1 00:00:00,040 --> 00:00:02,200 Hi, guys. All right, welcome to what I'm 2 00:00:02,200 --> 00:00:04,960 going to call an emergency episode of Inside Thoughts Out 3 00:00:04,960 --> 00:00:07,720 Loud. And that is because GLP ones 4 00:00:07,720 --> 00:00:11,760 have been such a topic for a while now, right, a couple of 5 00:00:11,760 --> 00:00:13,800 years. But I want to say acutely in 6 00:00:13,800 --> 00:00:15,800 this moment, it feels very confusing. 7 00:00:15,800 --> 00:00:21,240 It feels very divisive and it feels very, I want to say 8 00:00:21,240 --> 00:00:24,480 controversial when I think part of it doesn't have to be 9 00:00:24,480 --> 00:00:27,960 controversial. So I brought in the expert. 10 00:00:27,960 --> 00:00:32,080 I wanted to have someone on this podcast that is truly just 10 11 00:00:32,080 --> 00:00:36,040 toes down, an absolute expert in the medication, the metabolic 12 00:00:36,040 --> 00:00:39,760 effects of Physiology and really talk to us about what's the fear 13 00:00:39,760 --> 00:00:42,240 mongering that's going on. What is actually controversial 14 00:00:42,240 --> 00:00:45,200 and what what are we making into controversy that maybe doesn't 15 00:00:45,200 --> 00:00:49,120 need to be controversial. So for that, I am so excited to 16 00:00:49,120 --> 00:00:51,840 introduce all of you to Doctor Rekha Kumar. 17 00:00:51,840 --> 00:00:55,360 She is an associate professor of clinical medicine and a board 18 00:00:55,360 --> 00:00:58,480 certified endocrine at Cornell. Reka, welcome. 19 00:00:58,600 --> 00:01:00,520 Thank you so much for having me. Yeah. 20 00:01:00,720 --> 00:01:04,120 Doctor Kumar, I want to really talk about your expertise and 21 00:01:04,120 --> 00:01:07,360 your background so people really understand just how deep of an 22 00:01:07,360 --> 00:01:10,200 expert you are to be able to share your thoughts on GLP 1. 23 00:01:10,200 --> 00:01:13,400 So let me know all of the things that you've accomplished in life 24 00:01:13,400 --> 00:01:15,360 that bring you to your expertise today. 25 00:01:15,360 --> 00:01:17,400 So thanks for asking me about all of that. 26 00:01:17,400 --> 00:01:22,120 I am trained as an internist and endocrinologist, so I spent my 27 00:01:22,120 --> 00:01:25,480 subspecialty training in endocrinology, diabetes and 28 00:01:25,480 --> 00:01:30,800 metabolism, and then I specialized further in obesity 29 00:01:30,800 --> 00:01:34,520 medicine. My academic research, my 30 00:01:35,800 --> 00:01:40,240 clinical practice was all based on studying and learning 31 00:01:40,240 --> 00:01:44,400 metabolism for 12 years. And in that process I worked on 32 00:01:44,400 --> 00:01:48,600 clinical trials for the early GLP ones, including the SELECT 33 00:01:48,600 --> 00:01:52,160 trial that looked at cardiovascular outcomes in We Go 34 00:01:52,160 --> 00:01:55,600 V and I was the first medical director of the American Board 35 00:01:55,600 --> 00:01:58,280 of Obesity Medicine. That was established actually 36 00:01:58,280 --> 00:02:03,280 the year I finished my endocrine fellowship, which was 2012, and 37 00:02:03,280 --> 00:02:06,320 my role there was to write the credentialing exam that 38 00:02:06,320 --> 00:02:10,560 physicians take when they choose to become board certified in 39 00:02:10,560 --> 00:02:13,040 obesity medicine. So I was their clinical content 40 00:02:13,040 --> 00:02:14,520 expert. And just so everybody who's 41 00:02:14,520 --> 00:02:17,040 listening understands how this works, you can do an internal 42 00:02:17,040 --> 00:02:19,800 medicine residency to be an internal medicine doctor. 43 00:02:19,800 --> 00:02:22,640 But beyond internal medicine to be an endocrinologist, you're 44 00:02:22,640 --> 00:02:26,960 now doing additional years of training specifically focused on 45 00:02:26,960 --> 00:02:29,680 endocrinology, which is really the study of the hormones in 46 00:02:29,680 --> 00:02:32,120 your body and the glands in your body and all the things that 47 00:02:32,120 --> 00:02:35,920 they secrete and how they work together so your body functions. 48 00:02:36,080 --> 00:02:39,000 So let's dive right in. I want to first do like a little 49 00:02:39,000 --> 00:02:43,480 GLP one dictionary session. OK, We use the term semaglutide, 50 00:02:43,480 --> 00:02:47,000 GLP one between all of the terms that you hear. 51 00:02:47,000 --> 00:02:49,400 Give us a little bit of like, what is the actual definition of 52 00:02:49,400 --> 00:02:51,560 these of these terms? And people use them 53 00:02:51,560 --> 00:02:53,480 interchangeably. Is that accurate? 54 00:02:53,560 --> 00:02:58,720 So we'll go to the way basics GLP one or Glucagon like peptide 55 00:02:58,760 --> 00:03:01,480 or hormones we naturally make in our body. 56 00:03:01,480 --> 00:03:05,440 And they belong to a family of hormones called incretins, which 57 00:03:05,440 --> 00:03:07,960 are gut hormones. They're involved in body weight 58 00:03:07,960 --> 00:03:10,400 regulation and blood sugar regulation. 59 00:03:10,400 --> 00:03:13,400 And as we're learning, they have many other functions. 60 00:03:13,600 --> 00:03:18,280 So GLP one is Glucagon like peptide, It is involved in body 61 00:03:18,280 --> 00:03:20,800 weight regulation and blood sugar control. 62 00:03:21,440 --> 00:03:27,600 The medicine version is called AGLP 1 receptor agonist, meaning 63 00:03:27,600 --> 00:03:31,760 that it does the exact job of your own GLP one in your body, 64 00:03:32,760 --> 00:03:36,360 but it actually works for a longer period of time, which is 65 00:03:36,640 --> 00:03:41,440 where it becomes a pharmacologic agent or medicine versus your 66 00:03:41,440 --> 00:03:44,840 natural hormone. So it's modified slightly to do 67 00:03:44,840 --> 00:03:47,720 the same thing, but to act for longer. 68 00:03:47,760 --> 00:03:50,160 And I know you and I have been talking about this offline as 69 00:03:50,160 --> 00:03:53,600 well. Tell us how long the research in 70 00:03:53,600 --> 00:03:56,160 GLP one medication has been around because for a lot of 71 00:03:56,160 --> 00:03:59,120 people they think it just like got discovered yesterday and 72 00:03:59,120 --> 00:04:02,000 that's not actually the truth. Yeah, so the research is super 73 00:04:02,000 --> 00:04:04,960 interesting, and I know we don't have time for all of it, but 74 00:04:05,600 --> 00:04:09,880 originally the GLPS were isolated from the saliva of a 75 00:04:09,880 --> 00:04:13,920 yella monster in like the 1970s or early 1980s, see. 76 00:04:13,920 --> 00:04:16,200 You guys, she's an expert. Do you see what I'm saying? 77 00:04:16,200 --> 00:04:17,839 She knows these things. OK, continue. 78 00:04:17,959 --> 00:04:19,920 Sorry. I told my friends this like 79 00:04:19,920 --> 00:04:22,160 literally at a cocktail party. They were staring at me like I 80 00:04:22,160 --> 00:04:24,680 was a psychopath. This was like years ago. 81 00:04:24,680 --> 00:04:27,640 And now, like with where we are, they would remember that time 82 00:04:27,640 --> 00:04:29,360 you told us about the Yella monster. 83 00:04:29,920 --> 00:04:35,240 Anyway, the the the molecule, the peptide, the hormone has 84 00:04:35,240 --> 00:04:37,480 been now studied for 30 or 40 years. 85 00:04:38,320 --> 00:04:44,120 It's been an FDA approved medication for about 20 years. 86 00:04:44,240 --> 00:04:47,800 20 years, you guys, 20 years it's been FDA approved, OK. 87 00:04:48,080 --> 00:04:50,040 Yeah. We started prescribing the first 88 00:04:50,040 --> 00:04:54,400 GLP one for diabetes in 2005. It was called Byetta. 89 00:04:54,640 --> 00:04:58,080 For those of us that were in this field, we were using Byetta 90 00:04:58,280 --> 00:05:03,040 off label for metabolic disease and obesity because we knew how 91 00:05:03,040 --> 00:05:07,280 it worked and we saw that it was also leading to weight loss. 92 00:05:08,280 --> 00:05:12,240 But the first GLP one for obesity management, didn't get 93 00:05:12,240 --> 00:05:16,480 FDA approved until 2014, but that's still over. 10 years ago, 94 00:05:16,600 --> 00:05:17,920 yeah. And then talk to me about the 95 00:05:17,920 --> 00:05:22,440 term semaglutide, yeah. So semaglutide, or some people 96 00:05:22,440 --> 00:05:24,680 call it semaglutide. People fight over how they 97 00:05:24,680 --> 00:05:26,200 pronounce. It semaglutide. 98 00:05:28,520 --> 00:05:33,520 Is Novo Nordisk the pharmaceutical company's long 99 00:05:33,520 --> 00:05:36,760 acting GLP 1? So prior to that there was 100 00:05:36,760 --> 00:05:41,880 something called lyraglutide that was a shorter acting so it 101 00:05:41,880 --> 00:05:44,920 was prescribed every single day. It existed under the names 102 00:05:44,920 --> 00:05:52,760 Victoza for diabetes and Saxenda for obesity management in 2019 103 00:05:53,080 --> 00:05:57,040 ish. They modified it or 2017 104 00:05:57,040 --> 00:05:59,920 somewhere around there to make it longer acting. 105 00:05:59,960 --> 00:06:04,520 That became somaglutide and that was a weekly medicine. 106 00:06:04,880 --> 00:06:08,440 And so why did that explode? What was the difference between 107 00:06:08,440 --> 00:06:10,920 lyraglutide? That was a daily medicine. 108 00:06:10,920 --> 00:06:13,480 It was FDA approved for diabetes and obesity. 