones interact with each other, we're able to manipulate them with pharmaceuticals, which is what we do with a lot of conditions, right? Is we, you know, we replicate these. It's been, you know, the first GLP1 medication, you know, came to market for diabetes 25 years ago, right? So this has been a long time. And the reason why we could get people, yeah, new thing.

Yes. Yes. Yeah. Which is the myth everyone thinks, like, this is a new drug. Like no, it's not new. It's not new. Yeah. Yeah.

It's been out for a long time. Now they've gotten better. The first ones we had, you had to take them twice a day. It was injection you took twice a day. And then we were able to get to a once-a-day injection, which was laraglide or victosa or sexenda for weight management. And then we were able to get to a once a week, which was Ozempic and Wigovi. And so when we got to that once a week, that really was where things changed a lot because the efficacy of these.

you know, science kept getting better, which thankfully it does, right? I mean, we get new cancer treatments and we, you know, as scientists we investigate and we figure out what's better and and things get better, right? And so when w the real differential was when Ozempic came out or smagglotide.

Yeah. Yeah. Yeah. Yeah.

Yeah.

Now you have a medication when people take that medication in addition to their lifestyle, you know, interventions, right? Now 40% of people taking that medication at the end of a year, okay, 40% of people are able to lose 20% of their weight. If you look at lifestyle intervention alone, like Weight Watchers, good, you know, they study these types of lifestyle interventions a lot. That's one good thing that Weight Watchers, for example, as a company does is it does a lot of research. And if you look at their

Programming, only about 5% of people are able to lose 20% at the end of a year on Weight Watchers. So, and when you think about 20%, people might say, well, that's a lot of weight loss. Well, no. I mean, you think about it. If you weigh 250 pounds, that's losing 50 pounds. 20% of 250 is 50 pounds. Most people, if they're 250, would come in and say they want to lose 50 pounds, right? Like it's not unreasonable. In fact, some people might say they want to lose 100 pounds and go back to 150, right?

Crazy. Wow.

Yeah, yeah.

which is what what we have to recognize, what we have in the world too, society, is we have a over estimation of what the human body is capable of biologically.

Yeah, yeah.

Again, when we come in and if we weigh 250 pounds and we want to be 150, which isn't necessarily unreasonable for somebody, you know, like being 150 pounds would be, you know, normal body weight for someone like myself at my size, right? But like if I was 250, that would be a hundred pounds that I wanted to lose. And that would be 40% of my weight. The science says that that's extremely challenging.

To do without surgery and medication, right? Like, and it'd be like saying, you know, I want to cure my breast cancer with just herbs or something. I mean, people, you know, wouldn't be able to do that. They do that, but I mean, that's most of us, most people would say that's unrealistic, right? If you asked most of your listeners, how do we treat breast cancer? They would say surgery, radiation, chemotherapy.

Yeah. People do that too. Right. Then I'll do it well.

Yeah.

And that's not because anybody wants those things. Nobody wants surgery for breast cancer. Nobody wants radiation therapy, but they do it because they know they they they want the best outcome. They want the best treatment, right? And so they need that surgery to get the best treatment outcome, right? And that's what we have to start thinking about with obesity too, because for some patients, they might need surgery combined with medication in order to get the best outcome.

If that's what they want to get. And that's not because they're not doing something right and because that's what they think is that because that you know, it's just that that's what it takes to get to that end state, to get to that 40% weight loss, because 40% weight loss is just really, really hard. And 20% of the weight loss is hard. So let's go back really quick to like GLP1 and Oceampic.

Again. Absolutely. Yeah.

So when Ozemic came out, like I said, now 40% of people with that treatment are able to lose 20% of their weight. Whereas only 5% of people on lifestyle intervention can do that same thing. So it was a radical shift, like it was a radical like difference. It was enough of a difference because the older medications, only about 15% of people would lose 20% of their weight. And so again, when when only 15% of people are losing 20%, it's not as noticeable, right? But when you get up to 40% of people,

Sure. Right.

yeah.

close to half of the people able to get 20% weight off, that's much more noticeable by the by society. Like, you know, you walk out at the end of the year or at the, you know, in the summer, you see your neighbor and you're like, hey Joe, you're looking pretty good. You know, like, and it's noticeable, right? Whereas, you know, five or 10% weight, yeah, but a lot of a lot of it is not like, you know, like

What happened to you?

You dabbing yourself, Joe?

