Health Series 5: Dr Evan Nadler / Pediatric Obesity Surgeon

0:01 Welcome to another episode of Come Together, Just here. 2nd Doctor Nadler, Welcome. Welcome back to another episode. I really appreciate you coming. Thank you so much. My pleasure, thanks for having me. We just, it's so funny. You were just telling me that the audio, you had to correct it. I recorded a full hour and a half phenomenal conversation with a gentleman from Australia that was actually doing a little bit of research with LSD and micro dosing to cure depression, suicidal ideation.

0:41 And we recorded a phenomenal episode. And I thought I heard like Echo, you know, at the beginning and it's happened once before and then it was totally fine. So I just think, oh, I'm sure it's fine. And after a full hour and a half, I listened back and I'm like, you cannot, I can't use this. And it was such a shame I have to record Part 2 with him. And Riverside can't. It doesn't. Like clean that up. No, I tried running it through AI have a couple of buddies that pay for, you know, I guess more potential or you know, yeah, higher capabilities and they ran it through and it was because apparently it was a separate the Riverside was recording my input and then re recording the output on his end. So everything was was her twice.

1:24 But I welcome to the show, so I'm going to have you here. Everybody needs a show on how to podcast. You know what? I. Mean that's right, by the way, by the way, I'm not I've been learning that, as you know, throughout throughout the last year and change is, you know, I mean, it's a lot of learning lessons, but the truth is not to overthink it. That's what I found, you know, don't overthink it. Pick it up when you can and if it's a bad episode, you know, or not as good as you could make it, it's not as good as you can make it. Move on to the next one. You know, so you, you specialized in obesity, pediatric obesity particularly. Correct. I'm a pediatric surgeon by training, actually, and when I well, even before my formal pediatric surgery training, I had this sort of epiphany moment where I decided someone needed to do something about the obesity epidemic in the United States especially. What year was this or around what year? If you're going to date me and you're also going to test my memory.

2:27 But I think, well, I've told the story a few times and so to be consistent with the story I tell each time, say in the year 2000. OK, Was obesity an epidemic at that point already? So depending on who you ask, it's been around for 50 years, but we as a society didn't really recognize it. And my epiphany moment was actually at the Dolphin and Swan Hotel in in Orlando and Disney. I think I was at the Swan, but the pool was shared between the two hotels. And I was sitting in the pool at a pediatric surgery meeting, actually, where I was going to present my data on something completely unrelated to obesity. And I'm there with my wife.

3:08 And although I guess at that time, we got married in 2001, so at that time, she was not my wife yet. And we're sitting at the pool and across the pool, I see. And by the way, this is like May or maybe even Memorial Day weekend. And it's like hot, hot. Hot. Yeah. Orlando's miserable. This time of year or that time of year, Yeah. And or all times a year, but the, but that's a different story. The, so I'm at the pool and across the pool. First of all, everybody at the pool is, is struggling with weight issues. And the, but the, the, the epiphany or the kid that caught my eye.

3:49 And I certainly don't want to stigmatize this kid, although this was in 2000. So he probably will have no recollection of, of even if he knew I was talking about him, he wouldn't have no recollection. But he's probably about 12, clearly struggling with his weight. He had a big old greasy hamburger, giant hamburger, a 2 liter bottle of Coke, sugar Coke, and a 1 LB bag of Lays of potato chips. And I can still see the grease dripping down his arm. Yeah. And I was like, this is crazy. Like, how can we this like, so, you know, like what's going on here? And, you know, so that led to my pediatric surgery training where in 2004 I actually did my first pediatric bariatric surgery operation as part of a group of pediatric surgeons who were starting to explore it at the time.

4:42 And, you know, I just thought surgery was never going to be the cure at a population level, but certain people benefit from it. But I thought that maybe the lessons learned from surgery, like if we could figure out how surgery works, maybe we could come up with medications, maybe we could come up with other interventions that could mimic surgery, which frankly, 20 years later, we actually haven't really. Or 20? Yeah, 20 years later, we haven't really gotten there yet. I was going to ask what was the, what were the methods at the time? If someone, if you, if you were at at 20 in the year 20, I guess the year 2000, someone's like, OK, you need to lose some weight.

5:23 What do you do? You know, I mean, what would you tell someone at the point at that point? It's the same sort of basic stuff that's being talked about today. And frankly, it's the same basic stuff that the fitness guru gurus of the 50s and 60s, Jack Lalanne, I like to bring him up, but no one has any idea who Jack Lalanne is anymore. But he was the original. He was America's original fitness guru in the 1950s, and it was diet and exercise. And 75 years later, RFK is talking about diet and exercise. I mean, it's like, it's incredible to me that we haven't moved past that conversation. I mean, I get it because I, you know, so I do videos for like, TikTok and other things where I'm in a grocery store and I'm showing people what they should and shouldn't eat.

6:10 So yeah, everybody should eat better and everybody should exercise if they have the time, no doubt. I'm totally in favor of all that stuff, but to think that that's going to cure the 140 million Americans who suffer from obesity and the 15,000,000 children who have obesity. If you think that diet and exercise is going to fix them, then you just don't haven't been paying attention. Because there are, you know, boatloads of data, hundreds of studies in the medical literature showing that the diet and exercise programs, even at their best, even if it's like super intense, even if it's like The Biggest Loser, which by the way, there's a Netflix documentary that's exposing all of the bad things that were going on behind the scenes.

6:56 I don't see me. At that point in television, in entertainment history, there was bad things going on behind the scenes everywhere you looked. I mean, you could not catch a break from that point in time. And they're. Actually now a bunch of great documentaries being made because of that. But anyway, the but like the people from The Biggest Loser all regained their weight after they left their show. Most of them, but in the scientific. Community, do we do we know why that was? Was it because they did not maintain it or was it because there was other factors that were required or so you know, I feel yeah, go ahead. Oh. No. Well, so we know. So all this has been studied and studied actually really well now and there are hundreds of studies and medical leaders are showing this.

7:37 So 95% of people who used lifestyle intervention to lose weight will regain their weight once they stop the intervention. So you basically have to behave like you're on The Biggest Loser. For the rest of your life, the rest of your life, it's not going to work. And that's, and so with medications, the GLP 1 medications, and I'm sure we'll get to that at some point because it's a hot topic that everyone wants to talk about. 80% of people regain their weight after stopping. So better than better than lifestyle, but neither of them come even close to surgery where the numbers completely flips, flips flipped where only 20% of people after bariatric surgery regain the significant amount of their weight.

8:30 So. Surgery. Always been surgery has always been the most sustained weight loss and it's usually you asked why and in the early days people just blame the patient. Oh, you know, a firm must be cheating. He's he's you know, he, he, he got his surgery or he's on. He took his medication. He stopped his medication and now he's having a smoothie. It's Smoothie King every day and pounding sugar packets in his in his free time. Well, that you know that that didn't happen. People didn't do that. Like nobody sabotages themselves. Maybe not nobody. Few people sabotage themselves to that degree. Like why would why would you do that? Why would you purposefully do that to yourself? But that was what we thought for ages. We just blame the patient.

9:17 It's the easiest thing to do. But then we realized it's actually just the biology of of obesity, which we didn't really understand. We still don't understand big chunks of it. But there have actually been recent studies that are really interesting, which talk about epigenetics. And for your listeners who don't know what epigenetics is all about, that's the study of how the environment changes your genes. And then what that means is that your genes don't work the same. They may not work as well. They might make different proteins, they may not make any protein sort of different depending on the gene, but. Wait, yeah, I'm sorry, before we get there, which I'm I want, I want to get there.

10:03 I just have a couple of quick follow-ups just and a couple of things you said at first just to break it down in case anyone has any questions or that anyway because I just. Yeah, yeah, yeah. I'm trying my hardest to keep it simple, but it's complex. You're doing a great job. No, there's so far, so far this is perfect, but there's just a couple of like what I like to do is introduce a concept and then if I have any questions like that, I myself don't know, you know, would like to know more about to elaborate them real quickly and then kind of keep keep track along the way. Can you just explain real quickly how the surgery works? Sure. And what and what the process is for that, please? Sure.