109 00:06:13,480 --> 00:06:15,600 We were prescribing it. People were doing great. 110 00:06:15,800 --> 00:06:19,800 What changed when it became somaglutide, the weekly medicine 111 00:06:20,000 --> 00:06:23,440 that was slightly more effective or significantly more effective? 112 00:06:23,440 --> 00:06:27,480 So the older versions led to 10% loss of total body weight. 113 00:06:28,040 --> 00:06:32,040 Symaglitide was 15 to 20% loss of total body weight. 114 00:06:32,720 --> 00:06:36,080 And so just to like, I want to kind of bring it back to what 115 00:06:36,080 --> 00:06:39,080 these drugs do. And again, I am not an 116 00:06:39,080 --> 00:06:41,160 endocrinologist, but I did go to medical school and I'm a 117 00:06:41,160 --> 00:06:45,360 practicing surgeon. And this concept exists across a 118 00:06:45,360 --> 00:06:49,360 lot of different fields, right? Where you create a medicine that 119 00:06:49,360 --> 00:06:53,520 fits inside of a receptor so that it blocks something else or 120 00:06:53,520 --> 00:06:56,000 it augments something. So that we have medications like 121 00:06:56,000 --> 00:06:58,040 that in the cancer world that we use all the time. 122 00:06:58,400 --> 00:07:01,000 So what we're talking about with these GLP ones is that you have 123 00:07:01,000 --> 00:07:03,760 a receptor and the peptide or the molecule comes, sits in the 124 00:07:03,760 --> 00:07:07,640 receptor and it tells your body, I'm full, I'm good. 125 00:07:07,840 --> 00:07:09,840 I'm you don't need to eat more, right? 126 00:07:10,160 --> 00:07:14,080 And that then has profound pathway effects downstream that 127 00:07:14,080 --> 00:07:15,880 affect, well, if you're not eating more, that's going to 128 00:07:15,880 --> 00:07:17,800 affect your sugar. And all of that is a feedback 129 00:07:17,800 --> 00:07:19,640 loop. So if your body feels like it's 130 00:07:19,640 --> 00:07:21,760 full and it has enough, that's not only going to affect your 131 00:07:21,760 --> 00:07:24,840 hunger cues, but presumably, I'm assuming here, but it's going to 132 00:07:24,840 --> 00:07:27,720 affect how your body then metabolizes the sugar and what 133 00:07:27,720 --> 00:07:29,800 gets broken down and what's what gets stored. 134 00:07:29,800 --> 00:07:33,520 And so all of these very extensive pathways then get 135 00:07:33,520 --> 00:07:37,280 affected by a molecule sitting in that receptor signaling the 136 00:07:37,280 --> 00:07:39,240 gut to then do all of these other things. 137 00:07:39,240 --> 00:07:41,720 Is that a fair explanation of how this drug works? 138 00:07:41,720 --> 00:07:44,800 That is like the most beautiful endocrine explanation. 139 00:07:44,800 --> 00:07:46,800 Wonderful. Just to follow up your 140 00:07:46,800 --> 00:07:49,640 explanation, a lot of people will say, well then why can't we 141 00:07:49,640 --> 00:07:53,320 just take things or take supplements or do things that 142 00:07:53,320 --> 00:07:56,680 increase our own GLP one. And you'll see that that's out 143 00:07:56,680 --> 00:07:59,400 there a lot in the form of gummies, in the form of lots of 144 00:07:59,400 --> 00:08:01,520 supplements, people will say. These Oh my God, are we going to 145 00:08:01,520 --> 00:08:04,040 talk about Lemmy? That that's a great example. 146 00:08:04,440 --> 00:08:09,680 So the whole point is of the medicine is that it acts longer 147 00:08:09,680 --> 00:08:12,800 than your own GLP one. Your own GLP one is degraded in 148 00:08:12,800 --> 00:08:16,080 minutes. So even if you take Lemmy or any 149 00:08:16,080 --> 00:08:19,760 of these things that may or may not increase your own GLP one, 150 00:08:19,760 --> 00:08:24,920 if you truly have metabolic dysfunction or some gut brain 151 00:08:24,920 --> 00:08:28,840 disconnect problem, the supplements aren't going to be 152 00:08:28,840 --> 00:08:30,160 helpful. You're going to need the 153 00:08:30,160 --> 00:08:34,240 pharmacologic agent that actually acts longer to see a 154 00:08:34,240 --> 00:08:37,360 difference. And that's why semaglutide, did 155 00:08:37,360 --> 00:08:39,360 I say that semaglutides popped off? 156 00:08:39,480 --> 00:08:42,480 So I think another really interesting point that people 157 00:08:42,480 --> 00:08:46,680 keep bringing up is the FDA approval for these medications. 158 00:08:46,680 --> 00:08:51,360 And I want to bring an analogy to our listeners as a plastic 159 00:08:51,360 --> 00:08:55,040 surgeon. When I have implants, breast 160 00:08:55,040 --> 00:08:57,840 implants that I use for breast reconstruction, those breast 161 00:08:57,840 --> 00:09:01,560 implants can be approved for augmentation, but they may not 162 00:09:01,560 --> 00:09:04,640 be FDA approved yet for reconstruction. 163 00:09:04,960 --> 00:09:07,760 Does that mean that they haven't been used for 10/15/20 years in 164 00:09:07,760 --> 00:09:10,120 Europe for reconstruction? Does it mean that they're unsafe 165 00:09:10,120 --> 00:09:13,040 for reconstruction? No, and in fact, we have newer 166 00:09:13,040 --> 00:09:16,000 implants on the market or newer brands that are coming to the US 167 00:09:16,240 --> 00:09:18,440 that have a lot of benefit, right? 168 00:09:18,440 --> 00:09:21,960 They may be better than what we have, but they're not FDA 169 00:09:21,960 --> 00:09:24,080 approved yet because you got to go through a lot for FDA 170 00:09:24,120 --> 00:09:26,000 approval. And so that doesn't mean that I 171 00:09:26,000 --> 00:09:28,200 don't use them. I have patients who come in, 172 00:09:28,200 --> 00:09:30,080 they ask for it. They fit the criteria. 173 00:09:30,080 --> 00:09:32,720 They maybe had a certain series of complications with other 174 00:09:32,720 --> 00:09:36,640 implant manufacturers and it's reasonable to apply an off label 175 00:09:36,640 --> 00:09:39,200 use. So this belief that if you use 176 00:09:39,200 --> 00:09:43,240 any medication off label means that you're a bad doctor. 177 00:09:43,480 --> 00:09:45,360 I think really I want to like nip it in the butt. 178 00:09:45,360 --> 00:09:48,640 That is not true. Doctors, especially specialists, 179 00:09:48,640 --> 00:09:50,600 right? When you are down in that rabbit 180 00:09:50,600 --> 00:09:55,720 hole of nicheness like you and I are, we are constantly using the 181 00:09:55,720 --> 00:10:00,600 most recent, most available current data and information and 182 00:10:00,600 --> 00:10:03,200 technology to help solve difficult problems. 183 00:10:03,200 --> 00:10:06,360 So I want you to talk about, you know, I presented this analogy 184 00:10:06,360 --> 00:10:08,280 because I think it's easy to then understand what breast 185 00:10:08,280 --> 00:10:09,200 implants are. Breast implant. 186 00:10:09,200 --> 00:10:11,920 Like why would be reconstruction be different than augmentation? 187 00:10:11,920 --> 00:10:15,360 It's going in a human body. Yeah, but we still have strict 188 00:10:15,360 --> 00:10:18,080 FDA regulations and yes, you still have to go through that 189 00:10:18,320 --> 00:10:20,960 FDA approval process. So sort of coloring the 190 00:10:20,960 --> 00:10:25,360 landscape now talk to me about FDA approval for GLP ones. 191 00:10:25,400 --> 00:10:31,400 So GLP ones are FDA approved, certain ones are approved for 192 00:10:31,400 --> 00:10:37,360 type 2 diabetes and certain GLP one medications separately are 193 00:10:37,360 --> 00:10:42,640 approved for obesity or overweight with a weight related 194 00:10:42,640 --> 00:10:45,080 comorbidity. So that means a body mass index 195 00:10:45,080 --> 00:10:50,320 of 30 or a body mass index of 27 or greater with some weight 196 00:10:50,320 --> 00:10:53,880 related complication like high blood pressure, sleep apnea, 197 00:10:53,880 --> 00:10:56,520 high cholesterol. And just like you said, the 198 00:10:56,520 --> 00:11:01,640 same, you know, implant or and an or my and my and the same 199 00:11:01,640 --> 00:11:05,120 medicine has to go through two separate approvals. 200 00:11:05,320 --> 00:11:08,440 So it's not like these medicines that are approved for diabetes 201 00:11:08,600 --> 00:11:12,240 suddenly also can be used for weight loss. 202 00:11:12,240 --> 00:11:16,040 They have to go through a separate process and that can 203 00:11:16,040 --> 00:11:17,640 take. Years because it's the trials. 204 00:11:17,640 --> 00:11:18,560 Exactly. I don't know if people 205 00:11:18,560 --> 00:11:20,400 understand that. It's not like you like fill out 206 00:11:20,400 --> 00:11:22,800 a Google form and it gets FDA approved. 207 00:11:23,080 --> 00:11:26,720 There's layers of trials with really stringent requirements 208 00:11:27,040 --> 00:11:29,920 and often times multiple trials or multiple phases of trials 209 00:11:29,920 --> 00:11:33,760 that may be required to then get FDA approval for an indication 210 00:11:33,760 --> 00:11:36,240 that's different than what you got FDA approved for before. 211 00:11:36,360 --> 00:11:38,080 Yes. And the key there is with these, 212 00:11:38,400 --> 00:11:41,600 the design of these trials is technically it's different 213 00:11:41,600 --> 00:11:44,800 populations, right. So when you're looking like what 214 00:11:44,800 --> 00:11:47,000 you describe the difference with the breast implants, if they 215 00:11:47,000 --> 00:11:51,120 wanted to redo that trial, they're looking at a different a 216 00:11:51,200 --> 00:11:53,240 different population of patients. 