Hi, guys. All right, welcome to what I'm
going to call an emergency episode of Inside Thoughts Out
Loud. And that is because GLP ones
have been such a topic for a while now, right, a couple of
years. But I want to say acutely in
this moment, it feels very confusing.
It feels very divisive and it feels very, I want to say
controversial when I think part of it doesn't have to be
controversial. So I brought in the expert.
I wanted to have someone on this podcast that is truly just 10
toes down, an absolute expert in the medication, the metabolic
effects of Physiology and really talk to us about what's the fear
mongering that's going on. What is actually controversial
and what what are we making into controversy that maybe doesn't
need to be controversial. So for that, I am so excited to
introduce all of you to Doctor Rekha Kumar.
She is an associate professor of clinical medicine and a board
certified endocrine at Cornell. Reka, welcome.
Thank you so much for having me. Yeah.
Doctor Kumar, I want to really talk about your expertise and
your background so people really understand just how deep of an
expert you are to be able to share your thoughts on GLP 1.
So let me know all of the things that you've accomplished in life
that bring you to your expertise today.
So thanks for asking me about all of that.
I am trained as an internist and endocrinologist, so I spent my
subspecialty training in endocrinology, diabetes and
metabolism, and then I specialized further in obesity
medicine. My academic research, my
clinical practice was all based on studying and learning
metabolism for 12 years. And in that process I worked on
clinical trials for the early GLP ones, including the SELECT
trial that looked at cardiovascular outcomes in We Go
V and I was the first medical director of the American Board
of Obesity Medicine. That was established actually
the year I finished my endocrine fellowship, which was 2012, and
my role there was to write the credentialing exam that
physicians take when they choose to become board certified in
obesity medicine. So I was their clinical content
expert. And just so everybody who's
listening understands how this works, you can do an internal
medicine residency to be an internal medicine doctor.
But beyond internal medicine to be an endocrinologist, you're
now doing additional years of training specifically focused on
endocrinology, which is really the study of the hormones in
your body and the glands in your body and all the things that
they secrete and how they work together so your body functions.
So let's dive right in. I want to first do like a little
GLP one dictionary session. OK, We use the term semaglutide,
GLP one between all of the terms that you hear.
Give us a little bit of like, what is the actual definition of
these of these terms? And people use them
interchangeably. Is that accurate?
So we'll go to the way basics GLP one or Glucagon like peptide
or hormones we naturally make in our body.
And they belong to a family of hormones called incretins, which
are gut hormones. They're involved in body weight
regulation and blood sugar regulation.
And as we're learning, they have many other functions.
So GLP one is Glucagon like peptide, It is involved in body
weight regulation and blood sugar control.
The medicine version is called AGLP 1 receptor agonist, meaning
that it does the exact job of your own GLP one in your body,
but it actually works for a longer period of time, which is
where it becomes a pharmacologic agent or medicine versus your
natural hormone. So it's modified slightly to do
the same thing, but to act for longer.
And I know you and I have been talking about this offline as
well. Tell us how long the research in
GLP one medication has been around because for a lot of
people they think it just like got discovered yesterday and
that's not actually the truth. Yeah, so the research is super
interesting, and I know we don't have time for all of it, but
originally the GLPS were isolated from the saliva of a
yella monster in like the 1970s or early 1980s, see.
You guys, she's an expert. Do you see what I'm saying?
She knows these things. OK, continue.
Sorry. I told my friends this like
literally at a cocktail party. They were staring at me like I
was a psychopath. This was like years ago.
And now, like with where we are, they would remember that time
you told us about the Yella monster.
Anyway, the the the molecule, the peptide, the hormone has
been now studied for 30 or 40 years.
It's been an FDA approved medication for about 20 years.
20 years, you guys, 20 years it's been FDA approved, OK.
Yeah. We started prescribing the first
GLP one for diabetes in 2005. It was called Byetta.
For those of us that were in this field, we were using Byetta
off label for metabolic disease and obesity because we knew how
it worked and we saw that it was also leading to weight loss.