10:44 Yeah, thanks. So there, there are two major types of bariatric surgery in the United States make up the vast majority of procedures, although there are other procedures as well that are performed by some. But the two major ones are the gastric bypass, which is the one that most people know about and most people equate with bariatric surgery because that was the one that got really popular sort of in the late 90s, early 2000s. It's the one where people had some really bad complications. So it made a lot of news. What was that? What? How does that surgery work? How does the gastric bypass work? Right. So in that surgery, what we do is we well, so first of all, back in the old days, we used to do those surgeries via a cut on the abdomen.

11:30 Now we use laparoscopic instruments, which means five small holes, biggest one's about a inch. And we can do everything with a camera and instruments that look like, well, they almost look like chopsticks with little something on the end of it to, to, to do what you need to do. And so there's been a lot of advances in bariatric surgery since 1991, when the NIH, the National Institutes of Health first sort of approved bariatric surgery as a treatment of obesity until now, which is what, 35 years later. But with that operation, we make a, we take a stapling device, we make a small pouch out of the stomach, and then we actually divide the intestines and bring a piece of intestine up to that small pouch. So that food goes in, it goes into this little pouch. So you don't eat very much before you feel full. It goes.

12:28 Out into your intestines, but it bypasses A, hence the main bypass. But it bypasses the stomach and then a fair amount depending on how it's done. It bypasses a significant amount of your small intestine, so some of the foods you eat doesn't even really get absorbed that well. Right. So what happens to that food, hypothetically? Oh, it just runs through you for lack. Of OK, gotcha yeah, OK we're. Going to keep it PG. But it but it limits but it but so but it would so it essentially limits the amount that you can consume. It limits how much you eat and then OK also limits to some degree what you can absorb of what you eat.

13:12 So for kids that wasn't really a great option in my mind. And now about actually, I would say almost 20 years ago for adults as well, everybody, most people move to something called the sleeve gastrectomy, which is a much simpler surgery, easier to perform, easier left, lower complication rate. And with that operation, we basically just remove about 80 to 90% of your stomach, take it out. Yeah. So it also obviously limits how much you can eat, but it doesn't impact your absorption at all because your intestines are still in the normal anatomy.

13:55 And it it in kids has been shown to be pretty much just as good as bypass. In the adults. It's still a little there's still controversy. Which is better? What would be the controversy? Which is more effective? Well, they both have similar weight loss and similar resolution of the obesity related diseases. Upfront bypass is a little bit more weight loss, but there's some question about recurrence or weight regain and whether sleeve gastrectomy has higher weight regain, which I think is going to become irrelevant because I think what's maybe is going to happen is that when people start to regain their weight, they'll just that's when they'll get on their GLP one medication.

14:43 And because it is depending on whose numbers you look at, the sleeve is about 10 times as safe as the gastric bypass or 10 times safer. I guess is the is is English. 10 times safer. Yeah. So if you if, if a gastric bypass complication rate might be 1%, OK, sleeve gastric? Ah, I see, is 1/10 of that. .1% yeah. I see, I see, I see. So for kids that became like that was easy. But you know, when I started doing kids in 20 and and 2000 and I guess nine, well, I guess my first bariatric surgery operation on the kid was in 2004.

15:24 But then when I started my own program in 2010, I only wanted to do, I only wanted to do sleep gastrectomy because I didn't want, I was worried about the gastric bypass in terms of nutrition and because of the, of the amount of food you don't absorb for kids. And then I was also worried about the complication rate and I should, I should go back one step and say so from 2005 to 2009, I was doing laparoscopic adjustable gastric banding in kids, which that procedure is pretty much almost extinct now, although you can still find it.

16:06 What was it? We put a little device around the top of the stomach and it had it's basically like a belt with a balloon on the inside. And the balloon was attached to actually a port that sat outside of your abdomen underneath your skin. And you would come into the office, let's say once. What was it? It was early. It was becoming frequently and then it would spade maybe once a month and then he spaced out and you would just put a little bit of fluid into that balloon and eventually it would tighten up and it would basically make you feel full all the time. But it had lots of complications and it was a pain for patients to have to come in and get the adjustments and it just didn't really work that well.

16:50 It's still FDA approved and I still think one company makes them, I think, but it doesn't make up. It's not generally practiced right, right, right. And real quick, I'm sorry if when someone's walking into these cases, say either with surgery, you know, either of the surgeries say, right, what's the process look like in terms of weight loss? Does that happen immediately? Does that what do they walk out and they're £40 less or how does that work exactly? Can you explain that please? Yeah. So I should say first of all, almost every patient goes through a three to six month preoperative preparation period where you sort of learn how to eat, you sort of make some of the behavior changes that are going to be necessary. So it's not like you walk into surgery and then after surgery. The so one of the really interesting scientific findings that has spurred a lot of scientific discovery, including some of the GLP one type hormones is that for gastric bypass patients, they, if they had diabetes and they were on insulin, many of them, if not most of them would no longer require their insulin even before they left the hospital, even before they lost any.

18:14 Because you don't really lose weight. You lose weight in the first three months more or less. And you can lose 100 lbs in three months, but, but you don't lose it on the day of surgery. And so that was a really interesting finding that a lot of people have spent a lot of years trying to figure out why that happens. And I, I don't really think anyone has quite figured it out yet, but the. Yeah. So you, you get surgery usually go home one or two days post procedure. You really are almost doing nothing but drinking for the first two weeks. And then you get advanced on. Everybody has their own sort of special little diet, but most patients after either surgery can only eat about a handful of bites before they get full.

19:00 So we need to teach people before that, you know, if you're only going to eat this little bit, this is what you need to eat. You need, you need to take a multivitamin and you need to stay hydrated. And most recently there was a, a publication where I think it was the, whatever the lifestyle medicine association doctors are got together with the obesity society, I think, and then the obesity medicine association to talk about how to tell how to teach people how to eat after while taking AGLP one medication because it, it makes it so you don't eat very little and, and, or you don't eat very much. And as soon as it came out, I actually emailed like the lead guy because he's randomly some guy that I went to college with. And I said dude did, did no one bother to talk to the surgeons? We've been teaching people how to eat 5 bites of food three times a day for 30 years.

20:04 Like you guys, you guys didn't think that we could be of use. And he actually was honest with me. He was like, Oh yeah, I didn't think to. I didn't. I have nothing against the surgeons, but it didn't occur to me to include them in these guidelines. And I'm like, yeah, that's the problem. And that's the problem with like. Everything is too componentalized. Yeah, it's a problem with medicine in the in in America anyway, but it's certainly a problem with obesity. And it's getting better. We're we're starting to learn to play in the same sandbox more and more. And that's a great people understand that Like Medicaid, kind of like with cancer, where chemotherapy and surgery work together to best cure the cancer, treat the cancer. It's the same thing with obesity. It's like it's not, you know, do you need meds or do you need surgery?

20:50 There's a good and lifestyle goes for every, everybody gets lifestyle. But then what else? Is it medicine? Is it surgery? And the answer is, you know, you figure out which one's right for you to start, but you might need both and you might need, you know, medication, surgery, then medication. Or no one at the individual level can predict what your outcome is going to be like. I can't, you know, even with the best genetic testing out there, I can't say you're going to. Benefit, there's too many, there's too many variables, right? I mean, there's too many variables that you can't that that I couldn't even begin to tell you as a patient and you couldn't even begin to think to figure out as my doctor, right? Yeah. Well, that's why I think like, you know, they're, they're the, the medication advocates and, and I have nothing against them and I will, I'm starting a practice where I'll be prescribing these medications as well.

21:41 But there are a lot of folks who are really excited that someday there'll be a medication combination that can be as good as surgery. But I think that that probably is never going to happen because when you do surgery there are internal connections between the gut and the brain that get for a better. Word, I was actually about to start asking you about that, right, right then. And that's that that communication is through the gut microbiome, right, the communication. Between the gut. Potentially. I'm not sure either way. OK, please. There's something called a gut brain axis and basically you know, there's the vagus nerve which goes from your stomach to your brain. And then there are all sorts of like mediators like GLP, one that your gut releases that go through your circulation to your brain and they mostly.

22:38 Tell your brain you're hungry or not right? Which is. The part of your brain, that's what the hypothalamus does, it's sort of the hunger center it, but it turns out it's not only the hunger center, it's actually also the fullness center, the satiety center. And it's also where your weight set point gets for better, for lack of a better word. It gets determined probably in utero by your hypothalamus. And the hypothalamic set point may have to do with the mom's gut microbiome, the fetus, it doesn't have a gut microbiome when they're born, but it can certainly it's a possible mechanism by which the environment can impact your weight.