217 00:11:53,560 --> 00:11:56,560 And some of this sounds like, you know technicalities and 218 00:11:56,560 --> 00:12:00,440 that's the way it's been with GLP ones in diabetes versus 219 00:12:00,440 --> 00:12:03,360 weight management. Then you take it to the the next 220 00:12:03,360 --> 00:12:07,880 level, which I think we are going to talk about, which is 221 00:12:07,880 --> 00:12:13,280 this kind of off label use out of the obesity world. 222 00:12:13,680 --> 00:12:19,960 And we're seeing really, you know, rampant use, not like 223 00:12:20,400 --> 00:12:24,680 potentially in a good way of these medicines benefiting other 224 00:12:25,520 --> 00:12:28,160 metabolic conditions. And some of them are weight 225 00:12:28,160 --> 00:12:29,920 related. So if you think of things like 226 00:12:29,920 --> 00:12:33,720 fatty liver, sleep apnea, chronic kidney disease, these 227 00:12:33,720 --> 00:12:38,360 are all medical conditions we see in people who struggle with 228 00:12:38,360 --> 00:12:41,640 excess body fat. And so say somebody has a body 229 00:12:41,640 --> 00:12:47,200 mass index of 26 and not 27, but they have pre diabetes and high 230 00:12:47,200 --> 00:12:50,840 cholesterol and all of these other issues that are weight 231 00:12:50,840 --> 00:12:53,920 related. Is it really irresponsible to 232 00:12:53,920 --> 00:12:57,240 prescribe a GL P1? When we understand the mechanism 233 00:12:57,240 --> 00:12:59,960 of action, we know this is going to help the patient. 234 00:13:00,040 --> 00:13:02,440 So I want to, I'm going to double down on this because 235 00:13:02,440 --> 00:13:04,120 there is a lot of focal controversy. 236 00:13:04,120 --> 00:13:09,480 The criticism that was put forth was the the, you know, in the ad 237 00:13:09,480 --> 00:13:12,920 talking about using these medications and people who have 238 00:13:12,920 --> 00:13:16,120 sort of normal range or more normative BMI. 239 00:13:16,120 --> 00:13:19,240 And what I'm hearing from you is yes, absolutely. 240 00:13:19,240 --> 00:13:23,080 We have proven benefit in certain subpopulations that do 241 00:13:23,080 --> 00:13:25,240 have a quote normal BMI. Am I? 242 00:13:26,040 --> 00:13:27,600 That's not a reach, right? That's what you're saying. 243 00:13:27,880 --> 00:13:31,840 That's not a reach. So the statement that you can 244 00:13:31,840 --> 00:13:39,240 off label use GLP ones safely in normal weight people that that 245 00:13:39,240 --> 00:13:43,080 statement is true there Again, this is like the complexity of 246 00:13:43,160 --> 00:13:46,560 specialty training and nuances. Who are those normal weight 247 00:13:46,560 --> 00:13:50,800 people and why do they need or want to lose weight? 248 00:13:51,120 --> 00:13:53,680 And so there are many normal weight people. 249 00:13:53,680 --> 00:13:55,360 By by weight we're saying normal. 250 00:13:55,360 --> 00:13:59,160 BMIBMI is being debunked left and right every day. 251 00:13:59,160 --> 00:14:04,240 It doesn't say how healthy or how lean or how much fat mass 252 00:14:04,240 --> 00:14:06,200 someone has. It just says how big you are. 253 00:14:06,360 --> 00:14:09,440 And I always use the example. Arnold Schwarzenegger at his 254 00:14:09,440 --> 00:14:12,680 peak bodybuilding health fell into Class 1 obesity. 255 00:14:12,960 --> 00:14:17,200 He had 8% body fat. So there are limitations to the 256 00:14:17,200 --> 00:14:21,640 use of these BMI thresholds, but you know, at scale on a 257 00:14:21,640 --> 00:14:25,600 population level, it was the only tool we had that was cheap, 258 00:14:25,880 --> 00:14:29,840 quick and easy to use in the office setting. 259 00:14:29,840 --> 00:14:36,320 So things like DEXA scanners, those were expensive and not 260 00:14:36,320 --> 00:14:39,080 everyone had access to those. Now these, you know, body 261 00:14:39,080 --> 00:14:41,600 composition analysis are becoming more common. 262 00:14:41,800 --> 00:14:45,800 But BMI has limitations. There are people of normal BMI 263 00:14:45,960 --> 00:14:49,920 that may be unhealthy, prone to metabolic disease and could 264 00:14:49,920 --> 00:14:53,040 benefit from a GL P1. And these are conversations that 265 00:14:53,040 --> 00:14:56,640 doctors and patients have when they decide to prescribe off 266 00:14:56,640 --> 00:14:59,760 label. So there's off label prescribing 267 00:14:59,920 --> 00:15:04,200 but and and that is accepted. And at this point, we know that 268 00:15:04,200 --> 00:15:09,240 20% of GLP one prescriptions in the US that are branded 269 00:15:09,240 --> 00:15:11,680 prescriptions that we can track are prescribed off. 270 00:15:11,680 --> 00:15:13,480 Label so and that's not a bad thing. 271 00:15:13,480 --> 00:15:16,800 I think that's where people create controversy in a way and 272 00:15:16,800 --> 00:15:20,280 where it doesn't need to be. I mean, we use off again quote 273 00:15:20,280 --> 00:15:22,680 off label meaning the FDA approval hasn't come through 274 00:15:22,680 --> 00:15:24,600 yet. But I see this all the time with 275 00:15:24,600 --> 00:15:27,360 chemotherapies for certain resistant cancers or breast 276 00:15:27,360 --> 00:15:29,520 implants for breast reconstruction. 277 00:15:29,800 --> 00:15:33,360 We do this all the time. So criticizing a doctor for that 278 00:15:33,360 --> 00:15:35,680 in and of itself to me. Falls flat. 279 00:15:35,840 --> 00:15:38,600 So I agree with you, the scientific statement that you 280 00:15:38,600 --> 00:15:41,480 could use GLP one safely in normal weight people. 281 00:15:43,720 --> 00:15:45,360 That is true. You you can do that. 282 00:15:45,360 --> 00:15:46,680 There's nothing wrong with that statement. 283 00:15:47,000 --> 00:15:51,080 I think that there's off label prescribing that needs to be 284 00:15:51,080 --> 00:15:56,400 distinguished from off label marketing of medicines and and 285 00:15:56,400 --> 00:15:59,920 those two things are different and and the FDA looks at those 286 00:15:59,920 --> 00:16:00,920 differently. Yeah. 287 00:16:00,920 --> 00:16:03,040 Talk to me a little bit more about that because I think 288 00:16:03,040 --> 00:16:05,720 that's where a lot of the focal controversy is at the moment. 289 00:16:05,720 --> 00:16:09,320 Yes, every like I said, 20% of GLP one prescriptions that we 290 00:16:09,320 --> 00:16:13,320 know of and probably many or a higher percentage are prescribed 291 00:16:13,320 --> 00:16:17,280 off label and that is allowed, it's accepted in the clinical 292 00:16:17,280 --> 00:16:20,680 setting and that is part of shared decision making. 293 00:16:20,680 --> 00:16:23,440 And truthfully, a lot of off label prescribing is how 294 00:16:23,440 --> 00:16:27,320 innovations starts in medicine. It starts 100% in the doctor's 295 00:16:27,320 --> 00:16:29,680 office, patient, doctor conversation. 296 00:16:29,680 --> 00:16:32,080 You do something. That's literally what clinical 297 00:16:32,080 --> 00:16:33,680 trials are for. Yes, yeah. 298 00:16:34,920 --> 00:16:41,080 But technically off label advertising is is not considered 299 00:16:41,080 --> 00:16:44,640 OK by the FDA. So it's one thing to to do it 300 00:16:44,680 --> 00:16:50,360 between a patient and a doctor, but marketing it and advertising 301 00:16:50,360 --> 00:16:55,160 it I believe is what is considered a bit sketchy. 302 00:16:55,520 --> 00:16:59,760 OK, so when so talk to me about Noom, What is Noom? 303 00:16:59,760 --> 00:17:01,760 Because obviously everyone's talking about it. 304 00:17:01,760 --> 00:17:03,760 Everyone likes the idea that it's not an injection now it's 305 00:17:03,760 --> 00:17:06,560 going to come in a pill. Is it as long acting? 306 00:17:06,560 --> 00:17:09,720 Is it as good? Do we have efficacy data yet? 307 00:17:10,000 --> 00:17:11,640 Talk to me about Noom. Yeah. 308 00:17:11,640 --> 00:17:16,000 So, so Noom is a platform. It's a telehealth company that 309 00:17:16,880 --> 00:17:19,800 initially started as a behavioral platform for weight 310 00:17:19,800 --> 00:17:21,880 management and now they do medicines. 311 00:17:22,119 --> 00:17:25,680 So just like hymns, just like found where I'm the senior 312 00:17:25,680 --> 00:17:30,280 medical advisor, there's many companies that offer behavior 313 00:17:30,280 --> 00:17:33,160 change plus medical management of obesity. 314 00:17:33,160 --> 00:17:35,120 So that's actually really interesting because I didn't 315 00:17:35,120 --> 00:17:36,920 know that. I thought watching the ad, I 316 00:17:36,920 --> 00:17:39,400 thought the Noom was Noom was the name of the pill that 317 00:17:39,400 --> 00:17:40,680 everyone was going to start taking. 318 00:17:41,400 --> 00:17:42,680 And I think that does change something. 319 00:17:42,680 --> 00:17:46,480 So it's Noom that's putting out the advertisement and Noom is 320 00:17:46,480 --> 00:17:51,360 advertising their services being weight management services. 321 00:17:51,360 --> 00:17:53,280 OK, continue. Correct. 