A lot of it is not noticeable, right? With only like a small amount of weight loss. But as you get up into that 20% weight loss category, that's where you can really most people, a lot of people feel a difference, right? And so that was why it was really sort of revolutionary. And then we had terzepatide come out, which is GLP1 and GIP. So now it's activating two of these hormones, right? Or two of these receptors. And when you're activating more receptors, you just go get more results.

Barragic surgery activates about six of these. We know that from research. So you're when you're as we are getting more and more of these medications come out, Reditrutide is the new one that's coming down the pike that is not FDA approved yet. So please do not buy it off any untoward source on the internet. But once it is FDA approved and we can get it from a regular regulated, you know, pharmaceutical company,

Yeah, yes, yes, please.

it's closer, it's getting closer to surgery results because it activates three of these now, you know, three of these receptors. So it's really about the science advancing and then us as, you know, clinicians, you know, understanding how we can help people best. And you know, all these treatments have side effects and things that we should, you know, watch out for. So we have to be, you know, aware of that because we have to weigh that risk and benefit of any treatment.

Which I want to talk about with you in a second, but I wanna talk about what these medications do at the level of your brain and how you counsel patients on it, right? Because like I always talk to my patients and you're a foodie or you like this and that, and like how is this gonna affect your relationships and then we can talk about sex too later. But like I just feel like, you know, yeah, I I think there's something to it, like, you know, these medications and how they even change your relationships with people, right? Because food is such a

Yeah.

Gotta talk about that.

Food is, yes.

bringer together of people's, you know, in the social situation. So I'm curious to know how like, you know, obviously you tell them the risks and benefits of their medications. Like how do you tell them to discuss the the changes that can offer occur in their brain?

Yeah, you know, I really say to people that you know, we have to that that's why it's really important to be in a care, you know, care type of relationship with a care provider that you can see on an ongoing basis, because you're not gonna know that today. I can tell you all these things today, but that's gonna evolve over time. You know what I mean? Like this is not something where, you know, we're not gonna be able to you know, you're you're not gonna know if you're gonna be one of those people.

you know, that has more of those types of of relationship issues, right? As you lose weight, as you, you know, as things change, you know, with your body. And and that like you said, also you know, we'll hear from a lot of people.

They'll be like, my mother-in-law told me I should stop losing weight or something like that. You know, like it's like this sort of situation where, you know, families even can be saboteurs because that maybe they're worried. Maybe they're worried that person's going to leave or, you know, leave their other, you know, significant other because they're, you know, changing their body and making their body differ having their body, you know, look different, right? And so again, you know, the most important thing is for people to make sure that they're getting this treatment.

Yeah.

Yeah.

They're not just getting a medication, but they're getting the care that's wrapped around the medication with someone who can talk to them each time, you know, they come in to make sure that they're, you know, that that things are moving in a positive direction.

Right. 'Cause I think it's important for people to be aware of the fact that like, you know, when that food noise disappears, what's filling your brain at that time? I mean, I've seen women do transformational things on these medications because they're no longer thinking about food all the time. Like starting companies and doing this and that. But obviously if if you're someone that you know, you and your husband go out to eat every Friday night and this is not an interest of yours, it can start affecting relationships. You know.

Right. And I think for you know, I feel like for the vast majority of people though, they

While these medications decrease our appetite, right? They make us not as sort of, you know, the idea that we just maybe don't want a piece of cake, for example, or you know, there's been research to show it decreases our desire for alcohol, right? So like, you know, you might only have one glass of wine and and that's plenty, you know, like the whole night when you're at an event, right? Whereas maybe you had two or three in the in the past. and so again, you know, for most people,

Yeah. Yeah.

if they don't want wine and they're going to a a party, they'll just have something else versus not go to the party. But I think for some people, depending on how that relationship is embedded, you know, depends on on how that how much that affects them. Cause for the vast majority of people that I see, I mean, I'm talking like, you know, 80% of people I've taken care of in my twenty twenty five year career of doing this in in terms of weight management.

For eighty percent of people, maybe even ninety percent of people, it's much more of a positive experience than anything, right? Like in other words, it doesn't stop them from going to the restaurant, they just eat less and they take it home, you know, and they you don't get to have, you know, don't

Yeah. Yeah. Yeah.