23:28 And and the reason I'm a little bit of a skeptic about the microbiome, although I'm open minded about almost everything so I don't want. To. Close off that opportunity that the microbiome is important, but I'm a skeptic because I've done, I published one study in my own patients where we looked at their microbiome both before surgery and then after they'd lost, you know, 50 lbs. And it actually wasn't that different between before surgery and after surgery. Then we're back. Sorry about that. So sorry. So my question before we cut out was what factors determine or do we know if factors determine the gut microbiome health?

24:10 Because I mean, I'm sure weight has something to do with it, but if someone's like, especially post surgery, if someone's not getting a lot of nutrition, if someone's not eating a lot of food, I could imagine that it wouldn't necessarily be strengthened right away until they got back to a regular diet, no? Well, I think, I mean, I think it's a complicated question because I don't Well, first of all, the it's certainly possible that the reason for instance, in my study there weren't great microbiome changes is that we don't actually have a good way of measuring the microbiome, right. The microbiome mostly people measure in stool samples, but what's actually in your small intestine might be completely different than what is coming out in your stool. So part of the issue is that we don't have a great way of measuring it for most people.

25:04 But the the issue, so you know, I think, I think we're sort of staying away from ultra processed foods and eating foods that come right out of the ground and eating healthier. I think those things can contribute to a healthier microbiome. Again, I'm not 100% sure whether a healthy microbiome helps you lose weight or contributes to the the development of obesity or if it's just an innocent bystander where like if you lose weight and get healthier, your micro changes. Like what direction is the interruption? I don't know.

25:46 And there are companies who are trying to market like even, well, not just companies like there's now like you can buy a soda that has probiotics in it because. That's all over the place now. Right. People are playing on the idea that the microbiome can be manipulated for better health, but unfortunately the reality is that just like everything that seems to be a viral trend before before too long, the science just isn't there yet. Like people are like making companies based on the microbiome well before the microbiome has been shown to actually have an important place in human health.

26:28 Yeah, we're jumping the gun. And then what happens is people need to make money from that company. So they become they, you know, they get online influencers or they become online influencers. I like to, I'm positioning myself as AD influencer. So I'm going online or videos or podcasts like this one where I just basically talk about facts. I don't talk about like if I have a topic where I don't actually know the facts, I can present the facts that are on both sides if they're if they're they're not in in congruence with each other, if they don't jibe with each other. But I'm not going to go tell you, you know, go buy a supplement because I'm not selling any supplements and also because most supplements don't do anything for your health.

27:13 But where we're at as a society is where, you know, our HHS secretary and then the woman he's appointed to be the surgeon general. Yeah, Doctor means. Yeah. I. Mean yeah, they're basically peddling in the misinformation sort of business like they. You feel that way? Oh, for 100% if you like and I'll tell you why. Sure. So certain things that RFK says or wants to do are for sure great. Like they don't need our. The dyes, yeah. It needs those, yeah. And yes, everything should have has have less sugar totally support all that.

27:57 And I've actually been on TVA fair number of times talking about those things. But then in the next breath he talks about vaccine conspiracy theories or he talks about beef tower. And and these are things that are that completely have been vetted by the scientific community and there's no question about them anymore. But his base doesn't want to believe that. So they peddle in these sort of. Yeah, I understand. I think right now is actually we're living in a beyond fascinating time because there's been a collapse of. And I've talked about there's a bunch on the show, just, you know, both in a professional setting, you know, with professionals and shooting the shit with my friends.

28:40 But the sense that no one really kind of knows who to trust anymore, that there's just been such a breakdown of trust and, and processes. And, you know, and, and, and, and like what you just said, on one hand, someone could say something that makes a lot of sense, like food dyes are bad, you know, and, and you know, and you probably don't want to be consuming as much ultra, ultra processed food as we do, you know, and, and that, and that resonates with people. And So what follows is that any, you know, beef tallow, whatever follows next is, is held in the same light or associated with the same kind of positivity and vice versa on people that feel, you know, that if they feel disenchanted with the whole, you know, with everything that has to do with COVID, then all of a sudden anyone that makes any kind of recommendations for health, they say, what do you know, you did, you messed up with COVID. You know what, just because you're right about one thing doesn't mean you're wrong about everything else. And vice versa.

29:26 But even the COVID example and and getting back to to KC means like she never finished her medical training but she ended up starting like a sort. Of yeah levels medicine. You know, arthritis medicine practice and became a wrote a book and became a social media influencer. And now that's, that's who our surgeon general nomination is, not some, you know, academic guru who actually only talks about science and facts, but a woman who, you know, is on the fringe of accepted medical practice. But even with COVID, so like, or the COVID vaccines. So yes, some of the mRNA vaccines had side effects for sure. Like lots of people have had side effects from those vaccines and some of them were severe and some of them were not so severe. But it's been made into, it's been demonized actually to the point where now RFK has basically stopped running for all mRNA vaccines, which is like basically paralyzing us for the next COVID that comes along, the next virus that comes along. If we can't use mRNA technology, we are hosed. And so even if you didn't like the COVID mRNA vaccine, the answer is to study it more.

30:52 It's not. The answer is to stop all funding for that particular type of vaccine or even that vaccine in itself. Like there are still people who are getting, especially kids who get long COVID, and it's devastating for them. And they don't have the vaccine. It's not available this fall because RFK basically disbanded the committee that makes the decisions and then repopulated it with his sycophants, not medical like giants, but people who we knew were going to make his base happy. And that's sort of where we are in politics and in the world. And and as you said, it's just like it's really, I mean, I saw something in, I can't remember which news agency, whether it was, I don't know, anyway, some, some CNN or New York Times or Washington Post or something, U.S.

31:45 News Award report, can't remember. But somebody did a survey of sort of trust and leadership. Yeah. Across the different domains and it was crap. In life, it's been, it's been going down. It's been going down for 6070 straight years and the last five, the last five or six years have the last five or six years have really plummeted. I was actually curious to ask because, and I don't want to stick on it too long because I feel like it's a topic that's kind of been beat over the head so many times, but I think it's relevant just just as a finishing point. I think it's interesting because, you know, there at the beginning of COVID, everyone kind of was like freaked out.

32:28 And then at one point, I remember at one point there was a shift and maybe it was after a month or three months or five. I don't remember exactly what it was, but at some point I got the IT dawned on me like, Oh my God, this has turned into a political conversation. It's not a health conversation. Like this isn't a question of like is, you know, how do I, how do I make sure that I'm healthy and not sick? And how do we stop this? What feels like a rampant virus been going through now it feels like it's a question of like, are you, are you Republican? Are you Democrat? Are you moderate? What do you think? And I'm like, what the heck does one thing have to do with the next? And why, why is this even? Why is this even that? And so I was, you know, and I think that health, especially now with the, with the obesity conversation and the general, you know, the fact that and you know, again, I mean, I don't, there was a great point I heard recently, I forgot who was saying it, but I haven't heard anyone public figure in my at least in my life.

33:24 And I'm only, you know, I'm 30, but you know, ever, ever campaign politically on health, on Children's Health, on adults health, on the, you know, on fitness, on, on any of that. And I thought that was really, really fascinating. Yeah, I think RFK tried that because he didn't really have much to offer in anything else. But as you saw, it didn't get him anywhere close to enough of a support to be a major party candidate. But the Yeah, and like, again, if Anthony Fauci, he's not a perfect human being. I I know people who have worked with him said he was kind of like a know it all jerk in many ways, but he was trying to do what he thought was right for the country.

34:12 It wasn't because he had one political agenda or another. He was just trying to save as many lives as he thought as he could. And he thought he was doing what, you know, he was trying to accomplish that aim. So again, even if you disagree with him, and I think that again getting getting back to you, it goes back to like everything in our world today, rather than having a like an intellectual discourse with him or with other public health figures, it just became. You know, a shouting match, Everything's a shouting match, everything's a shouting match. The same thing happens today. Like, you know, again, I go back to the, you know, the example of the mRNA vaccine. Like there's nothing wrong with that technology necessarily until they prove that there is. But like, it's such a political hot button that, you know, it was like, oh, we're just.