322 00:17:53,280 --> 00:17:56,920 And and that is so interesting to me that it confused you 323 00:17:56,920 --> 00:17:59,600 because I think that's where some of the controversy lies. 324 00:17:59,600 --> 00:18:00,400 Yeah. Is that? 325 00:18:00,400 --> 00:18:04,120 I'm a doctor, I practice right, but I'm telling you, when I as 326 00:18:04,120 --> 00:18:07,360 again, not an endocrinologist, I'm just watching the ads, I 327 00:18:07,400 --> 00:18:09,440 genuinely thought it was the name, like it was going to be 328 00:18:09,440 --> 00:18:11,880 the, you know, the brand name of the medication. 329 00:18:11,880 --> 00:18:15,440 So again, that's why I have you on here to educate all of us, 330 00:18:15,440 --> 00:18:18,320 myself included. But no, but continue because I 331 00:18:18,320 --> 00:18:21,360 think this is really interesting to frame what Noom is 332 00:18:21,360 --> 00:18:25,240 advertising because it sounds like they're advertising their 333 00:18:25,240 --> 00:18:27,720 services. And in the particular ad that 334 00:18:27,720 --> 00:18:31,480 was controversial, they are, they are talking about the use 335 00:18:31,480 --> 00:18:34,520 of GLP ones. So in that context, talk to me 336 00:18:34,520 --> 00:18:36,720 about whether you felt like that ad was appropriate, 337 00:18:36,720 --> 00:18:38,400 inappropriate, somewhere in the middle. 338 00:18:38,520 --> 00:18:42,040 So there's a, there's so many layers of this ad and it's why 339 00:18:42,040 --> 00:18:46,360 it became controversial if you pull each piece apart on their 340 00:18:46,360 --> 00:18:48,440 own. So there's three layers of this. 341 00:18:48,680 --> 00:18:50,560 There's the white coat marketing, right? 342 00:18:50,720 --> 00:18:56,080 And there's a doctor that is being used in advertising and 343 00:18:56,080 --> 00:19:01,320 that can confuse patients potentially by using a doctor in 344 00:19:01,320 --> 00:19:06,200 an ad, does it give the message to patients that whatever this 345 00:19:06,200 --> 00:19:10,960 person is saying or doing is definitively safe and OK, which 346 00:19:10,960 --> 00:19:15,200 then the second layer of this is off label prescribing. 347 00:19:15,880 --> 00:19:20,840 So then you have a doctor potentially marketing off label 348 00:19:20,840 --> 00:19:23,800 prescribing, even though we feel the off label prescribing on its 349 00:19:23,840 --> 00:19:26,920 own is safe. The third layer is there was 350 00:19:26,920 --> 00:19:29,680 potentially a reference to compounded meds, right. 351 00:19:29,840 --> 00:19:34,160 So we have three issues here. We have and on on their own, 352 00:19:34,360 --> 00:19:36,800 like each one carries different meaning. 353 00:19:36,960 --> 00:19:41,440 I think the the one that we don't want to lose the science 354 00:19:41,560 --> 00:19:47,560 of or diminish the science of is the role of individualized 355 00:19:47,600 --> 00:19:49,360 dosing. Is this really a thing? 356 00:19:49,480 --> 00:19:51,560 What what does micro dosing mean? 357 00:19:51,680 --> 00:19:53,920 This this word has sorted. And we are definitely getting 358 00:19:53,920 --> 00:19:55,520 there. I will we will talk about micro 359 00:19:55,840 --> 00:19:57,480 dosing. I'm triggered by that word. 360 00:19:59,520 --> 00:20:05,800 But I would say on its own, the the ad for a service, I mean, 361 00:20:05,800 --> 00:20:07,680 this is what we see, see with everything. 362 00:20:07,680 --> 00:20:10,960 I think that one of the confusing things though, was 363 00:20:10,960 --> 00:20:16,360 that a physician was in the ad. Not only for a service, but 364 00:20:16,360 --> 00:20:22,040 potentially for an off label indication made in a compounding 365 00:20:22,040 --> 00:20:23,560 pharmacy. I think it was all the layers 366 00:20:23,560 --> 00:20:24,440 that. It was layers. 367 00:20:24,440 --> 00:20:26,960 I'll tell you, I watched the ad and I'm not going to I don't 368 00:20:26,960 --> 00:20:29,680 want to pull it and I don't want to put because it this episode 369 00:20:29,680 --> 00:20:31,560 isn't specifically about that, right? 370 00:20:31,560 --> 00:20:33,480 Like you guys can go. Totally for it and. 371 00:20:33,560 --> 00:20:35,520 Whatnot. Like I don't want to do that, 372 00:20:35,520 --> 00:20:37,720 but I bring it up because I think it's a really good sort of 373 00:20:37,720 --> 00:20:41,240 example or analogy for what is so confusing and why people are 374 00:20:41,240 --> 00:20:43,920 getting upset. And I think when I watched the 375 00:20:43,920 --> 00:20:45,280 ad, I actually thought nothing of it. 376 00:20:45,280 --> 00:20:49,600 And I am somebody who approaches GLP one dosing, especially micro 377 00:20:49,600 --> 00:20:51,520 dosing with a lot of caution. And we've talked again about 378 00:20:51,520 --> 00:20:54,440 this offline because of my perspective as a reconstructive 379 00:20:54,440 --> 00:20:57,080 surgeon for breast cancer patients and we'll get to that. 380 00:20:57,080 --> 00:21:01,120 But as someone who's already wary, when I watched it, I truly 381 00:21:01,400 --> 00:21:03,760 I felt like because I think there's a disclaimer at the end 382 00:21:03,760 --> 00:21:06,480 that it's not FDA approved yet and that we are talking about 383 00:21:06,480 --> 00:21:09,120 off label prescribing. So I felt like the disclaimer 384 00:21:09,120 --> 00:21:11,760 was out there. And I do think, look, I would 385 00:21:11,760 --> 00:21:15,600 much rather be a doctor talking about something that we actually 386 00:21:15,600 --> 00:21:17,600 do in medicine. I don't think that any 387 00:21:17,920 --> 00:21:21,160 individual statement made by that physician was incorrect. 388 00:21:21,160 --> 00:21:23,920 Do you? No, the individual statement 389 00:21:23,920 --> 00:21:27,680 wasn't incorrect, but it was an advertisement versus educational 390 00:21:27,680 --> 00:21:29,080 versus educational content. Yeah. 391 00:21:29,280 --> 00:21:31,520 And patients may not be able to tell the difference there. 392 00:21:31,640 --> 00:21:32,880 Right. And it was meant as advertising, 393 00:21:32,880 --> 00:21:35,000 right, because it was advertising the new platform. 394 00:21:35,200 --> 00:21:38,320 But I, when I'm listening to it, I didn't, I there was nothing 395 00:21:38,320 --> 00:21:40,480 that she said that I was like, oh, that's wrong. 396 00:21:40,480 --> 00:21:43,240 I'm like, no, we, we literally do use the medication For these 397 00:21:43,280 --> 00:21:45,400 reasons in normative BMI patients. 398 00:21:45,400 --> 00:21:46,880 I've heard of this, I've seen this. 399 00:21:47,120 --> 00:21:49,840 So nothing came off as propaganda and I didn't listen 400 00:21:49,840 --> 00:21:52,920 to it or see it and go, oh, why I didn't feel like that. 401 00:21:52,920 --> 00:21:54,720 And if anything, I felt like, well, I'm glad it's somebody 402 00:21:54,720 --> 00:21:57,640 who's speaking up about this, who literally has treated 403 00:21:57,640 --> 00:22:02,080 obesity as related to, you know, their, their specialty, which is 404 00:22:02,080 --> 00:22:05,320 a surgical specialty, but they, they have treated obesity as it 405 00:22:05,320 --> 00:22:08,120 relates to their specialty. They have prescribed GLP ones 406 00:22:08,120 --> 00:22:10,400 and they themselves have been open about their GLP one 407 00:22:10,400 --> 00:22:12,600 journey. So I felt like, you know what I 408 00:22:12,600 --> 00:22:16,240 like that because it's better than just some celebrity who 409 00:22:16,240 --> 00:22:20,160 really has no insight into sort of the profound effects of these 410 00:22:20,200 --> 00:22:23,200 of these messages. So I if anything, I I was like, 411 00:22:23,200 --> 00:22:25,080 oh, OK, this is cool. Like I I like that. 412 00:22:25,080 --> 00:22:27,200 Now, did I miss the boat on what Nume actually is? 413 00:22:27,200 --> 00:22:29,400 Clearly I did. I didn't know what that it was a 414 00:22:30,280 --> 00:22:32,320 general weight management platform, not just the 415 00:22:32,320 --> 00:22:34,520 medication. And I think you're bringing in 416 00:22:34,520 --> 00:22:39,600 the light of should we, can we advertise off label use as 417 00:22:39,600 --> 00:22:41,320 opposed to educationally promote it? 418 00:22:41,320 --> 00:22:46,320 And I, this is a hard topic because, and I'm going to be 419 00:22:46,320 --> 00:22:50,440 very honest here, I did an ad for a neuromodulator company and 420 00:22:50,440 --> 00:22:52,480 I use neuromodulators on my face. 421 00:22:52,480 --> 00:22:54,920 Neuromodulators are like, I don't want to name the 422 00:22:54,920 --> 00:22:58,320 companies, but they're basically are injectables that you can use 423 00:22:58,320 --> 00:23:00,960 for cosmetic reasons to help, you know, reduce and prevent 424 00:23:00,960 --> 00:23:03,200 wrinkles. So the company, which is really 425 00:23:03,200 --> 00:23:05,920 interesting, they said this is what we're FDA approved for. 426 00:23:06,480 --> 00:23:09,040 Don't you dare talk about what we're not FDA approved for. 427 00:23:09,040 --> 00:23:12,200 You can use it for the rest of your face all day long, but 428 00:23:12,200 --> 00:23:14,640 we're approved for here. So talk about here. 429 00:23:14,920 --> 00:23:17,480 And that's what I thought was really interesting was I having 430 00:23:17,480 --> 00:23:21,600 done one of these partnerships before, I was, I mean, they were 431 00:23:21,600 --> 00:23:24,160 really picky. I had to give the script, each 432 00:23:24,160 --> 00:23:27,280 word was analyzed, the video was analyzed to make sure that I 433 00:23:27,280 --> 00:23:30,080 stayed within the arena of what is FDA approved. 