You don't need to eat all the bread, you know, before it comes and and you can just, you know, have half of your meal, take it home, have two bites of dessert with the rest of the table and you feel, you know, full and satisfied, right? Whereas the the minority of people I think, you know, depending on how that how the

Right. Right.

medication affects them too, because for some people it really does make them not want to eat at all. And again, you know, that's not what we want. We don't want people to, you know, we want people to be able to go to the restaurant and order

a you know, a a meal and just enjoy half of it, you know, and take the other half home for lunch. But, you know, that's where we have to get, you know, the right dosing for pati patients, maybe the right medication. Nowadays we have an oral pill, a couple two oral pills, but one of them in particular is, you know, a little less efficacious than the others. So again, there's gonna be more options for people so that they can find the right medication and the right dose that fits them.

Right, especially for their goal, right? Like like we can talk about the women in perimenopause that we see who, you know, have done everything the same way all the time, but because of the biol biological changes that are happening from estrogen fluctuations and how it imp impacts their, you know, visceral fat accumulation and all the things, like it's not working anymore, right? And this is the people that you think about micro dosing, which I know is like a taboo term, but but

Right.

I wish we would just get rid of that. Like I don't know. That's what I mean, it's really just the appropriate dose, right? Like we do this all the time in medicine. You know, if this if if if 10 milligrams is too much blood pressure medicine, then we give you five or we give you two and a half. You know, that's just what we do. and I know, yeah, right? That's what I'm saying. You could be, but it's still the other part that's really weird is I think, you know, that came out of the fact that

Yeah.

Right. Right. Yeah. Yeah.

Cut it that. Yeah. Yeah. my god, microdose and glycardin. You know like

cymaglatide in particular starts at 0.25 milligrams, right? That's the starting dose. So technically that's a microdose, micrograms. 0.25 milligrams is is micrograms. and you know, it this the reason I don't like microdosing as a terminology is that it sort of evolved out of a world where people were taking these medications that that

didn't necessarily need to, right? So they were taking even just like two little clicks out of the Ozempic pen, you know, which is who knows what dose, you know, right? Like like point you know, one five milligrams, right? So like, you know, and and so again, they were, you know, doing it for various reasons that, you know, we

Yeah.

may or may not have you know data that suggests it's helpful. And, you know, again, everybody has to make their own choices there. But at the same time, you know, we don't even know that if you took that small of a dose that it's even doing anything to you. Like it might just be placebo, because we haven't studied it. You know, and and we know placebo has 30% of people respond to placebo. So like we know that there's a placebo effect, which means that there are people, when you give them a placebo,

Sure. Sure.

Right. Right. Right.

They actually respond because they think that they're taking a medication. And the brain is very powerful, you know, to the to the fact that 30% of people are able to get positive results from sleep with sugar pills, you know. So that's why we do these controlled trials because you might say, this is helping me when I'm taking these four clicks, but it it you know, we don't know that that actually has a a benefit. We also don't know that it has a risk, right? I mean.

From discriminate. Right, right, exactly.

It might also have a risk. And especially for people that are smaller to begin with, you know, that most of our research has been, all of our research to date has been in people that live in larger bodies. So, you know, with a BMI of 27 or greater or BMI of 30 or greater, right? So just looking at that BMI number as a number, right? is how we would, you know, pick people to be in these trials. So we really ha don't have data on people that say that are.

they maybe they all their life they had a BMI of twenty-one and now they have a BMI of twenty-five. Well, that's not good either to go up four points, you know.

over the course of menopause, we we know that that's not necessarily good for us, you know, from a visceral fat and and health and meta metabolism and metabolic health and cardiovascular risk, et cetera. But what we don't know is if we take if we treat that that person with a BMI of 25 and take them back to a BMI of 22 where they used to be, we don't know the risk of that because we just haven't studied it. And the biggest risk that we worry about is people's bone health. Like when we lose weight, and even if we lose weight when we're heavier, we know there's a risk

Yeah.

Right. Right.

risk to bones, like making a risk of osteoporosis, making your bones, you know, not as strong. And so again, we but when you have obesity, people with obesity have stronger bones, you know, because of their obesity. So when they lose bone mass w during the weight loss process, it's not as bad for them, if you will, because they had stronger bones to begin with. And and so if you take somebody with, you know,

Yeah.

Right. Right. Yeah, to begin with.

not as strong bones and then now you have them lose weight, they may get even weaker bones. So it is something that people should really take heart to and have a discussion with their care provider, you know, as to, you know, how to mitigate those risks, you know, strength training, vitamin D, you know, making sure that you're, you know, you're getting your calcium and vitamin D and, you know, really sort of screening then in appropriate intervals for osteoporosis to make sure, you know, we're we're

Catching it as it develops so that we can treat it appropriately.