35:04 Going to yeah, it's going to be very even even if there is even if anything's done, it's going to be hard for it to be objective because it's become so politicized. So. And now, yeah, that's. On the flip side, like anything that comes from the vaccine committee that RFK has now reappointed, everybody, no one's going to believe that either. Like no one's everybody's like. That right and either way, we either way, we end up worse off, which is a shame, you know, and that's kind of yeah. And I mean that was that was actually, you know, you know, full circle back to even my podcast. It was, you know, there was that things have strayed so far from just being able to have a regular conversation that it's obscene, you know, and it's really, it's really a shame.

35:47 And I think that and, and yeah, I mean, I don't want to, I don't want to get, I don't, I don't think much more into it than this. Because I think that it's a different episode it. Is and and you know what at the end of the day, I also think that this particular topic also has been being on being over the, you know, everyone's head until like a dead horse. And I think that I think that, you know, it's, you know, what I think for a lot of people, their opinions are their opinions at this point about it. And there's not much else that that we're really going to do because echo chambers and yelling and podcasts and everything like that, you know? And so, you know, I welcome, I welcome everyone's perspective. And you know, I think it's really great. But that's why I'm sort of positioning myself as a quote UN quote D influencer.

36:30 Yeah, that's a great. It's it's really cool. Because like, I don't really have an agenda other than getting people healthier. Like I don't really care. I like to. I often describe myself as intervention agnostic. Like I don't care if you want to use diet and exercise. I don't care if you want to use medications. I don't care if you want to use surgery. I just want you to to to get healthier. And I can tell you the, the, the data, I can tell you the facts, the data. And then you as the patient should do what you want with them. Because that's the great thing about being, you know, being a human is that you get to decide, well, at least in this country, you get to. Decide what you want to do. And so, like, again, it's like, why are there people out there who are saying things like, oh, if we just change food policy, that's all we need to do.

37:16 Everything's going to get, you know, everything. Everybody's going to get healthier or you know. There's no magic button. There's no magic button. But I think it's just in general, I think it's like, I think at least from what I I try to be charitable, my, my, I think that these are all positive steps that if we did would only have, I feel essentially net positive. It's only net positive to get rid of the dyes from the food. I mean, unless you can make a case otherwise. Yeah. And actually, you know, so I think that people in general were held. Go ahead, please. Oh, I. Was just going to say even if, even if those things don't cause problems, like no one needs them, no one needs their ice cream to be bright blue or bright green, right?

38:02 Like I said, like it's not a big deal when you do some of those things and you're right those are probably net positives. They're either neutral or positive. There's no downside, but there are some downsides to some of the other things. So that's when you really have to be a little bit more careful about what you're saying. And you know, again, I think the, the the obesity world is starting to learn to play together much better. And I think that's the key step in the right direction. And I think docs in general have started to realize that the old fashioned paternalistic, do as I say type of model is not really well received. Yeah, not much anymore, yeah.

38:49 So it's like it's called shared decision making or something like that. And so I think we're starting to move in the right direction in terms of that kind of stuff. But you know, yeah, the rest of the. I mean, can I ask you about alcohol and and obesity? Do do, do, do, do, do, is there a correlation between people that, that drink a lot frequently and people that are overweight or vice versa? Or what do you what have you seen? So actually, so alcoholism is a, an example analogy that I used to talk about obesity quite often because, you know, 30-40 years ago people thought alcoholism was a disease of the weak minded and the weak willed.

39:34 And you know, you just couldn't keep away from the bottle. The temptations were too great and you just indulge. But then people realized that it's actually a heritable, it's a genetic disease that you can inherit from your parents. And it changed a lot of the stigma around alcoholism and it changed how we treat it and how we view it. And obesity is the same way. Like people just think obesity is because people don't work out enough or eat well and that they're lazy or whatever, which is insane. And we actually now know that there are a lot of it is genetically inherited, but it's still so stigmatized that folks don't want to, they don't want to appreciate that.

40:15 They don't want to consider that. So take some time I think. Yeah, so it's actually the opposite. People with alcoholism tend not to, they actually, they're usually skinny because they don't eat enough anything else. So most people with alcoholism are actually on the thinner side. But if you drink a lot of sugar sweetened beverages, certainly, certainly alcohol has a lot of calories too. And obviously everybody knows, everybody knows somebody with a big beer belly. So it it, it's not black and white, but yeah. So calories consumed by drinking are probably the number one modifiable behavior for people if they really want to start to think about their weight or address their weight and get healthier is, you know, like every, there's sugar in almost every drink that's out there unless you specifically look for things without it.

41:13 And obviously, like I had a, I was in New York. I used to live in New York City. I haven't lived there in a while, but I was in New York, let's say, I don't know, 15 years ago. Which part of the city are we living in? I lived in Murray Hill, which is so I worked at NYU, so I. Lived in Murray Hill, gotcha even. Before that I was in the Upper East Side, so I did my general surgery training at. I love the East Side, by the way. I love it. It's a great, it's a great, it's my favorite part of Manhattan. It's it's, it's quiet, it's residential, and it's affordable or more affordable, relatively speaking. Yeah, everybody has their own. Everybody has their own favorites. But I remember I was downtown, probably in Soho because that's one of my favourites. And I went to, I can't remember, I was meeting, I mean meeting my wife.

42:02 I don't know who I was meeting, but I was at bar and I, they were sort of famous for their mojitos and I had them make me a mojito and that one of their things is they make them right in front of you. And the dude or dudette woman, I don't know who was started making one and he or she opened four of those little sugar packets. Oh man. To put it in the bottle of the mojito with the, I guess the mint to, to muddle it and then put it in the rum and whatever. And I've never had a mojito since I was like, Oh my God, if I knew that a mojito had each one of those sugar packets is usually about 5 grams of sugar or 4 grams of sugar. So if I knew a mojito, I had 20 grams of sugar in it, I never would have had them.

42:52 So that's where alcohol can really, mixers especially can really increase your calorie intake. I had the same thing, by the way, with beer, right, because I love craft beer. And so Ipas apparently part of the way or sours, the way that they get these Ipas or sours up to 8910 percent ABV is by dumping more sugar in or more fruit, you know, more, more fruits, you know, and, and it might. I think it's, I don't actually know the caloric difference between an IPA and or a sour and let's say a lager. Well, I mean, a Bud Light, a buddy has less than 100 calories, right? Or Guinness, I think has famously, you know, they say whatever that whatever that means.

43:37 I don't know what the equivalent of whatever it says on the bottle, you know, 100 calories. But I, there was a brewery I went to where they had the calories next to the beers and they had a stout which was like a heavy barrel aged, you know, you know, sweet beer. And I think I had like 450 calories for an 8 oz pour or something crazy like that. Well, right. And you know, I'm no brew, no brew Meister, but I do know that, you know, the sugar is the fuel for the yeast to make the alcohol. So I think, you know, they have to add more sugar in it to to get the higher alcohol contents. But yeah, like it's a, it's a, it is AI think that's sort of helped start the whole like the White Claw craze or whatever the, the the seltzer.

44:22 Craze. Because they can make them with relatively little few calories. You know, it's basically like. Alcohol consumption in general feels like it's going down, I. Mean, yeah, I just saw that actually in a I'm always scouring the news because I'm always looking for things to sort of pitch to TV, cable TV networks because I, I've been, was doing a bunch of them, although it's dried up over the last month or so. But anyway, the I think mostly because there's so much other news other than health that people talk about. But I did see another survey that did and it was actually interesting because it said that that so in general, alcohol consumption is down for sure.

45:07 But they, for whatever reason, they they compared it by political party, which I have no idea why that anybody. But supposedly the there's a bigger decrease in alcohol consumption among Republicans than Democrats. I have no idea what that means. I don't. Even if I were to take a wild, a wild stab, really I would. I would just probably say that younger crowds tend to be left-leaning. Younger crowds are a little bit more leaning towards weed and cannabis today than they are towards alcohol in general. And I think that, but it's I think that. It's Republicans who've dropped less, dropped more than Democrats.

45:57 Oh, yeah. Well, because I don't think, but I don't think Democrats were drinking very much recently anyway. So a lot of, you know, these, you know, Logan Bros Bros or whatever, you know, I've been hearing about this last five years. I think a lot of those kind of people have been, you know, have been dropping that. But either way, it's fascinating. I bet you're going to say, I thought you're going to say it's due to the, you know, Trump one and Trump 2 that the Democrats are still drinking their sorrows. No, that's funny. I didn't think about that. So can we get back to epigenetics a little bit now? I'm sorry that, you know, that's right, that's right because I, because I think it is the perfect spot back-to-back. Well, we're back to it, right? Because now we're talking about people.