434 00:23:30,400 --> 00:23:32,040 So I think it's almost a little interesting. 435 00:23:32,040 --> 00:23:35,320 I, I almost feel like was this person set up poorly by the 436 00:23:35,640 --> 00:23:36,880 person that they did the ad with? 437 00:23:36,880 --> 00:23:38,720 Because if you yourself have been the recipient of a 438 00:23:38,720 --> 00:23:41,280 medication and it worked well for you and you know, the 439 00:23:41,280 --> 00:23:44,080 medicine behind it and you know, people use it off label all the 440 00:23:44,080 --> 00:23:48,720 time, but maybe you weren't educated on the sort of what it 441 00:23:48,720 --> 00:23:50,720 means to market something off label. 442 00:23:51,120 --> 00:23:54,840 Isn't that also the company's responsibility to sort of think 443 00:23:54,840 --> 00:23:57,680 about those things? So I think the disclaimer there 444 00:23:57,680 --> 00:24:02,120 was Noom addressing the off label prescribing and saying 445 00:24:02,120 --> 00:24:05,800 this isn't FDA approved. But I think the complication was 446 00:24:05,800 --> 00:24:09,480 that there were so many confusing layers that may have 447 00:24:09,480 --> 00:24:13,080 thrown people off. You had actually more context 448 00:24:13,160 --> 00:24:17,400 even than I did. So you know this person, you 449 00:24:17,840 --> 00:24:21,240 even I would never have known this person prescribed AGLP 1 or 450 00:24:21,240 --> 00:24:25,000 even had their own journey. So I was missing contacts. 451 00:24:25,000 --> 00:24:29,240 So I think you had a lot of information. 452 00:24:29,240 --> 00:24:31,840 I had some information. I knew that that was a doctor. 453 00:24:32,000 --> 00:24:34,760 And so to me, I said, OK, what she's saying makes scientific 454 00:24:34,760 --> 00:24:40,600 sense, but I think that I always forget the number of people 455 00:24:40,600 --> 00:24:44,520 seeing these things don't have the context that any of us have. 456 00:24:44,520 --> 00:24:49,200 And so theoretically, somebody could see that not know what 457 00:24:49,200 --> 00:24:54,320 Numa is, not know who the doctor is and see a neurosurgeon 458 00:24:54,400 --> 00:25:01,400 advertising on a medicine. And so the concern is that 459 00:25:01,400 --> 00:25:04,760 somebody would think, well, she's saying that this is OK to 460 00:25:04,760 --> 00:25:10,960 do, but the push back there is, but it's off label I. 461 00:25:10,960 --> 00:25:12,240 Mean that's why it's great, right? 462 00:25:12,240 --> 00:25:15,160 That's why we're all kind of like, I think both of us and a 463 00:25:15,160 --> 00:25:18,800 lot of people we're choosing our words because I, I don't know, I 464 00:25:18,800 --> 00:25:22,040 see both sides of the coin. I go also, if there is off label 465 00:25:22,040 --> 00:25:25,240 use and it is helpful for people who maybe have, you know, fatty 466 00:25:25,240 --> 00:25:29,280 liver or sleep apnea or whatnot, these other conditions and they 467 00:25:29,280 --> 00:25:31,040 could benefit from it. How are they going to know about 468 00:25:31,040 --> 00:25:33,640 it if they don't, if they're not approached? 469 00:25:33,640 --> 00:25:35,920 So is it that we should do it through education? 470 00:25:35,920 --> 00:25:39,600 But I can also tell you talking about GLP ones online gets a lot 471 00:25:39,600 --> 00:25:42,080 of backlash. I had posted just a quick little 472 00:25:42,080 --> 00:25:46,360 tidbit about GLP ones because I honestly, the word micro dosing 473 00:25:46,360 --> 00:25:49,840 is so triggering to me. I would say 30% or more of my 474 00:25:49,840 --> 00:25:51,800 patients that come into my clinic for breast cancer 475 00:25:51,800 --> 00:25:54,800 reconstruction are on GLP ones. And when I asked them, who's 476 00:25:54,800 --> 00:25:59,240 prescribing it, does your oncologist know less than 10% of 477 00:25:59,240 --> 00:26:03,360 them are getting these from doctors who or they don't even 478 00:26:03,360 --> 00:26:05,880 know who the person is on the other end, presumably a medical 479 00:26:05,880 --> 00:26:07,920 professional, but we don't really know. 480 00:26:07,920 --> 00:26:10,240 And I'll say things like, well, do they know all the medications 481 00:26:10,240 --> 00:26:11,600 you're on? Do they know you're on Keytruda? 482 00:26:11,600 --> 00:26:12,960 Do they know this? Do they know that? 483 00:26:13,440 --> 00:26:15,920 And it's a lot of skirting around the issue. 484 00:26:15,920 --> 00:26:18,440 And when I asked them, does your oncologist know that you're on 485 00:26:18,440 --> 00:26:20,720 this medication? Not everybody says yes because 486 00:26:20,720 --> 00:26:23,800 they may have felt like their oncologist wasn't on board, but 487 00:26:23,800 --> 00:26:25,920 maybe the oncologist wasn't on board because she doesn't, he or 488 00:26:25,920 --> 00:26:27,920 she doesn't want you taking this medication while she's 489 00:26:27,920 --> 00:26:30,320 prescribing other medicines, right? 490 00:26:30,320 --> 00:26:32,640 And then they're getting this conflicting data online because 491 00:26:32,640 --> 00:26:35,920 there's breast cancer influencers saying I'm on AGLP 1 492 00:26:35,920 --> 00:26:39,160 and it reduces breast cancer recurrence rates and I feel 493 00:26:39,160 --> 00:26:40,520 great. So they feel like they're 494 00:26:40,520 --> 00:26:44,440 missing this golden opportunity because how desperate are all of 495 00:26:44,440 --> 00:26:48,960 we, all of we, Jeez, all of us, how desperate are, are, is 496 00:26:48,960 --> 00:26:54,560 everyone to, to pursue something that could decrease cancer risk, 497 00:26:54,560 --> 00:26:56,240 especially if you've already been diagnosed with it. 498 00:26:56,240 --> 00:26:58,840 So I, I see it really play out in real time. 499 00:26:58,840 --> 00:27:02,600 And I, you know, have had patients not heal well from 500 00:27:02,600 --> 00:27:04,720 surgery. I've had to cancel surgery 501 00:27:04,720 --> 00:27:06,640 because they didn't disclose they were on the medication. 502 00:27:06,640 --> 00:27:10,080 And it very much affects your GI function and the risk of 503 00:27:10,080 --> 00:27:13,040 aspiration and the safe safety of anesthesia. 504 00:27:13,320 --> 00:27:16,960 I've had patients admitted for severe pancreatitis because they 505 00:27:16,960 --> 00:27:19,800 were on other meds at the same time and they weren't in ICU for 506 00:27:19,800 --> 00:27:21,800 a month. So I see this sort of other side 507 00:27:21,800 --> 00:27:25,720 of it where I feel like I'm capturing this subpopulation of 508 00:27:25,720 --> 00:27:28,680 people that are prone to complications and it makes me 509 00:27:28,680 --> 00:27:31,640 very wary. So I posted like AI think micro 510 00:27:31,640 --> 00:27:34,160 dosing is a scam. And in retrospect, I felt like 511 00:27:34,160 --> 00:27:37,120 it was a little bit of like a click baity kind of, you know, 512 00:27:37,400 --> 00:27:40,240 everyone wanted to click. But my point, which I had put in 513 00:27:40,280 --> 00:27:44,600 in the caption in the comments, was micro dosing is nuanced 514 00:27:44,600 --> 00:27:47,400 dosing, right? If you are nuanced dosing, a 515 00:27:47,400 --> 00:27:51,560 medication that should be coming from a specialist, Someone Like 516 00:27:51,560 --> 00:27:54,760 You who's an endocrinologist who specializes in obesity medicine 517 00:27:55,120 --> 00:27:58,080 that understands and can work comprehensively with your 518 00:27:58,080 --> 00:27:59,640 medical team. Because chances are if you need 519 00:27:59,640 --> 00:28:02,040 this medication, you've got other things going on. 520 00:28:02,040 --> 00:28:05,120 You've got a primary care doctor, for example, and I find 521 00:28:05,120 --> 00:28:09,640 it frustrating when people dive right into this, this magical 522 00:28:09,640 --> 00:28:12,920 medication and they are not getting the adequate 523 00:28:12,920 --> 00:28:14,760 comprehensive assessment and care from a. 524 00:28:14,760 --> 00:28:18,240 Specialist, you are 100% right on all of that. 525 00:28:18,520 --> 00:28:24,360 And actually, several years ago, I chose to go from being super 526 00:28:24,360 --> 00:28:27,760 specialized in all of this to going back into primary care. 527 00:28:28,080 --> 00:28:31,040 And so I do primary care as well as endocrinology. 528 00:28:31,040 --> 00:28:35,480 And the reason is everything you're saying is that I felt 529 00:28:35,480 --> 00:28:39,160 like I saw it coming, by the way, with these drugs and kind 530 00:28:39,160 --> 00:28:41,400 of the explosion and how good they were going to be. 531 00:28:41,720 --> 00:28:45,560 And I was like, I really need to make sure I'm taking full care 532 00:28:45,560 --> 00:28:49,360 of people in order for them to be on this journey with me 533 00:28:49,360 --> 00:28:52,840 because I am not comfortable just being involved in this 534 00:28:52,840 --> 00:28:57,160 prescription because of everything you said, the, you 535 00:28:57,160 --> 00:29:01,160 know, the supervision, the counseling on nutrition and 536 00:29:01,160 --> 00:29:05,240 exercise, the really detailed guidance on stopping before 537 00:29:05,240 --> 00:29:11,120 surgical procedures, before routine colonoscopies, before 538 00:29:11,640 --> 00:29:16,320 egg transfers for fertility. There's so many things over the 539 00:29:16,320 --> 00:29:20,160 course of a person's life that touches their health that this 540 00:29:20,160 --> 00:29:22,680 GLP one just lingering in the background. 