But the first GLP one for obesity management, didn't get
FDA approved until 2014, but that's still over. 10 years ago,
yeah. And then talk to me about the
term semaglutide, yeah. So semaglutide, or some people
call it semaglutide. People fight over how they
pronounce. It semaglutide.
Is Novo Nordisk the pharmaceutical company's long
acting GLP 1? So prior to that there was
something called lyraglutide that was a shorter acting so it
was prescribed every single day. It existed under the names
Victoza for diabetes and Saxenda for obesity management in 2019
ish. They modified it or 2017
somewhere around there to make it longer acting.
That became somaglutide and that was a weekly medicine.
And so why did that explode? What was the difference between
lyraglutide? That was a daily medicine.
It was FDA approved for diabetes and obesity.
We were prescribing it. People were doing great.
What changed when it became somaglutide, the weekly medicine
that was slightly more effective or significantly more effective?
So the older versions led to 10% loss of total body weight.
Symaglitide was 15 to 20% loss of total body weight.
And so just to like, I want to kind of bring it back to what
these drugs do. And again, I am not an
endocrinologist, but I did go to medical school and I'm a
practicing surgeon. And this concept exists across a
lot of different fields, right? Where you create a medicine that
fits inside of a receptor so that it blocks something else or
it augments something. So that we have medications like
that in the cancer world that we use all the time.
So what we're talking about with these GLP ones is that you have
a receptor and the peptide or the molecule comes, sits in the
receptor and it tells your body, I'm full, I'm good.
I'm you don't need to eat more, right?
And that then has profound pathway effects downstream that
affect, well, if you're not eating more, that's going to
affect your sugar. And all of that is a feedback
loop. So if your body feels like it's
full and it has enough, that's not only going to affect your
hunger cues, but presumably, I'm assuming here, but it's going to
affect how your body then metabolizes the sugar and what
gets broken down and what's what gets stored.
And so all of these very extensive pathways then get
affected by a molecule sitting in that receptor signaling the
gut to then do all of these other things.
Is that a fair explanation of how this drug works?
That is like the most beautiful endocrine explanation.
Wonderful. Just to follow up your
explanation, a lot of people will say, well then why can't we
just take things or take supplements or do things that
increase our own GLP one. And you'll see that that's out
there a lot in the form of gummies, in the form of lots of
supplements, people will say. These Oh my God, are we going to
talk about Lemmy? That that's a great example.
So the whole point is of the medicine is that it acts longer
than your own GLP one. Your own GLP one is degraded in
minutes. So even if you take Lemmy or any
of these things that may or may not increase your own GLP one,
if you truly have metabolic dysfunction or some gut brain
disconnect problem, the supplements aren't going to be
helpful. You're going to need the
pharmacologic agent that actually acts longer to see a
difference. And that's why semaglutide, did
I say that semaglutides popped off?
So I think another really interesting point that people
keep bringing up is the FDA approval for these medications.
And I want to bring an analogy to our listeners as a plastic
surgeon. When I have implants, breast
implants that I use for breast reconstruction, those breast
implants can be approved for augmentation, but they may not
be FDA approved yet for reconstruction.
Does that mean that they haven't been used for 10/15/20 years in
Europe for reconstruction? Does it mean that they're unsafe
for reconstruction? No, and in fact, we have newer
implants on the market or newer brands that are coming to the US
that have a lot of benefit, right?
They may be better than what we have, but they're not FDA
approved yet because you got to go through a lot for FDA
approval. And so that doesn't mean that I
don't use them. I have patients who come in,
they ask for it. They fit the criteria.
They maybe had a certain series of complications with other
implant manufacturers and it's reasonable to apply an off label
use. So this belief that if you use
any medication off label means that you're a bad doctor.
I think really I want to like nip it in the butt.
That is not true. Doctors, especially specialists,
right? When you are down in that rabbit
hole of nicheness like you and I are, we are constantly using the
most recent, most available current data and information and
technology to help solve difficult problems.