46:37 Don't you know, think that it's not just a stigma anymore, just like alcoholism. And so, So what, what, what are epigenetics and what are the, what's the context for alcohol, for, for sorry for, for obesity? Yeah. So epigenetics is the field of how genetic material gets altered by the environment, by the extreme environment. And it's a burgeoning field. It wasn't even really a field until maybe like 1520 years ago. And it's not really well understood. But what is understood is that your DNA can be altered by. Experience.

47:18 Yeah, let's say ultra processed foods or let's say environmental toxins, you know, that's that's how radiation meets the cancer, for instance, potentially. And what what is known now is that the epigenetic, the epigenetically modified DNA genes passed down can be passed on from parent to right. So it, you know, the people who are in the food camp, like the food is medicine people, which I don't necessarily support because food is food and medicine is medicine. But they argue that the obesity epidemic can't be about anything other than food because food is the only thing that's changed in the last 50 years. And as we talked about earlier 50 years about when the obesity prevalence really started to rise. But what they don't consider is that, yes, it's the food, but it's the food and how it interacts with your genes. And that's how it gets passed on from parent to child. That's why you know, me as a pediatric surgeon and a pediatric obesity expert, I see kids who are 8 or 9 who haven't been on earth long enough to to eat enough to eat themselves into obesity.

48:32 Even if I believe that anybody did that, which I don't like, nobody eats themselves into obesity. People eat and then their bodies react with obesity because, you know, we all know. We all either have a sibling or a family member or a cousin or a friend who eats the same as we do but is either, you know, 20 lbs heavy. Yeah, of course, 20. Pounds lighter. Like, sure, or you can be a freak athlete and you can work out every day and eat garbage, sorry and eat garbage and you're fine and then they're sorry. Vice versa, you know you're healthy all day and the people that you know genetically, they just walk out of the bag of candy all day and they're totally fine and they're good to go.

49:13 Right. So, so it's clearly more complicated than diet, but the study that came out recently, which I think really is going to help shed light on, on the whole weight regain thing that we were talking about with both medicines and surgery and lifestyle, is that there's now evidence that fat cells have what's, what people are calling memory. So like the the genes and the proteins that are being made in fat cells, even if you lose weight, they still, they may not change.

49:57 So when you stop your intervention, they may still basically drive you back to the unhealthy. Fascinating that you. Had originally and it actually makes a lot of sense if you think about it because. Would that be coming to form of a craving? Is that like is is this? Or is this just that it reacts to food in a similar way? Well, so again with the gut brain axis, we don't really know how fat cells interact with the brain directly or even indirectly. But let's say they have let's say fat cells have a memory and fat cell when you have obesity is has changed your brain to, you know, prefer salty foods or or or processed foods or.

50:45 Or. Sugar, sugar, foods, whatever and then you have surgery and if you have surgery, let's say and you respond well. So we didn't haven't talked about statistics, which bores everybody, but I'd like to. Talk about No, I'd love to. I'd love to talk about it. Yeah, please. Well, mostly because everything's a bell curve. So like when you hear average patient, what does that actually mean and what does that mean for you as an individual? It almost means nothing for you as an individual. You might be average or you might be a super responder or non responder. And the data are that like with any bell curve, 2/3 of the people are within one standard deviation above the average or below the average 2/3, but then 1/3 live on.

51:30 The either end live. Further out. So if you're in the one for 1/3 that is a super responder, good for you. Like you're going to respond to surgery like gangbusters. You might probably not going to need anything else ever, like medication or anything else. But you also might be in the lowest 5% where surgery doesn't really do much for you. And some of that might be due to your epigenetics and whether your fat cells are still, whether the epigenetic modifications are so entrenched that you can't fix them or are they still modifiable. And that may explain why, you know, 20% of people gain weight from surgery, but 80%, I mean, to regain their weight, you know, two years after surgery. And 80% of people don't.

52:16 It also there are data from pediatric bariatric surgery that show that the effects of surgery are actually longer lasting than they are in adults. And it could be the same thing, like maybe we're getting the kids before these epigenetic changes are so entrenched in there fascinating fat. It could be other cells around the body, like it's such a new field that we really don't even we don't even have enough information to to hang our hat there. Although I, I've always believed in the what what's called the intergenerational transmission of obesity, meaning from parents to kids, because I've seen so many young kids with obesity.

53:00 And again, there's just no way, even if I believe that poor behavior, not poor behavior, lack of exercise and not eating right could lead to obesity, which again, I don't believe that. But even if I did, you can't tell me that, you know, 8 year olds can do that in eight years on earth. Like it's just. Well, I mean, we know, I know, for example, and I don't know whether what like what this has, I'm sure this has to do with genetics for sure. But my, you know, my wife just a couple months ago was just, you know, she gave birth thing, you know, and thank God everything was smooth and OK, thank you very much. She's really exciting little girl. And, and, you know, and we're talking to the nurse and she was telling and the baby was born I think at 7/1 or 7/3. And the nurse said that she was just coming. And she's like this past, you know, the last couple of days I've seen, you know, 1012 LB babies being born on a regular basis.

53:57 And, you know, I mean, I grew up and I'm one of six and none of us were anywhere ever really anywhere near that. You know, it was considered, it was considered crazy at that point. But apparently it's becoming pretty common. I'm sure that has to do with what we're talking about, right? Right. So we know that moms who gain excess weight during their pregnancy or get gestational diabetes or actually have diabetes from their weight going into pregnancy, their babies all have a much higher incidence of obesity. And actually interestingly, another interesting study that is relatively recent, it turns out that those same babies have a higher incidence of autism spectrum disorder.

54:39 So like in when all this again, the vaccines causing autism furor came up, there were a lot of publications that showed that actually, you know, there are a lot of other factors outside of even before people are born that can impact your autism risk. So, yeah, no. So for sure the obesity epidemic has has impacted fetuses, for lack of a better word, and they are being born bigger and they are born with often with again, higher hypothalamic weight set points. And there was even a study at CNN that I saw that showed that sugar exposure, what was it in the first 100 days?

55:27 No, 100 days. Wait, what was it first? Thousand days first. Hundreds are lost. Thousand days is 3 years, right? Yes. So the first thousand days from conception from from nine months pre. Right to two years old. Post birth sugar exposure in that period of time was and sugar obviously on the fetus is coming from mom. Sugar exposure in that period of time was critical to your risk of developing type 2 diabetes as a child. And again, it's like no one thinks about people that young, right? They just think, you know, kids will be kids if they're chubby, they'll grow out of it or it doesn't really matter how much what they eat because they're going to be exercising, running around all day so they can eat whatever they want. And for lots of people that's true. And that may be true even for the majority of people. But I think where the like the genetic scores that are being developed and some of the other predictive models that are coming out, this is where this is where they can be useful. Because like, well, first of all, I encourage any woman, any person actually, man or woman who's thinking of conceiving to think about their own health before they conceive. Because if you optimize your own health before you conceive, you're going to optimize the health of your child that you're going to conceive, probably also

56:58 optimize your chance of conceiving. And you know, so, but not only, you know, not only do you do moms have to pay attention to their not only mom could not only would it help if moms pay attention to their or potential moms pay attention to their weight before they conceive, but during pregnancy and then in the first 2-3 years of life and on. Because obviously it's not only sort of the direct impact of what you're feeding or of what the kids eating or whatever, but also just think about the behavior that you're modeling, right? So if you're a a young parent, mom or dad and you're eating chips in front of your 4 year old, your 4 year old's going to automatically be like, Oh yeah, chips are like that's normal. Yeah, chips.

57:49 Yeah. So like. We grew up thinking of wanting a tree, and you have a strawberry. We thought like, you know, we thought, we thought that, you know, blueberries, like my mom would be like, OK, if you're good, we'll give you a strawberry, you know, but you grew up. In a stricter household than I did. I grew up and I'm also 25 years older than you, so things were, you know. Yeah, I think it was. Heavily easier, but. It was, it was, it was I think my mom was heavily influenced by her Eastern European parents, you know, which there's a whole generation in them of themselves, you know, But yeah, tough cookies. And they're very, very, you know, very sensitive, I guess, towards this kind of stuff. So I just, you know, I like my, my youngest brother is 13, you know, he'll make himself a snack.