541 00:29:22,680 --> 00:29:26,120 If they're getting it or buying it from, you know, buying it off 542 00:29:26,120 --> 00:29:28,760 the Internet without supervision, it is a big 543 00:29:28,760 --> 00:29:31,080 concern. And then they land in either 544 00:29:31,080 --> 00:29:34,520 your office with something very serious and potentially could 545 00:29:34,520 --> 00:29:37,960 have a surgical complication or they land in my practice have 546 00:29:37,960 --> 00:29:41,520 been having been on these meds for a long time without adequate 547 00:29:41,520 --> 00:29:43,920 support and that's not healthy either. 548 00:29:43,920 --> 00:29:47,240 They're many things can be true at once. 549 00:29:47,240 --> 00:29:51,240 And I think we said this on the phone together that these could 550 00:29:51,240 --> 00:29:55,040 practically be miracle drug drugs, but has it gone too far? 551 00:29:55,040 --> 00:29:57,880 Absolutely. Is there inappropriate use and 552 00:29:57,880 --> 00:30:01,040 inappropriate prescribing? There are all of those things, 553 00:30:01,160 --> 00:30:06,680 but when done right I think that these medicines can be life 554 00:30:06,680 --> 00:30:10,720 changing not only for on label use, but certain off label uses 555 00:30:10,720 --> 00:30:12,320 too. Yeah, absolutely. 556 00:30:12,320 --> 00:30:14,880 So I want to bring it back to these platforms you are involved 557 00:30:14,880 --> 00:30:19,280 and found, you know, we had been talking about Noom, how as a 558 00:30:19,280 --> 00:30:23,160 consumer can someone that whether a platform is like 559 00:30:23,160 --> 00:30:25,280 they're doing it the right way or if it's sketchy. 560 00:30:26,400 --> 00:30:27,680 How does one know? Yeah. 561 00:30:28,840 --> 00:30:31,480 I mean, do you interact with a clinician? 562 00:30:32,000 --> 00:30:34,360 I would say that that is a big question. 563 00:30:34,400 --> 00:30:38,120 How much of A medical history is required in order to get a 564 00:30:38,120 --> 00:30:41,200 prescription? How detailed is the interaction 565 00:30:41,200 --> 00:30:43,760 with the prescriber? So if you're using a platform 566 00:30:43,760 --> 00:30:46,280 where you just have to fill out a form, somebody reviews it and 567 00:30:46,280 --> 00:30:48,320 sends you the prescription, would you agree that that is 568 00:30:48,320 --> 00:30:54,920 insufficient? I think that that is a different 569 00:30:54,920 --> 00:30:57,520 type of care. So there are a group of 570 00:30:57,760 --> 00:31:02,840 consumers that really do value price, speed and convenience. 571 00:31:02,840 --> 00:31:06,120 The thing is what is that vetting process of deciding who 572 00:31:06,120 --> 00:31:09,960 that patient is versus the more complex patient where that's not 573 00:31:09,960 --> 00:31:14,000 adequate. So I would say that it depends 574 00:31:14,000 --> 00:31:16,480 on the level of care you want. Is there an amount of? 575 00:31:16,560 --> 00:31:17,800 What do you? Think that's safe? 576 00:31:17,800 --> 00:31:19,960 Do you think it's safe if they're, because how is the 577 00:31:19,960 --> 00:31:22,720 patient supposed to know that they are more complicated or 578 00:31:22,720 --> 00:31:24,800 not? If they again, everybody's 579 00:31:24,800 --> 00:31:28,120 looking for speed, convenience, obviously price is, is 580 00:31:28,120 --> 00:31:30,680 important. And if they find you know, 581 00:31:30,680 --> 00:31:33,680 because I see the stuff linked on breast cancer influencer 582 00:31:33,680 --> 00:31:37,560 profiles and I'll go to the link and I am shocked at how easy it 583 00:31:37,560 --> 00:31:40,520 is to get these medications. So to me. 584 00:31:40,520 --> 00:31:42,800 I think people need to interact with a clinician. 585 00:31:42,880 --> 00:31:45,680 Right, that's how I feel. I mean, do a virtual visit. 586 00:31:45,680 --> 00:31:48,240 I do virtual visits with patients all the time, right? 587 00:31:48,240 --> 00:31:51,400 We just hop on, we see each other, we ask some questions. 588 00:31:51,400 --> 00:31:54,120 There's an exchange if you can just fill out a medical history 589 00:31:54,200 --> 00:31:58,200 reform, send it off to somebody and they mail you medications to 590 00:31:58,200 --> 00:32:00,160 me. That's not that's not it. 591 00:32:00,160 --> 00:32:02,000 We've missed the mark if that's how it's going to be. 592 00:32:02,000 --> 00:32:04,320 Yeah. Just something for our prior 593 00:32:04,320 --> 00:32:07,080 conversation. So the whole like off label 594 00:32:07,080 --> 00:32:11,440 thing, off label marketing is like technically not allowed by 595 00:32:11,480 --> 00:32:13,240 the FDA just so we. Yeah. 596 00:32:14,000 --> 00:32:15,600 OK. I wasn't sure if we like clearly 597 00:32:15,600 --> 00:32:17,800 said that, I just wanted to. Keep it in there guys. 598 00:32:17,800 --> 00:32:21,440 Whoever it the added team like we're keeping it in there. 599 00:32:21,560 --> 00:32:24,640 The FDA does not approve of off label marketing and I think. 600 00:32:24,640 --> 00:32:27,800 That doesn't the FDA is not against off label prescribing 601 00:32:27,800 --> 00:32:30,080 between a doctor and a patient. But that's really important 602 00:32:30,080 --> 00:32:32,160 because I'll tell you, I didn't know that. 603 00:32:32,920 --> 00:32:35,320 Yeah, I didn't know that. Now I have not off label 604 00:32:35,320 --> 00:32:38,600 marketed something. But if I could see how if I am 605 00:32:38,600 --> 00:32:41,760 someone who does off label use certain things, for example, 606 00:32:41,760 --> 00:32:44,440 this implant that I'm really excited to try in my 607 00:32:44,480 --> 00:32:46,480 reconstructive patients again with a conversation, if that 608 00:32:46,480 --> 00:32:49,400 implant company came to me and said, hey, you've had a year of 609 00:32:49,400 --> 00:32:52,680 really good results, you have noticed an improvement in XYZ, 610 00:32:52,920 --> 00:32:55,600 do you want to partner with us? I could see myself saying, yes, 611 00:32:55,640 --> 00:32:58,360 I, I could. And I, I just think like we're 612 00:32:58,360 --> 00:33:00,840 all so quick to attack, attack, attack. 613 00:33:01,120 --> 00:33:06,480 And I find that sometimes, a lot of times it's really, we're not 614 00:33:06,480 --> 00:33:09,000 giving people the benefit of the doubt, especially when again, 615 00:33:09,240 --> 00:33:11,840 parcel by parcel, what this person said on the ad I don't 616 00:33:11,840 --> 00:33:14,440 think was incorrect. I feel like I can factually pull 617 00:33:14,720 --> 00:33:17,800 really good data. So I to me, if I had to boil 618 00:33:17,800 --> 00:33:21,760 down that entire controversy into one action item, that 619 00:33:21,760 --> 00:33:24,520 action item would be as physicians, we are not allowed 620 00:33:24,520 --> 00:33:26,720 to advertise off label indications. 621 00:33:27,040 --> 00:33:30,280 Now what about education? Are we allowed to talk about it 622 00:33:30,280 --> 00:33:32,160 on our social media profiles because in a certain. 623 00:33:32,160 --> 00:33:36,040 Way we're allowed to when we like do lectures and things like 624 00:33:36,040 --> 00:33:37,480 that, we just. But what about social media? 625 00:33:37,480 --> 00:33:39,920 Because social media is advertising in a huge way. 626 00:33:40,080 --> 00:33:41,920 What if you talk about it but you don't link it? 627 00:33:42,200 --> 00:33:43,000 I mean, do you see what I'm saying? 628 00:33:43,000 --> 00:33:45,000 Like, how do we draw these guidelines? 629 00:33:45,000 --> 00:33:48,640 Because I think that's where we're at as we probably need a 630 00:33:48,640 --> 00:33:52,040 set of guidelines from like the AMA, you know, that come forth 631 00:33:52,040 --> 00:33:55,240 and say, if you're going to be a medical professional, this is 632 00:33:55,240 --> 00:33:56,520 what's OK and this is what's not. 633 00:33:57,480 --> 00:34:00,320 And I, I think, you know, reimbursement obviously matters. 634 00:34:00,320 --> 00:34:04,560 So when I do, when I did that neuromodulator collaboration, I 635 00:34:04,560 --> 00:34:08,639 get paid a, a base amount to speak about that, that product. 636 00:34:08,639 --> 00:34:10,080 And I literally use that product. 