So I want you to talk about, you know, I presented this analogy
because I think it's easy to then understand what breast
implants are. Breast implant.
Like why would be reconstruction be different than augmentation?
It's going in a human body. Yeah, but we still have strict
FDA regulations and yes, you still have to go through that
FDA approval process. So sort of coloring the
landscape now talk to me about FDA approval for GLP ones.
So GLP ones are FDA approved, certain ones are approved for
type 2 diabetes and certain GLP one medications separately are
approved for obesity or overweight with a weight related
comorbidity. So that means a body mass index
of 30 or a body mass index of 27 or greater with some weight
related complication like high blood pressure, sleep apnea,
high cholesterol. And just like you said, the
same, you know, implant or and an or my and my and the same
medicine has to go through two separate approvals.
So it's not like these medicines that are approved for diabetes
suddenly also can be used for weight loss.
They have to go through a separate process and that can
take. Years because it's the trials.
Exactly. I don't know if people
understand that. It's not like you like fill out
a Google form and it gets FDA approved.
There's layers of trials with really stringent requirements
and often times multiple trials or multiple phases of trials
that may be required to then get FDA approval for an indication
that's different than what you got FDA approved for before.
Yes. And the key there is with these,
the design of these trials is technically it's different
populations, right. So when you're looking like what
you describe the difference with the breast implants, if they
wanted to redo that trial, they're looking at a different a
different population of patients.
And some of this sounds like, you know technicalities and
that's the way it's been with GLP ones in diabetes versus
weight management. Then you take it to the the next
level, which I think we are going to talk about, which is
this kind of off label use out of the obesity world.
And we're seeing really, you know, rampant use, not like
potentially in a good way of these medicines benefiting other
metabolic conditions. And some of them are weight
related. So if you think of things like
fatty liver, sleep apnea, chronic kidney disease, these
are all medical conditions we see in people who struggle with
excess body fat. And so say somebody has a body
mass index of 26 and not 27, but they have pre diabetes and high
cholesterol and all of these other issues that are weight
related. Is it really irresponsible to
prescribe a GL P1? When we understand the mechanism
of action, we know this is going to help the patient.
So I want to, I'm going to double down on this because
there is a lot of focal controversy.
The criticism that was put forth was the the, you know, in the ad
talking about using these medications and people who have
sort of normal range or more normative BMI.
And what I'm hearing from you is yes, absolutely.
We have proven benefit in certain subpopulations that do
have a quote normal BMI. Am I?
That's not a reach, right? That's what you're saying.
That's not a reach. So the statement that you can
off label use GLP ones safely in normal weight people that that
statement is true there Again, this is like the complexity of
specialty training and nuances. Who are those normal weight
people and why do they need or want to lose weight?
And so there are many normal weight people.
By by weight we're saying normal.
BMIBMI is being debunked left and right every day.
It doesn't say how healthy or how lean or how much fat mass
someone has. It just says how big you are.
And I always use the example. Arnold Schwarzenegger at his
peak bodybuilding health fell into Class 1 obesity.
He had 8% body fat. So there are limitations to the
use of these BMI thresholds, but you know, at scale on a
population level, it was the only tool we had that was cheap,
quick and easy to use in the office setting.
So things like DEXA scanners, those were expensive and not
everyone had access to those. Now these, you know, body
composition analysis are becoming more common.
But BMI has limitations. There are people of normal BMI
that may be unhealthy, prone to metabolic disease and could
benefit from a GL P1. And these are conversations that
doctors and patients have when they decide to prescribe off
label. So there's off label prescribing
but and and that is accepted. And at this point, we know that
20% of GLP one prescriptions in the US that are branded
prescriptions that we can track are prescribed off.
Label so and that's not a bad thing.
I think that's where people create controversy in a way and
where it doesn't need to be. I mean, we use off again quote
off label meaning the FDA approval hasn't come through
yet. But I see this all the time with
chemotherapies for certain resistant cancers or breast
implants for breast reconstruction.
We do this all the time. So criticizing a doctor for that
in and of itself to me. Falls flat.