58:31 Like he doesn't go to the, he doesn't go to the supermarket to, or it's the gas station. He grabs an apple, you know, or a couple of, a couple of oranges. And that's how he just, that's all he knows. That's all he's used to. Yeah, but even in communities where that sort of dietary behaviour is common and like I used to work at in, in New York City, at NYU and there were, you know, Hasidic communities, you know, in the in, in Brooklyn and elsewhere. And they have the same Eastern European roots as you do. But there were families with severe obesity problems in it. I believe it most, it's mostly genetic. It just got passed down from generation to generation and you know, I, I've taken care.

59:25 Of, well, they, they, a lot of these guys don't eat like Saints either. I'll, I'll tell you that. Well, and not anymore, right? They may have, it may have started that way, but but maybe not anymore. But but but but it definitely, I mean it runs in families. And then I'd see families where, let's say you said you had you're one of six, I'd see families where everybody in the family eats as you described, but one of the six kids has a weight problem. And the parents would come in and they'd be like super upset because I don't understand why is my one child having weight issues when nobody else in the family has? And they eat the same stuff and they exercise the same amount, you know, And then I'll start asking like, well, does, does, does mom or dad do either of you guys have any obesity that runs in your families?

1:00:12 Oh, yeah. You know, somebody's brother or somebody's uncle or cousin or whatever. Somebody. And then you can usually chase it back to where. It might have had some genetic origins, but again, that's sort of it's like the natural experiment that I've lived throughout, taking care of all these. Patients. Where I mean, I know, I know for a fact that diet and exercise do not impact obesity in everyone because again, because I've seen families where it. Yeah, it's, it's it if, if it the we're, we're so used to trying to come up with 111 word answers for all these things. You know, I mean, think about how long we it took. So how many years it did it take. And I'm not comparing, you know, at all by any means, of course, but you know, the homeless issue that we've had in the last, you know, 30-40 years or maybe less, but you know, how many, how long people spent saying it's a money problem, You know, where as, and now we're having the conversation, a lot of it's a mental health problem as well.

1:01:15 A lot of this is a sickness. A lot of this is, you know, other factors that, and I'm, and I'm, I'm not saying this to compare, God forbid, I'm not trying to do that. I'm just trying to say that anyone that says it's, it's one thing, it's just diet. It's just if you, if you were, if you just got off the couch, a random marathon, then you wouldn't be obese anymore. You know, like, I'm sure that's not the case either. Well, so, you know, it's human nature. Humans don't like ambiguity and they don't like not knowing the answers. It's much more satisfying to be able to say yes or no, black or white, you know, like people don't like grey. And so like, people don't like, even in medicine, people don't like the, you know, doc, what should I, what should I have surgery or should I take a medication?

1:02:01 Right. You know. It's that that there's there are no answers to those types of questions. And the reality is, again, I go back to statistics and it's because of bell curves and how statistics work. And it's just, it's never going to be most questions are never binary. These questions are, you know, what's the solution to immigration? It's not just throwing people out of the country. It's something far more complex. That's the, you know, any, any major issue you brought up homelessness, poverty, you know, whatever. Whatever divorce rates that's a it's a big deal in the in the country for the last 20. Years or like, I mean, just freaking look at what's going on internationally.

1:02:46 What's the what's the solution in the Ukraine? What's the solution? In Gaza, it's yeah, yeah, like. There, there's no. I mean, I don't want to be too. I don't know what the right word is, pessimistic or nihilistic, but there are no solutions to those. There are. There are like, there are compromises that everybody hates. Yeah, there's no solution like. Yeah, I don't, I don't, Yeah, especially because all because, you know, because issues that are complicated to get to require complicated and nuanced answers too. You know, I think that's also the thing, right. Not to like again, if we can't even tell you what the factor, what factors epigenetics have or not, then how in the world you're going to tell me whether or not it's going to be something that's going to be part of the part of the answer. Like I, I, I, I, I hear you.

1:03:34 I right. It's a great. Point, but I do think you know, again going back to that the positives with RFK and the positives with the food is medicine movement. Like there are, there are modifiable food factors and dyes and ultra processing and things that we can definitely improve upon to make food in the United States healthier, but it's not going to. Cure. It's not going to cure obesity. It's not going to cure obesity. It might help prevent obesity in future generations. But the only like, real solution, if you're talking about solutions, and I'm not even sure this would be a solution, but it's the best I can come up with, is you basically have to do everything all at once. You have to treat everybody who has obesity now before they have the next generation of kids, while improving the food and improving exercise opportunities and getting rid of the stigma and dealing with mental health and adverse childhood experiences and all the other things that have been shown to. It's a societal problem.

1:04:35 So if you could do all that at once, yeah, if you could do all that at once, that's like the same as saying, well, you know, if you can, you know, you know, again, all these complicated problems have, as I said, complicated solutions. And maybe even like I like I was sort of alluding to with the international affairs type of stuff. Maybe it's not, maybe solutions aren't even really what we should be looking for. Maybe we should just be looking like to make things better to a degree, like or, or just, you know, making things like if we can make, let's say we can even get obesity rates. The basically rate in America right now is about 40%, which is crazy. And it keeps going up. It's, it hasn't like plateaued, but maybe we could just get it to plateau.

1:05:20 Like maybe that's what we should be like. That's the first step. Let's just try to get things to stop getting worse. And now we can start to think about how do we make things better And how do we, you know, how do we stop things from getting worse by letting people get treatment and encouraging people to get treatment. And you know, like the healthcare costs related to obesity and the cancers, Oh my gosh, obesity. It's like, it's just like all this, there's all this data and information that frankly is mind blowing that it hasn't spurred some sort of massive, as you said, like not even maybe not a political movement, but like a movement. Awakening. Yeah. Awareness. Yeah, if we wanted to, if we wanted to deal with the with our 30, whatever it is, 3 trillion or $30 trillion debt or whatever our national.

1:06:06 Yeah, yeah, yeah. 30 trillion. Treating obesity actually might be the best way to do it because if we could figure out, and of course treating obesity right now is expensive, but the long term savings, if we could figure out, you know, like how to maintain the health benefits, long term savings would be immeasurable. And again, that's never that's never going to happen. Like that's pipe dream that. I you know, so you think, do you think that it's one of those like shoot for the moon and if not, you land along along the stars kind of, you know, cutesy things where like you try to, you say, let's try to cure it. And then the people, if people are a little better and don't even if they don't make it to the finish line, at least they're better than they were before. So like you're kind of hoping for that. I mean, like, I guess like that's just my immediate thought when I think of that.

1:06:51 Well, on the individual level, people can definitely get better and get healthier and live happier and healthier and longer lives 100% on a societal level and a population level. I mean, I think that's actually why sort of food is medicine has so much traction is because it's, it's somewhat achievable. It's just not likely to have a huge impact. So how do you like what, what's the right strategy? Shoot for the moon and hope that you get somewhere along the way. Or, you know, bite off something that's relatively easier to achieve and hope that it accomplishes something. But. Even I don't know like. I think. I mean, when it comes to it, I think, I think, I think when it comes to, I think when it comes to health, it's hard. I, I don't because I think that it's also something that's not even rational for something for most people, you know, this kind of thing is, has nothing to do with rationality or whether, you know, it's good or not, You know, I mean, when I, I beg my dad, I, my dad and I are very close. We work together and, you know, very close and I beg him to exercise because he's in his late 50s and he doesn't work out a ton.

1:07:58 And I'm like, it could only make your life better. It could only be good for you. You know, I'm, you know, please. And he's like, I know, I know, I know, I know, I, I, I know it's good for me. I know I have to. You just can't. But like, it's not about rationality. It's not about whether you know something, you know there's something. Else and there's been yeah, right, there's been lots of advocates who feel like education campaigns are what we need to to health America's health. But I would argue no one drinks a Coke thinking it's good for them. No one eats a bag of chips thinking it's good for them. Everybody knows what's. Good for you. Yeah, but you deny it's that bad for you. A lot of people deny. Oh, it's not so bad, you know, I'm drinking a Diet Coke. It's better than a Coke, you know, Like by the way, which I do want to ask though. Sorry, I think it's like like your dad like most people know that they should eat better and exercise more. It's not rocket science.