637 00:34:10,080 --> 00:34:13,560 I swear by that product. And I use it both on label and 638 00:34:13,560 --> 00:34:14,560 off label. But again, I have those 639 00:34:14,560 --> 00:34:19,320 conversations with my patients, but I do not get paid for like 640 00:34:19,320 --> 00:34:23,040 number of clicks or how many times I there's no kickback 641 00:34:23,360 --> 00:34:27,120 involved, right? And that I think is critically 642 00:34:27,120 --> 00:34:29,199 important. So if you're going to be an MD 643 00:34:29,199 --> 00:34:32,960 influencer and in this case, the person is getting paid to speak 644 00:34:32,960 --> 00:34:37,600 about a platform that he or she engages with about a medication 645 00:34:37,600 --> 00:34:40,400 that they've personally used, again, I don't see anything 646 00:34:40,400 --> 00:34:41,880 wrong with that. And I think villainizing 647 00:34:41,880 --> 00:34:44,000 physicians for that, I don't think is it, I think we've 648 00:34:44,000 --> 00:34:45,760 missed the market for villainizing physicians for 649 00:34:45,760 --> 00:34:47,520 that. But I do think we can help the 650 00:34:47,520 --> 00:34:51,120 public gain trust by being transparent on the on the 651 00:34:51,120 --> 00:34:53,679 payment model. Hey, I got paid to talk about 652 00:34:53,679 --> 00:34:56,320 this because these are all the reasons why, because I've used 653 00:34:56,320 --> 00:34:58,200 it, because I'm a doctor, because I've prescribed it. 654 00:34:58,680 --> 00:35:02,560 But also let me be very clear that there is no payment model 655 00:35:02,560 --> 00:35:05,160 involved in this where I'm getting paid for number of 656 00:35:05,160 --> 00:35:08,320 clicks or number of purchases. Totally. 657 00:35:08,320 --> 00:35:10,480 And I mean, that is like the whole purpose of the Sunshine 658 00:35:10,480 --> 00:35:12,560 Act, right? Yeah, yeah, exactly. 659 00:35:12,600 --> 00:35:14,160 I mean it is publicly available data. 660 00:35:14,160 --> 00:35:17,800 You can go look up how much your doctors get paid by industry. 661 00:35:18,400 --> 00:35:20,840 Industry needs us guys. If you want innovation in 662 00:35:20,840 --> 00:35:23,400 medicine, you need these pharmaceutical companies and 663 00:35:23,400 --> 00:35:25,600 implant companies, whether it's orthopedic implants or a 664 00:35:25,600 --> 00:35:29,920 pacemaker or a breast implant or chemotherapy or GLP ones, they 665 00:35:29,920 --> 00:35:32,480 need to partner with doctors. We have to be on the advisory 666 00:35:32,480 --> 00:35:34,600 boards. We have to be consultants to 667 00:35:34,600 --> 00:35:39,240 help and also enroll for the clinical trials, but we should 668 00:35:39,240 --> 00:35:41,760 also get reimbursed for our time and expertise. 669 00:35:42,080 --> 00:35:45,960 I think the Sunshine Act is is important in bringing clarity to 670 00:35:45,960 --> 00:35:49,640 how much we're making, but I think we can do even better by 671 00:35:49,640 --> 00:35:53,560 forcing transparency on what the pay model is, because I think 672 00:35:53,560 --> 00:35:56,920 you and I and all doctors would agree you should not be paid per 673 00:35:56,920 --> 00:35:58,120 use. That's a kickback. 674 00:35:58,520 --> 00:36:04,440 Completely. And I, I just, it's so hard 675 00:36:04,440 --> 00:36:07,160 because I too am an MD influencer and I, I watch what 676 00:36:07,160 --> 00:36:09,520 plays out and it helps me, you know, be accountable. 677 00:36:09,520 --> 00:36:12,400 Even when I posted that I, I know you had reached out and 678 00:36:12,400 --> 00:36:14,240 that's how we had originally connected because you said, hey, 679 00:36:14,240 --> 00:36:17,440 there is a lot to micro dosing and this is where I use it. 680 00:36:17,440 --> 00:36:18,680 And this is where it's not a scam. 681 00:36:18,680 --> 00:36:20,000 This is where it works really well. 682 00:36:20,000 --> 00:36:22,720 And I was like, you know what, you're right, I shouldn't have 683 00:36:22,720 --> 00:36:24,200 said that. But I was speaking from the 684 00:36:24,200 --> 00:36:27,400 point of view of someone who has a bunch of people in our clinic 685 00:36:27,440 --> 00:36:31,160 every week saying they're getting micro dosing, but Lord 686 00:36:31,160 --> 00:36:34,200 knows from where who's prescribing and they're they are 687 00:36:34,200 --> 00:36:35,480 not connecting the dots of their own. 688 00:36:35,480 --> 00:36:38,000 Health No, I I think I think you should have said something 689 00:36:38,000 --> 00:36:42,680 because the word micro dosing has to a certain degree been Co 690 00:36:42,680 --> 00:36:46,200 opted from like the recreational drug use culture and it's 691 00:36:46,520 --> 00:36:51,760 created this impression that when you micro dose something 692 00:36:51,760 --> 00:36:56,480 it's definitively safe, less serious yes, exactly right. 693 00:36:56,680 --> 00:37:02,600 And so that isn't true. Like technically is taking a 694 00:37:02,600 --> 00:37:07,880 smaller dose micro dosing, yes, literally you can say that. 695 00:37:07,880 --> 00:37:14,400 But unfortunately that word has made it from like literally 696 00:37:14,400 --> 00:37:20,520 recreational drugs to psychedelics to GLPS now it's 697 00:37:20,520 --> 00:37:24,560 like a marketing word. And so it's like lost its true 698 00:37:24,560 --> 00:37:29,560 meaning of are there populations of people that can benefit from 699 00:37:30,200 --> 00:37:33,080 what would be considered sub therapeutic doses because they 700 00:37:33,080 --> 00:37:35,800 don't have the full blown disease that was initially 701 00:37:35,800 --> 00:37:38,440 studied. That is really what we're trying 702 00:37:38,440 --> 00:37:40,360 to say. We also do across all 703 00:37:40,360 --> 00:37:43,120 specialties and medications, changing the dosage of a 704 00:37:43,120 --> 00:37:46,320 medication in a more new, I mean, we deescalate chemotherapy 705 00:37:46,960 --> 00:37:49,440 dosages all the time based on toxicities and the side effects 706 00:37:49,440 --> 00:37:52,400 that patients experience. That's a medical decision and a 707 00:37:52,400 --> 00:37:55,440 clinical decision that's made together through informed 708 00:37:55,440 --> 00:37:58,840 consent and conversation between the doctor and the patient. 709 00:37:59,160 --> 00:38:03,200 And so I, well, thank you. I mean, I'm glad you reached out 710 00:38:03,200 --> 00:38:05,120 about that post I made. It's funny, I actually had to 711 00:38:05,120 --> 00:38:08,520 archive that post because so many people were linking GLP, 712 00:38:08,520 --> 00:38:11,360 what's in the comments, literally posting links in the 713 00:38:11,360 --> 00:38:12,880 comments. And I'm like, Oh my God, this is 714 00:38:12,880 --> 00:38:14,800 literally what I was trying to warn against. 715 00:38:15,680 --> 00:38:18,200 I'm not saying don't have a virtual appointment with the 716 00:38:18,200 --> 00:38:19,680 doctor. I do virtual appointments. 717 00:38:19,680 --> 00:38:23,080 But you should know who this person is, what their name is, 718 00:38:23,080 --> 00:38:26,760 what their credentials are, and you should hold them to the same 719 00:38:26,760 --> 00:38:30,040 standard as all of your other healthcare providers. 720 00:38:30,560 --> 00:38:33,400 Do they meet with you regularly? Are they checking in? 721 00:38:33,400 --> 00:38:35,320 Are they looking at biochemical markers? 722 00:38:35,800 --> 00:38:39,720 And that, that was another sort of buzz term that I know ended 723 00:38:39,720 --> 00:38:41,720 up being criticized of this new MAD. 724 00:38:42,040 --> 00:38:44,040 But we do look at biochemical markers. 725 00:38:44,040 --> 00:38:46,880 I mean, I, I think 1 should be if you're on GLP ones. 726 00:38:46,880 --> 00:38:48,640 And I didn't see fault with that either. 727 00:38:48,960 --> 00:38:51,120 I I had, I see no fault with checking labs. 728 00:38:51,120 --> 00:38:53,240 I think that in the doctor world, that just means we check 729 00:38:53,240 --> 00:38:54,560 labs, yeah. Right. 730 00:38:54,560 --> 00:38:58,120 So I thought, you know, to see somebody come so full on attack 731 00:38:58,120 --> 00:39:02,080 mode, I felt was unnecessary. And I, I really hate the 732 00:39:02,080 --> 00:39:06,040 infighting that I see in the medical community because I find 733 00:39:06,040 --> 00:39:08,880 that most of us are all on the same side. 734 00:39:09,120 --> 00:39:11,320 And I think if you break it down and if you have a conversation 735 00:39:11,320 --> 00:39:14,120 with someone one-on-one like we're doing, you can say, OK, 736 00:39:14,120 --> 00:39:17,040 maybe there's one particular aspect such as off label 737 00:39:17,480 --> 00:39:20,600 marketing is not something that is condoned by the FDA. 738 00:39:20,600 --> 00:39:23,760 We should revisit that. But I even wonder, like this was 739 00:39:23,760 --> 00:39:26,600 recorded months ago, how much was this person made aware of, 740 00:39:26,600 --> 00:39:29,040 whether it was off label? Was it a disclaimer that was 741 00:39:29,040 --> 00:39:30,520 added after the fact? We don't know. 742 00:39:30,520 --> 00:39:33,720 We haven't given this person a chance to defend themselves or 743 00:39:33,720 --> 00:39:36,120 talk about it. We're just ripping them to 744 00:39:36,120 --> 00:39:39,520 shreds and then taking it 10 steps further going into all 745 00:39:39,520 --> 00:39:41,800 sorts of other things about this person's reputation. 746 00:39:42,400 --> 00:39:44,720 I actually would say you're doing a lot more harm if you're 747 00:39:44,720 --> 00:39:48,760 the person attacking to that degree because you can have a 748 00:39:48,760 --> 00:39:51,080 nuanced conversation. And also as we've shown in this 749 00:39:51,080 --> 00:39:54,120 episode today, I don't think anything specific that was said 750 00:39:54,120 --> 00:39:55,520 was necessarily. Incorrect. 751 00:39:56,520 --> 00:39:59,360 I would not say something was scientifically incorrect, but I 752 00:39:59,360 --> 00:40:04,880 think this person has been used as an example to, yeah, 753 00:40:05,840 --> 00:40:10,800 highlight several confusions. Yeah, yeah. 754 00:40:10,920 --> 00:40:12,920 Sort of like patient zero, right? 