Yeah, a hundred percent. And I think, you know, people always, you know, have these their points around, you know, weight loss and you're not really losing weight, you're losing muscle, you know, this all these myths around, you know, what's happening to our bodies when we t when we talk about these medications or muscle wasting medicines and all these things. Can you address that myth? 'Cause I know you hear it a lot too.

Yeah.

Yeah, yeah. Well, the we do lose we lose muscle mass as we age anyway, right? regardless. Even people that are doing some strength training are expected to lose some muscle mass as they age, unless you're really doing, you know, fairly significant training. and we also know that

when we lose weight, you know, what however we're losing weight, whether it's lifestyle intervention or these medications or surgery, that people can't only lose fat. It's it's very challenging to only lose body fat. That's what we want to lose, is the fat, because that's the stuff that's not good for us. But we also lose what's called lean mass. But the important thing we have to understand is lean mass is not just muscle. So when you see these reports, these patients lost 25% of their weight as lean mass, that is not all muscle.

Lean mass is muscle, bones, organs, and fluid. So a lot of the weight loss is fluid that comes out of that lean mass compartment. And then the other part is that we have actually fat in our muscles and in our organs, you know, because and that's bad for us. You know, fatty, yeah, we want to lose that. Fatty liver disease is where you have excess fat in your liver, it causes cirrhosis, people die from that, you know, unfortunately. So identifying that early is very important and getting that fat out of the liver. Well, when that fat leaves

And then we want that. Right. Yeah.

The liver, it looks like you're losing lean mass, not fat mass, because the fat in the liver sits over in this lean mass category because it's inside the organ. So it looks like the liver is being lost, right? Is getting smaller, which it is, which is good because it's, you know, we're not losing a liver like a piece of our liver. We're losing the fat out of our liver, which is making the mass smaller. Same with muscle. I mean, there's even, you know, data to show that people with obesity have extra.

Yeah. Yeah.

fat in their muscle, right? And then that fat goes away. So the muscle mass of the muscle gets smaller because there's not fat in it anymore. You think of a wagyu steak, you know, it's all marbled. There's lots of marbling in there. That's fat. That's what makes it taste so good, makes it so moist. And

If we got that fat out of there, the mass of the steak would get smaller, right? And so again, we have to recognize now again, that's where if people are taking these medications that don't have obesity, that are a more normal weight, they may be at risk. We don't know because we haven't studied those people to know if they're more at risk of losing more proportionally, more lean mass, right? Because of the fact that they don't have as much fat in those organs and in those muscles, right? Because they just don't have as much fat.

design.

in general proportionally. So again, we have to just mostly focus on too that for the vast majority of people when they're taking these medications to help with weight loss, that they feel more functional, right? You shouldn't be taking one of these medications and feel like crap. I mean, that's just not the way it should be. because I have plenty of patients that are taking these medications and they don't feel like crap. so you need to get the right medication, the right dose, and you know

Yes.

Right, right.

be in sort of under the right care, exactly. Not just getting a medication off of a website on the internet and you know and taking it. Cause you really need to make sure that you're feeling well in addition to an energetic. And now you're gonna feel some

Under the right here. Yeah. Yeah.

decrease in energy when you're losing weight because I mean tired, but usually it's not sort of a bad tired. It's kind of like when you're tired when you're pregnant, you know, because you're growing a human inside of you and you're like, I gotta take a nap. You know, so it's kind of like that sort sort of tired also happens when we're losing weight because, you know, it's it's a lot of work for the human body to lose weight. It's burning calories, right? It's burning extra calories, it's burning fat. And when you're burning fat, it's it's a like a workout, you know, yeah.

Yeah, yeah, yeah

Yeah. So you feel tired. So you might have to go to bed in the beginning. You might have to go to bed earlier, you know, because you're you're more tired. But also we have to make sure that there's not some other reason for that, right? Many people are iron deficient, especially if they're menstruating. We want to replace that. So that's where we really have to look at, you know, the whole picture, not just, you know, getting the weight off.

The vitamin D, the iron, all the things. let's talk about the side effects, 'cause you mentioned being tired. Like what are the biggest side effects you're seeing and and how do you mitigate those?

Yeah.

Yeah, well, the tiredness in particular is to make sure people are eating adequately too. 'Cause many people, you know, well, because of this diet culture that's existed for so long, right? Imagine, you know, maybe you've had obesity since you were

Did you have calendar?

you know, 12, right? And for the past, you know, 40 years, because now you're a 52-year-old woman, someone's been telling you you just need to eat less and exercise more. And then we give you a medication that helps you to eat less and you just don't you just don't eat. Like it's like this is great. I I've been told, you know, I have to do this. You know, so we but we don't want to feed into that, right? We need to eat. We need to eat planned portions of plants and protein. So every you know we should be eating three times a day.