1:08:49 And, and people have heard that message for years. It's how do we make that easier for folks? And you know, and then again, part of it is that like your dad will go through a period where if he ever starts to exercise, where it sucks because starting to exercise sucks. And he's going to be, but if he can fight through that period, he'll then get to a period where he feels great. And they're like, Oh my God, I wish I'd done this 10 years ago or whatever. But it's getting to that first initial suckatude or or yeah, pick a word that's. You. Yeah, I like soccer tea. Soccer tea is good. Is good. Can we, can we talk a little bit about? Can we talk a little bit about? That sodas are terrible.

1:09:32 That's. Probably work that sodas are probably terrible. Are terrible. They're probably almost worse for you than sugar soda. OK, right. So forget about soda. So we could use soda, diet soda in the as like a, as like a base metaphor, but the fake sugar versus real sugar or the, you know, stevia, Splenda, you know, artificial sugar world. Yeah. How does that impact? Yeah, it's interesting. I wish I knew more about stevia because I think of the artificial sweeteners that one might have more because at least it's from a plant, so it's not as manufactured as some of the other ones. But usually those sorts of. Well, first of all, there's now data that there was always data that saccharine caused cancer.

1:10:18 But back in the 70s, long before you were born, there was a soda called Tab that basically got run off the market because it had saccharine in it and it. Caused. Cancer. Turns out that you had to be a lab rat and you probably had to drink like 2 liters worth of tab every day to get saccharine that you would need to to get cancer. But that didn't matter once the word got out that saccharine caused cancer. Like you still see some saccharine packets like sweet and low is still saccharine and they're still in some like delis and and restaurants. But that saccharine basically was run off the face of the earth by by, you know, by whomever by lobbyists or or some other folks that probably isn't probably was never as bad as as it was made out to be. But all of those different artificial sweeteners have some negative health consequences.

1:11:09 Some are linked to cancers, some are linked to diabetes. Some data suggest that they actually just stimulate the same part of your brain that makes you crave sugar and it just makes you crave sugar more. So in general I am not a fan of. Those That's interesting because your brain thinks you're getting sugar, but you're not actually getting enough. Right, Yeah, exactly. Like it makes you want more sugar. It's like having a sweet tooth that like gets worse, I guess. But I think like, you know, so the reason that fruits when they're eaten whole are not nearly as bad for you as when they're turned into a juice and and obviously good for you because of some of the nutrients they provide. Is that the fibre that's in a real plant in a, in a strawberry or blueberry like you mentioned, that makes it so that some of the sugar that's in the fruit actually doesn't even get absorbed.

1:12:06 But when you concentrate that fruit into a juice, you basically remove all the fiber, but you keep all the sugar. And now you just have like, like, you know, growing up again, everybody was thought was told that orange juice was like the best thing for you. Orange juice isn't actually very good for you at all. And it's like, you know, it's just like it's part of the issue with this field in general and potentially why people have so much mistrust in docs is that it's not intentional, but things change and our understanding of of these things change. So sometimes we make recommendations and then ten years later we're like, you know what, all that low and that stuff we had you eat in the in the 90s or the 2000s or whatever, whenever low fat was a thing. Turns out those are all bad for you. So sorry our mistake are bad gave you all this dietary recommendations that were totally off base, but that's. Scary, but that's scary for people, no? Right, of course.

1:13:04 Well, that's why it's, it's easiest for like, and, and they're actually data even it's easiest for people to just sort of stick to the basics like the Mediterranean diet, like eat fish, eat olive oil, eat nuts, eat things that come out of the ground. If you forget about everything else, that's probably still and the data suggested is still the best diet for you. So rather than try to get too fancy and do everything else, it's just really, you know, it probably comes back. It goes back to what your parents parents taught them and my parents parents taught them.

1:13:45 It's just everything in moderation. Like that's probably like still the best advice now as food has gotten lower quality there. And there are certainly some things that even in moderation are not good for you. But again, we don't have to get too, I don't think we have to get too analytical about it. We really just need to, you know, lean proteins, fish, lean meats, legumes, nuts, vegetables, fruits, things that come out of the ground. It's like, and, and if you do that most of the time, you know, if you want an ice cream sundae on, you know, once every couple weeks, it's OK. Yeah.

1:14:25 Like because you're generally healthy and again, I don't think you need to necessarily depends on who you are. Everybody, it's different and everybody reacts differently. And and you know, most people probably don't need to go crazy with that sort of diet as long as they stick to the tenets of it. But if you have a high genetic predisposition towards obesity, maybe that's just how you have to eat your whole life. Like maybe that's just what you need from preconception, postconception year old, 4 year old, 5 year old. You just need. And even if that happens, you probably there's still going to be people who still get obesity even with doing everything quote UN quote, right, You know? That's crazy.

1:15:08 Do you, do you, have you, have you seen that a bunch? Have you seen someone that's diet is good and they kind of move around and I'm not saying work out every day, but like really move around. Yeah. And, and what is it? They can't lose weight or they keep gaining weight. What is it? Well, it depends more of it. Well, I would say that some of them can't lose weight, some of them gain weight. But like you know, again, and that's it's sort of why I used to tell. I have lots of great stories of people calling me a monster for offering surgery for weight loss in children, which we can come back. We can talk about that some other episode when you want an episode on like, Worst Stories of my career.

1:15:51 Please, I would love that. But I used to tell that like the haters, I'd say, listen, just spend the day in my clinic and actually talk to these children who come in to see me. They're like 15 year olds who are on the soccer team and who don't eat terrible. And they're on their high school soccer team, but they're like the goalie or the centre back because they're too big to play some other position where they can run up and down the field as easily. And you know, they're not, they're not eating at McDonald's five times a week and they're not sitting on their butt playing video games all day every day, which is what everybody thinks of kids who have obesity.

1:16:33 And yes, there are some people who aren't exercising and there are some people who aren't eating right. But I've also seen the people who are totally doing everything they're supposed to do and they still they still either can't lose weight or just kept gaining weight so. So how does so how does so how does so and so and may and maybe hopefully let's see if you could try to if it's a little bit too long of an answer detail of a question and you could just tell me. But if that's the case, then how do how do drugs like like Ozempic or whatever work and successfully having a physical impact? Because if it is genetic or you know, if you know the other, if other things don't seem to be working that do work for other people, then what works about the drugs that that the other other stuff can't, can't, can't touch really.

1:17:27 Right. So the simplistic, so I've had patients who I've offered a sleep gastrectomy to where I tell them I'm going to take out 89% of your stomach. They will say to me, but doc, I already eat like almost nothing. So I don't understand how this surgery is going to help me and it's obviously a legitimate question. But with surgery, there are all these other hormones that regulate your metabolism that are impacted. And actually again, we talked about the gut brain access a little bit. There is probably direct gut brain access changes in the hypothalamus that change your weight set point because the body does what's called something called metabolic adaptation, where if you lose weight, your body will react by slowing down your metabolism because it doesn't want you to lose too much weight.

1:18:24 It thinks you're like starving or dying. So it'll slow down the metabolism to keep you from losing more weight. The same thing actually happens in the other direction in a in a in a short term, like a short term experiment like the guy who did super size me. If you like, try to gain weight intentionally. Your body will speed up its metabolism because it wants you to stay within a fairly narrow range. Oh, interesting. And it may be that the ultra processed foods are impacting obesity rates by changing your hypothalamic set point where people set points are being artificially elevated. Yeah, that's a whole nother so. Common my brother-in-law who's in high school is very focused on on on working out and he his friends call it dirty dirty weight. A dirty what's it called?

1:19:11 Dirty weight gaining where like in order to bulk up dirty bulking in order to gain in order to get bigger. If there's scrawny kids, they eat a lot of garbage food and they get big on purpose, and then they work out and they work out like crazy and then they kind of sculpt that into whatever they want. But I can't imagine that's a very good for you either, right? No, and it's actually not going to work long term either. There were actually studies back in the early 2000s where, and this is talking about things that could never be done again today. But there is a study that where they had inmates at some prison intentionally gained like 20 lbs. Like they just fed them 24/7 until they gain weight. And then when they stopped feeding them like that and just like let them go back to their natural eating habits, they all came back down to their starting weight.