So I agree with you, the scientific statement that you
could use GLP one safely in normal weight people.
That is true. You you can do that.
There's nothing wrong with that statement.
I think that there's off label prescribing that needs to be
distinguished from off label marketing of medicines and and
those two things are different and and the FDA looks at those
differently. Yeah.
Talk to me a little bit more about that because I think
that's where a lot of the focal controversy is at the moment.
Yes, every like I said, 20% of GLP one prescriptions that we
know of and probably many or a higher percentage are prescribed
off label and that is allowed, it's accepted in the clinical
setting and that is part of shared decision making.
And truthfully, a lot of off label prescribing is how
innovations starts in medicine. It starts 100% in the doctor's
office, patient, doctor conversation.
You do something. That's literally what clinical
trials are for. Yes, yeah.
But technically off label advertising is is not considered
OK by the FDA. So it's one thing to to do it
between a patient and a doctor, but marketing it and advertising
it I believe is what is considered a bit sketchy.
OK, so when so talk to me about Noom, What is Noom?
Because obviously everyone's talking about it.
Everyone likes the idea that it's not an injection now it's
going to come in a pill. Is it as long acting?
Is it as good? Do we have efficacy data yet?
Talk to me about Noom. Yeah.
So, so Noom is a platform. It's a telehealth company that
initially started as a behavioral platform for weight
management and now they do medicines.
So just like hymns, just like found where I'm the senior
medical advisor, there's many companies that offer behavior
change plus medical management of obesity.
So that's actually really interesting because I didn't
know that. I thought watching the ad, I
thought the Noom was Noom was the name of the pill that
everyone was going to start taking.
And I think that does change something.
So it's Noom that's putting out the advertisement and Noom is
advertising their services being weight management services.
OK, continue. Correct.
And and that is so interesting to me that it confused you
because I think that's where some of the controversy lies.
Yeah. Is that?
I'm a doctor, I practice right, but I'm telling you, when I as
again, not an endocrinologist, I'm just watching the ads, I
genuinely thought it was the name, like it was going to be
the, you know, the brand name of the medication.
So again, that's why I have you on here to educate all of us,
myself included. But no, but continue because I
think this is really interesting to frame what Noom is
advertising because it sounds like they're advertising their
services. And in the particular ad that
was controversial, they are, they are talking about the use
of GLP ones. So in that context, talk to me
about whether you felt like that ad was appropriate,
inappropriate, somewhere in the middle.
So there's a, there's so many layers of this ad and it's why
it became controversial if you pull each piece apart on their
own. So there's three layers of this.
There's the white coat marketing, right?
And there's a doctor that is being used in advertising and
that can confuse patients potentially by using a doctor in
an ad, does it give the message to patients that whatever this
person is saying or doing is definitively safe and OK, which
then the second layer of this is off label prescribing.
So then you have a doctor potentially marketing off label
prescribing, even though we feel the off label prescribing on its
own is safe. The third layer is there was
potentially a reference to compounded meds, right.
So we have three issues here. We have and on on their own,
like each one carries different meaning.
I think the the one that we don't want to lose the science
of or diminish the science of is the role of individualized
dosing. Is this really a thing?
What what does micro dosing mean?
This this word has sorted. And we are definitely getting
there. I will we will talk about micro
dosing. I'm triggered by that word.
But I would say on its own, the the ad for a service, I mean,
this is what we see, see with everything.
I think that one of the confusing things though, was
that a physician was in the ad. Not only for a service, but
potentially for an off label indication made in a compounding
pharmacy. I think it was all the layers
that. It was layers.
I'll tell you, I watched the ad and I'm not going to I don't
want to pull it and I don't want to put because it this episode
isn't specifically about that, right?
Like you guys can go. Totally for it and.
Whatnot. Like I don't want to do that,
but I bring it up because I think it's a really good sort of
example or analogy for what is so confusing and why people are
getting upset. And I think when I watched the
ad, I actually thought nothing of it.