Then you don't eat and then you don't exercise. Yeah. Yeah.

We should be, depending on what you feel about intermittent fasting, that's a whole nother discussion. But you know, the idea would be we should eat three times a day, breakfast, lunch, dinner, and we should have plants and protein, plants being vegetables or fruits or whole grains, like farro or something like that, quinoa, right? That's a plant. and then protein, right? Meat, eggs, dairy, beans, if you're you know, especially if you're vegetarian or not, you know, eating more beans is good for you in general, fiber, right? So

plants and protein at each of our meals, because if you're not doing that, you're gonna feel like crappy, right? And and hydration too, right? You want to hydrate yourself. When you're not as hungry, you also don't drink as much. When you don't drink as much, you also feel quite poorly. And so again, making sure people are hydrating themselves, like just saying, I got this water bottle, I'm gonna make sure I drink two of them a day, even if I don't feel like it, right? I'm gonna like really, you know, do that. And then

Yeah, yeah.

The other common side effects, most common are gastrointestinal side effects. So nausea, vomiting, diarrhea, constipation. And they can be for a number of reasons. They can be directly medication effects, but they can also be due to, again, if people are not drinking enough throughout the day, if they're not eating enough throughout the day, that makes you more nauseated. We get nauseated when we're what we call ketotic. So when we're burning fat and we're you know making these ketones, it does cause you to be nauseated. So the more

you can you know like I said eat regularly even if it's small we're not talking about you have to have a big old breakfast like from you know number five from Denny's or whatever it is you know like a giant thing I'm talking like you know you have like a you know an egg or something right and or you know you have some yogurt and blueberries right so you know we want to

Yeah. Yeah.

really focus on managing those side effects. Constipation is mostly from fiber and hydration, but also the medication can slow down your GI system. So, you know, some of that is hard to can be hard to manage because it's just biological, right? So working on that though is key.

Can we talk about the in the anti-inflammatory effect that you see with GLPs? like I think that, you know, we've talked about how I've used it in different capacities in the office with different patients who you know pelvic pain or you know, some general arousal, some of these things that we've seen this remarkable impact for them. Where how do how do you see the anti-inflammatory effect working with these medications?

Yeah.

Mm-hmm.

Well, we see it definitely. But what we and we see it in lab results, you know, that I mean in the clinical trials, they've looked at these inflammatory markers. high sensity CRP in particular is one of them that has shown to go down. But what we don't know is is, you know, how much of that, right? And how it's happening and

and who it's gonna happen to, right? So we cannot, at this point in time, we can't say, like, you know, if all you have is something inflammatory going on, that this would benefit you in and of itself as a medication, as an anti-inflammatory drug, like an NSAID, right? NSAIDs are anti-inflammatory, those are non-stradal anti-inflammatory medications, right? Like ibuprofen. but you know, we just can't say that these drugs are actually anti-inflammatory.

alone by themselves, because we also know that obesity is inflammatory, right? Having excess body fat's inflammatory. So all these people we've studied are high-risk inflammatory people. They're inflamed for multiple reasons. So we don't know if it's the medication causing a decrease in inflammation or is it the the fat going away that is also playing a role, right? How much is is both? We suspect that there is an anti-inflammatory effect of GLP1, meaning there's a mechanism by which people can scientifically

suggests that it is anti-inflammatory, decreasing things like interleukins and TNF and all these inflammatory things that happen. But we just don't know at this point. But for some people, you know, especially if they're wanting to affect change in their weight, you know, trying it is, you know, is certainly something you can do, especially under the care of somebody, you know, who you can trust and you know that they're gonna make sure that you're, you know, doing this correctly, so to speak.

okay, I just wanna briefly talk we talked about this at the conference together about sex and how you know, what what is the GLP effect on your sex life or even weight loss in general? Like we we think it's obviously, you know, there's multiple factors involved with how it might affect your sexual function. where are you what are you seeing in your clinic?