1:19:58 Because that's what your body wants to do. Your body wants you to be at whatever weight it thinks you should be at, for better or worse. But so the drugs again, like so if you don't, let's say you exercise and you don't eat a lot yet you're still struggling with weight. I think the medications sort of can do some of the same stuff. That the surgery does in terms of changing your metabolism certainly changes your food preferences certainly get sort of like food noise. So even if you so if you are eating some, if you have some unhealthy foods mixed in with your healthy eating, because no one's perfect, it certainly limits that.

1:20:42 But yeah, I mean, that's, it's sort of it's, it's, it's why obesity is such a complex and interesting disease, because if it was just purely eat less and exercise more and you'll lose weight, then that should work for everybody. And it actually works for almost nobody. So it's just a, you know, it's just it, it, it's why frankly, it's why it's super interesting to me because it's a completely unsolved mystery. And I think it makes it more interesting to me that because I'm from New Jersey and I, I like to pick fights with people. I think it makes it more interesting for me because I think everybody else does it wrong. Like I think the rest of the world, not the rest of the world, but most people, especially the people who are in power these days, they have it wrong. So it's like super interesting and then super important because they're sort of gaslighting the country by telling people this. And, and it's just not, it's not accurate. And that's just not just RFK and HHS and case Cali means or whoever Casey means, whichever means it is. But it's also like all the online influencers and and like, again, even some medical professionals who who will tell their patients, if you just, you know, lifestyle medicine docs or the food is medicine people, they're also gaslighting patients to a degree because again, there's because. We don't know what it is.

1:22:10 Well, there's hard science that shows that it doesn't work. There's hard science that shows that dynamics. Well, they didn't work for everyone, we said, right? Right. Well, so in the most intense behavioral lifestyle treatment programs, you lose about 5 to 7% of your body weight. So I shouldn't say it doesn't work, but because it works, you lose 5 to 7%. But that's not enough for most people with obesity and even the weight loss medications that you know, the reason there was so much excitement about them is that you lose closer to 15 to 20%, really 10 to 15%. Let's say surgery is a minimum of 20 percent, 20% or more. So that's why if you have obesity, So if you weigh 300 pounds, 5% of your body weight is 6 lbs. So at the end of your intensive lifestyle treatment, you'll weigh 294.

1:23:07 And that's not really right. Is that right? No, that's not right. That's the maths wrong. 300 when I say 5 percent, 15 lbs. So you weigh 285 but. If you have £300 right, Well, OK. And I guess this would be, I should have actually opened with this question. Well, I guess I guess I'll close with it. What's, what's the, what's the definition of obese versus overweight? So. Well, so the. I really should have opened with that. Yeah, exactly. You can put in the front, you can always put in the front of the podcast, But the and I, I have to correct you because you shouldn't use obese as an adjective because it's a we're moving away from it's called patient first language. So rather than say someone is obese, you should. So it suffers from obesity.

1:23:52 Yeah, someone who has obesity, right, Because you don't want to call someone you want to call someone a diabetic anymore. You want to call them a person with diabetes. Because it's more you want to define people by their disease. I see. Yeah, yeah, yeah, definitely. OK. Yes, absolutely. So anyway, that's just the preferred language for for all diseases. The nomenclature, right? Interestingly, the autism community is the one, sort of. Yeah, that's right. They don't want that. They want to be called autistic. They don't want to be called someone with autism, which is weird, but whatever. Again, patient advocacy patients should be able to do whatever they want. So there is a medical definition of overweight and obesity. And actually the definition of obesity is still being debated in recent debate over the diagnosis of obesity and how one should define it.

1:24:41 But right now we use BMI, which is a ratio of your weight to height and they're cut offs, so 20. So what is it? 18 to 25 is normal weight. BMI of 25 to 30 is overweight, 30 and above is obesity, and then there are different classes of obesity when you get to 35 and 40 and 45 and 50. I see. But the reality is that BMI is a surrogate. It doesn't really necessarily tell you. Like you could be a very muscular person, you could be a bodybuilder and have almost 0% body fat, but by BMI you'd probably be classified in the obesity range because.

1:25:24 Oh, fascinating. Because you've got so much muscle mass. So it's, it's, it's just a proxy and it's a screening tool. But I mean, that's why there's so much argument about whether or not, you know, what really truly defines obesity. And I like to, I like to joke that similar to autism spectrum disorder, that we should change the name of obesity to something like weight gain spectrum disorder because like, it's just not one disease. Most likely it's probably a lot of different quote UN quote diseases that just look the same at the end of the day. Oh, fascinating, right? We call it a phenotype, which is how something looks, but it comes from different genotypes. Genotypes are how things like come.

1:26:05 To be. Yeah, yeah. So. That's so interesting. Wow, that's so fascinating. We should come up with. I think that's the point. That's the point of language, and that's the point of vocabulary is like that. Specific words encompass specific contexts and. And so the F word fat now has negative connotations because you call someone fat. Oh, you're fat, and that's negative. But fat just started as a way to describe adipose tissue, like adipose tissue is fat. There's brown fat and there's white fat. It didn't always start as a. Negative. Well, of course some people deal with it, right? So it's sort of Obcs the. Same. That's why I think that changing the term doesn't necessarily help because if people are going to just use a different term to be just as derogative, then I think they have to just stop being derogative. That might be definitely help if it's. Weight gain spectrum disorder.

1:26:54 So WGSD, they'll just change those initials. They'll say like, they'll just make it into like. Yeah, they'll just sprout a new word that we'll see you floating around on the Internet. Like WGSD will be it'll it'll be stand for white guy with serious I don't know. D. Diameter there it is. So that's what they're going to, you know, they'll just change it into something bad, into something mean or whatever you. Know. That's just what we do, unfortunately. Well, not not not in this podcast, I guess. You know, like I do think they're, you know, I don't know what the, there's the obviously the Joe Rogans in the world who sort of made their podcast world from being controversial and argumentative and, and frankly sometimes being mean or, or not necessarily positive.

1:27:53 I actually think it's it's, it's kind of like I'm trying to just do the opposite. I figure like, you know, and maybe I'll get nowhere because maybe no one will want to listen to me unless I start to be, you know, calling. People. I don't think that I don't, yeah. It's just, I have to hope that like it's just enough people in medicine and other fields just get out there and just start speaking truths and stop with all the opinion and all the hoopla and all the whatever, that maybe maybe that'll help get the world back to sort of some sense of normalcy. Like, you know, I don't even need it to be a perfect world. I just need it to be like a relatively normal and stable world where you can predict, can predict what the next day is going to mean or like what the next political movement's going to mean.

1:28:43 You don't have to like worry about all kinds of, you know, like, I don't think anybody who grew up post Roe V Wade actually thought there would be a day where it would get reversed. Like, I don't think anybody ever even contemplated that that could happen. But but that's where we are like, it's just, you know, it's just the world is just whatever. The world, it's, it's a pendulum. Everything's a pendulum. It just gets them swinging in different directions, you know, and, and the only thing you can, the only thing that I, I'm kind of hoping for is that it doesn't swing so wildly and that the motions are a little bit more, a little bit less volatile. You know that if it is going to be a pendulum, then it shouldn't.

1:29:26 It should be a clock going from, you know, 7 to 5 instead of 1:50. Exactly or like a metronome where it's, you know, like it goes back and forth, but it goes back and forth in a more predictable pattern and again with not such wide variation with each movement back and forth, but. Yeah, well, anyway, Doctor, I really appreciate the time. This is really awesome. Maybe we'll do I I would, I would Love Actually to do a Part 2 of your horror stories. I think that'll be a lot of fun. But until then, this was really great. I'm so happy we found it. I'm happy we made this work last minute. But thank you so much for the time. This is it's really enlightening and a lot of fun and I think really, really interesting and really informative. So it's. Always fun to chat with, you know?

1:30:08 Again, it's like anyone who's open minded and wants to have a discussion about almost any topic. It's it can be super fun and interesting and informative. Like we, you know, we don't have to agree with everything, we just need to. Have a good time people, and. Talk about it and have fun and not get so worked up if people don't agree or whatever. But yeah, happy to come back and yeah, let me know. Yes, absolutely. And I'll make it happen. Doctor, thank you so much. It's such a pleasure. Have a great day. My pleasure. Take care. Thank you. Bye, bye. Bye. Bye.