755 00:40:12,920 --> 00:40:16,520 This person has now taken on the brunt of all sorts of 756 00:40:16,520 --> 00:40:19,080 controversy and questions and speculation. 757 00:40:19,080 --> 00:40:22,480 And again, the public, I think, in general struggles with this 758 00:40:22,480 --> 00:40:24,840 degree of trust. And it is weird to have so many 759 00:40:24,840 --> 00:40:27,600 doctors on social media. For a lot of people, they don't 760 00:40:27,600 --> 00:40:29,480 like seeing us outside of their clinic. 761 00:40:30,400 --> 00:40:32,880 And I think that's unfair. I think it's great to spread 762 00:40:33,200 --> 00:40:36,000 good information, but I think unfortunately, this person 763 00:40:36,320 --> 00:40:39,040 really was made an example out of to an extreme. 764 00:40:39,360 --> 00:40:43,080 And I hope podcast episodes like this can help sort of breakdown 765 00:40:43,080 --> 00:40:46,600 the nuanced aspects and instead of marking someone with a 766 00:40:46,600 --> 00:40:50,040 scarlet letter, giving everybody an opportunity, opportunity to 767 00:40:50,040 --> 00:40:51,880 talk about like, what's really the issue here? 768 00:40:52,760 --> 00:40:53,920 Yeah. I mean, I think you did a great 769 00:40:53,920 --> 00:40:58,240 job of kind of summarizing the issue on your own platform 770 00:40:58,240 --> 00:41:00,720 because again, for those of us that didn't have contacts, and 771 00:41:00,720 --> 00:41:02,880 that was even me, I just happened to have a busy week 772 00:41:02,880 --> 00:41:04,800 with patients. I didn't know what was going on. 773 00:41:05,120 --> 00:41:08,520 And then you made a 16 minute video explaining the whole thing 774 00:41:08,880 --> 00:41:11,960 and I was like, OK, I have to figure out what's going on. 775 00:41:11,960 --> 00:41:15,160 And then you happen to also reach out, which I mean, I think 776 00:41:15,160 --> 00:41:17,400 that that was great. Like you literally were like, 777 00:41:17,400 --> 00:41:23,400 OK, let me just call an expert on this and figure out what what 778 00:41:23,400 --> 00:41:25,640 was scientifically incorrect, if anything was. 779 00:41:25,640 --> 00:41:29,080 And really it wasn't. It was more all of these other 780 00:41:29,080 --> 00:41:33,200 issues that this person was, you know, being raked over the 781 00:41:33,200 --> 00:41:35,120 coals. For yeah, absolutely. 782 00:41:35,320 --> 00:41:37,840 Like, thank you for joining me last minute on a Sunday, but a 783 00:41:37,840 --> 00:41:40,640 very special day because it's International Women's Day and I 784 00:41:40,640 --> 00:41:44,560 am so, so grateful for women like you who have a voice, share 785 00:41:44,560 --> 00:41:48,600 such good educational content real quick for everybody, say 786 00:41:48,600 --> 00:41:51,200 your handle out loud so they can all follow you. 787 00:41:51,200 --> 00:41:53,560 For all of the incredible endocronology content content 788 00:41:53,560 --> 00:41:56,280 you share. Of course I'm I'm at Doctor 789 00:41:56,280 --> 00:41:59,640 Rekha Kumar on Instagram. I was so happy to be here for 790 00:41:59,640 --> 00:42:04,760 you on a Sunday and I hope I can like be as glamorous on social 791 00:42:04,760 --> 00:42:08,920 media as you are talking. To any would anyone believe that 792 00:42:08,920 --> 00:42:12,400 this woman has teenagers as children, you need to drop your 793 00:42:12,400 --> 00:42:14,840 skin care routine. I will bug you for that offline, 794 00:42:15,480 --> 00:42:18,120 but I will also add her handle to the posting so you guys can 795 00:42:18,120 --> 00:42:21,080 all see it. And I'll link your associate 796 00:42:21,080 --> 00:42:24,200 professor page at the university as well in case anybody's 797 00:42:24,200 --> 00:42:26,040 interested in seeing you as a patient. 798 00:42:26,400 --> 00:42:29,320 Thank you so much for your time. Do you have any parting words? 799 00:42:29,320 --> 00:42:31,080 Parting message? It doesn't even have to be about 800 00:42:31,080 --> 00:42:33,320 GLP ones or endocrinology. It could be about anything. 801 00:42:34,440 --> 00:42:37,440 I mean, I just would, you know, want everyone that's listening, 802 00:42:37,800 --> 00:42:42,560 patients, consumers, just people who watch to know that we are 803 00:42:42,560 --> 00:42:44,960 like at a real turning point in medicine. 804 00:42:44,960 --> 00:42:50,280 I think that there are so many new innovations that are really 805 00:42:50,280 --> 00:42:55,320 going to change how we see our health and how we take care of 806 00:42:55,320 --> 00:42:58,480 people. So I do hope that people 807 00:42:58,640 --> 00:43:01,720 understand that we had this conversation to say that, you 808 00:43:01,720 --> 00:43:04,400 know, there's a lot of really exciting stuff happening in this 809 00:43:04,400 --> 00:43:07,640 field and science, and I hope people can find doctors they 810 00:43:07,640 --> 00:43:09,400 trust to have these conversations. 811 00:43:09,880 --> 00:43:11,000 I love that. I love that. 812 00:43:11,240 --> 00:43:13,520 All right, guys, that is inside thoughts out loud. 813 00:43:13,520 --> 00:43:15,360 I will check all of your comments. 814 00:43:15,360 --> 00:43:17,800 I will make sure Doctor Kumar is listening in as well. 815 00:43:18,120 --> 00:43:20,480 Thank you all and until next time. 816 00:43:20,680 --> 00:43:23,640 So we just heard from Doctor Rekha Kumar, an absolute icon 817 00:43:23,640 --> 00:43:26,320 and expert in the fields of endocrinology about GLP ones. 818 00:43:26,320 --> 00:43:29,000 But we didn't only talk about the medication, which of course 819 00:43:29,080 --> 00:43:31,160 could be many podcast episodes by itself. 820 00:43:31,520 --> 00:43:34,800 We also talked about the weight that physicians and healthcare 821 00:43:34,800 --> 00:43:38,720 providers hold and carry when we are also on digital platforms. 822 00:43:38,840 --> 00:43:40,600 What does that responsibility ability look like? 823 00:43:40,600 --> 00:43:42,120 What is taking something too far? 824 00:43:42,240 --> 00:43:44,320 When are we being attacked unnecessarily? 825 00:43:44,560 --> 00:43:46,800 And I really think the lesson that I learned from all of this 826 00:43:46,800 --> 00:43:51,040 as a physician who is also on social media is that we really 827 00:43:51,040 --> 00:43:53,000 do need to be kinder to each other. 828 00:43:53,000 --> 00:43:54,720 You know, we don't know the back story necessarily. 829 00:43:54,720 --> 00:43:58,000 We don't know what that person was told or not told or prepped 830 00:43:58,000 --> 00:44:00,280 with, or what information has come to light about the platform 831 00:44:00,280 --> 00:44:03,280 or medication since these are conversations we can have in 832 00:44:03,280 --> 00:44:08,760 nuanced ways and in high IQ kind ways with each other to hold 833 00:44:08,760 --> 00:44:12,360 each other accountable without just throwing attack after 834 00:44:12,360 --> 00:44:14,120 attack. Not to mention, just because 835 00:44:14,120 --> 00:44:16,520 somebody criticizes somebody else doesn't mean that person is 836 00:44:16,520 --> 00:44:19,360 100% correct either. We also heard today that 837 00:44:19,560 --> 00:44:22,320 factually the things said in that video are independently 838 00:44:22,320 --> 00:44:26,360 verifiable with scientific data. So I really want to leave my 839 00:44:26,360 --> 00:44:28,960 listeners with this. I think we should hold each 840 00:44:28,960 --> 00:44:30,920 other accountable. I have been held accountable and 841 00:44:30,920 --> 00:44:33,640 thankful for that. But I'm grateful for the fact 842 00:44:33,640 --> 00:44:36,200 that when people do speak out about content that I put out, 843 00:44:36,560 --> 00:44:40,920 it's it's done in a way that is that is kind and factually 844 00:44:40,920 --> 00:44:43,560 based. And it isn't just full on attack 845 00:44:43,560 --> 00:44:45,280 mode. Because when you start 846 00:44:45,480 --> 00:44:48,160 undermining somebody's credentials, their skill set, 847 00:44:48,160 --> 00:44:53,600 their abilities based on one singular item, I find that it's 848 00:44:54,000 --> 00:44:55,440 personal. It's like a vendetta. 849 00:44:55,440 --> 00:44:58,560 It's really not actually holding somebody accountable in a way 850 00:44:58,560 --> 00:45:00,400 that can actually make for a good change. 851 00:45:00,400 --> 00:45:03,200 You're just trying to bring somebody down and that we are 852 00:45:03,200 --> 00:45:05,400 not into that. So thank you so much for joining 853 00:45:05,400 --> 00:45:07,160 me on this. Again, I'm going to say it's 854 00:45:07,160 --> 00:45:09,040 like an emergency episode of Insight Thoughts Out Loud 855 00:45:09,040 --> 00:45:11,480 because I really wanted to get this conversation out there. 856 00:45:11,680 --> 00:45:13,480 I can't wait to hear your comments. 857 00:45:13,480 --> 00:45:16,640 Let me know and if you guys want another follow up episode, if 858 00:45:16,640 --> 00:45:19,080 there are any other questions you've had about GLP ones, I'm 859 00:45:19,080 --> 00:45:20,960 sure I can get Doctor Kumar to comment on those. 860 00:45:20,960 --> 00:45:23,360 So let me know and we can always follow up with another episode 861 00:45:23,360 --> 00:45:24,520 if that's something you guys want.