Well, for the most part, we see a lot of people, you know, have improvements in their sex life because, you know, again, for many people, as they feel better, you know, about their bodies, that that, you know, increases their confidence and then they, you know, can have improvements there. Although I do think so, you know, the other issue we have is that

the vast majority of people that we're treating in the clinic are women. That's the that's more more women come in for care than men at this point in time. Not that we don't I mean we should the men should come in. So if the men are listening, they should come in too and get treatment. But you know, we have a lot of data in general that you know it's for whatever reason men don't tend to access the healthcare system until something happens to them or their their their significant other makes them come in, you know. so I think that we should like

you know really look more at what's happening there because you know there's ideas that these medications right decrease your craving for things right so if you get you know a lot of of craving sort of you know

addictive like pleasure out of sexual interactions, that might be where you're not getting that anymore, right? As much as you did before. And so, you know, that is can also affect things. And then like I said, because these are women that

Life women get those cravings.

I know. Well that's the thing. That's what I was gonna say next. Is that the vast majority of people are coming in are women and the vast majority of people

women are midlife, right? That are coming in. And so that's overlaying things too. And I think, you know, for some people, if if they are, you know, if depending on what their sex life is to start with, and then, you know, maybe they feel a little bit more confident in their body and they feel more sexual, but then they notice that all these other things aren't working like from a from a menopausal, because they're not talking about menopause either. So they're not talking about their vaginal dryness, but but it's not bothering them because maybe they're not as sexually active.

Yeah, yeah.

Yeah.

you know, but now they are becoming more sexually active and now they're more bothered, you know, by some of these other symptoms. So I think the point is we need to talk about this more overall, right? We need to talk about our sexual health. We need to like as you've written about in your book and stuff, right? We need to not be, you know, we need to start talking about this more and getting help, you know, getting treatment for it.

I you know, I love the new study of the, you know, women with UTIs and the vaginal estrogen. I mean, such an easy thing to do to, you know, give people vaginal estrogen, but so under underdone for for yeah, for women who are older. I mean, are going through menopause, paramenopausal.

Yeah.

Yeah, absolutely. Under Emacs for sure, yeah.

Yeah. A hundred percent. okay, w how can we get over the stigmas around using the warm the using GOP? Like I feel like, you know, there's a so much still that like, I you know she uses it and she doesn't admit it, or like even in the celebrity world, right? Like you can absolutely tell that someone is and and so like why not just admit it? Like I don't know it's not taking an easy way out. You're still doing the work, you're still doing all the things. Like I don't know why

I know.

Yeah, yeah.

I know.

Well that's problem. There's stigma and bias. There's stigma and bias when you do when you don't use it, right? Because when you live in a larger body. And then there's stigma and bias when you do use it. Like I don't know. You know, it's like you can't win. I mean, you know, this isn't

Yeah, yeah, yeah, yeah.

Isn't the way we should have it for sure. And I think it'll change. I think it'll change the more, you know, if we did have a obesity treatment or weight, you know, weight treatment in general, right? You know, discussions around our weight and being able to talk about that biologically, right? And not in a stigma and biased fashion, right? And and therefore we could it definitely start to affect change. I do think

potentially the next generation of people that grew up with these medications, if you will, you know, will will definitely, you know, similar to I I liken it to the mental health community as well. Like for a long time, there still is stigma around mental health disorders, obviously. But, you know, there was much more stigma 20 years ago. And now, you know, people might be, yeah, they're like taking a medicine, they're talking about it to each other, like, what do you want?

The Gen Z are really embracing it. Yeah.

Well yeah.

Yeah. So like, you know, like it's it's more of like a I think it'll become more hopefully, you know, that stigma and bias will reduce and especially if we made it an actual treatment option, you know, meaning that people had access to it, I think because people are, you know, feeling like they have to get it through some other

Yeah.

potentially a subversive source because there isn't, you know, access within their sort of like health, you know, right, like community. I think that's where it'll get better.

Yeah, I think so too. are you and you said you do your your double bore certified in pediatrics and adult medicine. Are you seeing it a lot in your pediatric population using it? 'Cause obviously obesity is on the rise and and at what age can they start?

Yeah, I mean so these medications are approved down to age twelve at this point.

for and and at this point only Wigovi, so Wigovi and and Sexenda, which is the older one, the Laraglitide, the once-a-day medication. But Wigovi and Sexenda are approved down to the age of of 12. now these medications like Ozempic, for example, which is the same as Wigovi, same exact drug, two different packages, right? Like one is for diabetes, one is for weight management.

Ozempic is approved down age 10. So it's like it's it's weird that you know, like we shouldn't really have this like dichotomy. But anyway, so we will, you know, occasionally when we can get access to it off label, it's called right, meaning it's not approved, but we feel comfortable because we have science, you know, we have this other drug that's actually, you know, approved, but it's the same drug. it's kind of semantics. And so we will treat treat patients, you know, in that sort of 10 to you know, 18.

That is

category because it does, you know, we do find scientifically that when we treat obesity earlier, and 20% of our pediatric population today has obesity. I mean has, you know, a disease, has enough excess adiposity that it's affecting them, you know, negatively as it relates to their health.

Do you worry about like like the onset of puberty and are you working around, you know, what's happening in that capacity as well?

Connection.

I think I I think I lost you for a second, Angela. It'll it'll reload. But I was just asking you about puberty and and like the onset of puberty, is that making a difference in terms of when you're utilizing it or does it seem to impact

Yeah yeah. Yeah yeah.

Well, you know, we that's one of the things that we need to do more research on. I mean, we don't seem to think that it is, you know, necessarily negative it negatively affecting it. But as you know, with for example, with

with, you know, PMOS and PCOS and you know, there are people that, you know, have maybe not had a period yet where when you start treating them, then they get their period, right? Cause they lose enough body fat that it get enough insulin sensitivity because of this insulin resistance that they may have that that then they s start their period, right? So it's not that it's changing puberty, it's just that it's you know helping, you know, it does alter people's menstrual cycles.

as it relates to that. So we do have to keep that in mind for sure.

Okay, and the last question around compounding. Give us your hot take about compounding. I know how you feel, but I want them to hear. I want the people to hear from the expert.

Well I know.

So, first of all, I want to preface it by saying, you know, I want everybody to have access, right? And I want people to have access at affordable prices. This is the challenge that we have today we have a disease affecting 45% of our US population. And probably if you add another 25% on there for people that are in the overweight category, right? So you're talking about, you know, close to 80% of the US population that deserves and needs access to these medications. As of yesterday, July 1st, we now have coverage for medical.

care patients for decades we have not had coverage for these medications for obesity treatment we've had them for diabetes but you know I would have people coming into my office literally wishing they had diabetes. I mean that's the sad part is they're like can I do I have diabetes? Like I want diabetes so I can get coverage. I'm like that's so sad you don't want diabetes you know like but people want diabetes so they can get coverage. But on compounding the issue is not the compounding people

I don't know why people can't understand this. The we we get it that there are places in the United States that can take a drug and put it together and put it into a vial, right? Mix it up. That's the compounding of the drug. The issue is where the source drug is coming from, right? But people don't understand is there's no generic versions of these medications. Now there is cur now there's a generic version in

in Canada, there is now a generic version of semaglatide, semaglatide only. So there's no generic versions of trzepatide. It doesn't exist. And so people have to make this this drug and they're just making it. Random people. Like I mean I mean they're they're pharmaceutical companies, but they're not like necessarily under any kind of guidance to make it appropriately. And then there's no

oversight, very little oversight as to how it comes into the US market and then how it gets, you know, mixed together and compounded. And so the point is that like they've done testing on these types of products and some of them have half the amount in them that they're supposed to, you know, and others have twice as much in them as they're supposed to. And the issue is you can't do that with these. That's okay if you're taking like, you know, like, I don't know, like you're taking, you know,

A blood pressure medicine, it's probably not gonna affect you that much, right? I mean, your blood pressure is gonna maybe go up a little bit. But with these medicines, if you're taking twice as much one month and you might get one month, you get one dose, and the next month you're getting twice as much. Like even though you think you're getting the other dose that you want to be on, and now you're sick and you're throwing up and you don't know if that's because you got a virus or if that's because you got bad stuff. I mean, that it's like, it's like

Yeah.

Yeah, I know. Right.

Yeah. Gallbrater pancreatitis. I had a patient that

It's like, yeah, it's like i I mean, it's really like illicit drugs, you know, in the sense of like, you know, heroin or cocaine or whatever we get, you know, people are like, I've even had people tell me, Well, I have a good supplier. And I'm like, How can you say that? I mean, that's like

Like breaking bed. I feel like you're talking about breaking the bed now.

It is! No, seriously! But this is what it's come down to, and it's really sad because it shouldn't have to be this way. All those people should fight and fight their insurance, you know, like picket and walk the streets or something, you know, because unfortunately the compounding, well, yes, it's it's giving people access. It's not helping us in the sense of like, you know, getting it covered. Yeah. And

Yeah.

Getting changed legislative. Yeah.

So it and again, I really worry about the integrity of the drug. Like because if you get bad stuff, you don't know. It's not like if you're putting a pill in your mouth, it's going through your intestines and you know, y you have some protection there, right? I mean you eat some dirt, it's not the end of the world, you know, your body can protect you from eating the dirt, you know, it's not a big deal.

That's why our stomachs are like that, right? They they have protective mechanisms so things don't get in there that are harmful. But if you're injecting something and it has lead in it or arsenic or something, and it could yeah, it could, but it's not even that they lace it intentionally, it's just their manufacturing processes are not regulated, right? And so they could be using a lead container to make the product. You know, you make these products in these containers, right? Like in these drums or whatever.

Yeah. Who knows what they lace it with, right? It's like being laced with stuff.

And they can use whatever and that can leech in there and it's not being tested. And then people will say, well, well, look at even the pharmaceutical companies, they get in trouble when they have, you know, something goes wrong and they have to correct it. But that's but they're held accountable. And that's they they figure out that it's that's why we have an FDA to go inspect them and they say, wait a minute, you guys are cutting corners, because everybody cuts corners. And especially if you're trying to sell this for really cheap, you're definitely going to be cutting some corners, people. And

They're called accountable.

Yes.

So you're getting corner cut crap. That like, I mean, I get it that you want to have treatment. And I feel the utmost of wanting everybody to have treatment is just we have to find a better way to do that. Meaning there are better ways we could do that and really get sort of access to these medications for everybody if we really would fight at the legislative level and say it's not okay that 80% of the US could

Yeah, exactly. Or C C C.

be living longer, healthier, less cancer, less heart disease lives, right? With this treatment, and we can't get it at a good price. That should be something we we have control over, especially given that it's close to 150 million people. Like it's this is a lot of people. And the CEO of Eli Lily, Dave Ricks, even said at one of his at one of this was a recorded

thing at the Deal Book Summit, which is a big meeting that they have in in New York City every year. It's like a big, you know, people come in, famous people, they do this, they talk like this in front of everybody. And he said, I could, I could charge $100 a month for these medications if everybody had access. Because if he knows that he has a market of 200 million people, then he knows what he can price it at. If he doesn't know what his market is today, if today his market is

Yeah, yeah.

Yeah. Yeah.

you know, some of those people. And then all of a sudden all the insurances drop coverage. So now his market is half. That's very hard to like manage, right? From a how are you going to price it? Right. And so, and that's why Medicare negotiated for this $254 price point, which the you know, the Medicare beneficiaries are paying $50 copay. So you're paying as a country, we're paying $200 a month, you know,

Mm. Right.

They are, they're dropping coverage left and right, I think. Yeah.

Right. Yeah.

for the medication where it's listed at a thousand, right? Because of this differential of these rebates that are that are baked in there. So I think, you know, what if we could all get it for 250? Like, you know, through this negotiated panel, right? And and then, you know, insurances would definitely be seeing a benefit from that because we have data to show.

Right. I know.

Even in the first year, at least for people with obesity, that in the first year of treatment it saves $3,500. You know, in and other healthcare costs in that first year of treatment if you have obesity. and so again, you know, if we're saving $3,500, but it costs us $200 a month, because the patient, let's say, is paying $50, right? You know, at $200 a month, you know, that's $2,400 and it you're saving $3,500. So you're saving $1,000.

Yeah. Yeah.

Yeah. Yeah. A thousand dollars. Yeah. Right. That's a big savings. Yeah, absolutely. Absolutely. Well, thank you so much, Angela. This has been great. I want to be cognizant of your time, but I could ask you a hundred other questions too to talk about because I there's so much information out there, misinformation. you know, where should patients go to look for the best information?

on each patient, that should be the reason we do it.

Well, they can go to the Obesity Action Coalition. I'm one of the board members in full disclosure. Obesity Action Coalition is the patient advocacy arm for all things related to this. And certainly you know, our clinic is called known well, kn o w n w e-l dot co is our website, not dot com. So knownwell.co. And we have a lot of resources on our webpage as well.

And you know, like on the obesity action coalition, you can there is a find a doctor page. So you can find clinicians that may be more certified, you know, in in helping with these sorts of conditions too via the via that channel.

Wonderful. Well, thank you so much, Angela. This has been great. you know, as more stuff evolves, I'll have to have you on again. But for now, this has been an excellent eye opener for a lot of people, I think. So thank you so much. Wonderful. Thanks everyone for joining me today. I'm Dr. Smeenerman, Gaino Girl. Remember, I'm here to educate so you could advocate for yourself. See you next week.

Thank you for having me, it's a pleasure.