And I am somebody who approaches GLP one dosing, especially micro
dosing with a lot of caution. And we've talked again about
this offline because of my perspective as a reconstructive
surgeon for breast cancer patients and we'll get to that.
But as someone who's already wary, when I watched it, I truly
I felt like because I think there's a disclaimer at the end
that it's not FDA approved yet and that we are talking about
off label prescribing. So I felt like the disclaimer
was out there. And I do think, look, I would
much rather be a doctor talking about something that we actually
do in medicine. I don't think that any
individual statement made by that physician was incorrect.
Do you? No, the individual statement
wasn't incorrect, but it was an advertisement versus educational
versus educational content. Yeah.
And patients may not be able to tell the difference there.
Right. And it was meant as advertising,
right, because it was advertising the new platform.
But I, when I'm listening to it, I didn't, I there was nothing
that she said that I was like, oh, that's wrong.
I'm like, no, we, we literally do use the medication For these
reasons in normative BMI patients.
I've heard of this, I've seen this.
So nothing came off as propaganda and I didn't listen
to it or see it and go, oh, why I didn't feel like that.
And if anything, I felt like, well, I'm glad it's somebody
who's speaking up about this, who literally has treated
obesity as related to, you know, their, their specialty, which is
a surgical specialty, but they, they have treated obesity as it
relates to their specialty. They have prescribed GLP ones
and they themselves have been open about their GLP one
journey. So I felt like, you know what I
like that because it's better than just some celebrity who
really has no insight into sort of the profound effects of these
of these messages. So I if anything, I I was like,
oh, OK, this is cool. Like I I like that.
Now, did I miss the boat on what Nume actually is?
Clearly I did. I didn't know what that it was a
general weight management platform, not just the
medication. And I think you're bringing in
the light of should we, can we advertise off label use as
opposed to educationally promote it?
And I, this is a hard topic because, and I'm going to be
very honest here, I did an ad for a neuromodulator company and
I use neuromodulators on my face.
Neuromodulators are like, I don't want to name the
companies, but they're basically are injectables that you can use
for cosmetic reasons to help, you know, reduce and prevent
wrinkles. So the company, which is really
interesting, they said this is what we're FDA approved for.
Don't you dare talk about what we're not FDA approved for.
You can use it for the rest of your face all day long, but
we're approved for here. So talk about here.
And that's what I thought was really interesting was I having
done one of these partnerships before, I was, I mean, they were
really picky. I had to give the script, each
word was analyzed, the video was analyzed to make sure that I
stayed within the arena of what is FDA approved.
So I think it's almost a little interesting.
I, I almost feel like was this person set up poorly by the
person that they did the ad with?
Because if you yourself have been the recipient of a
medication and it worked well for you and you know, the
medicine behind it and you know, people use it off label all the
time, but maybe you weren't educated on the sort of what it
means to market something off label.
Isn't that also the company's responsibility to sort of think
about those things? So I think the disclaimer there
was Noom addressing the off label prescribing and saying
this isn't FDA approved. But I think the complication was
that there were so many confusing layers that may have
thrown people off. You had actually more context
even than I did. So you know this person, you
even I would never have known this person prescribed AGLP 1 or
even had their own journey. So I was missing contacts.
So I think you had a lot of information.
I had some information. I knew that that was a doctor.
And so to me, I said, OK, what she's saying makes scientific
sense, but I think that I always forget the number of people
seeing these things don't have the context that any of us have.
And so theoretically, somebody could see that not know what
Numa is, not know who the doctor is and see a neurosurgeon
advertising on a medicine. And so the concern is that
somebody would think, well, she's saying that this is OK to
do, but the push back there is, but it's off label I.
Mean that's why it's great, right?
That's why we're all kind of like, I think both of us and a
lot of people we're choosing our words because I, I don't know, I
see both sides of the coin. I go also, if there is off label
use and it is helpful for people who maybe have, you know, fatty
liver or sleep apnea or whatnot, these other conditions and they
could benefit from it. How are they going to know about
it if they don't, if they're not approached?
So is it that we should do it through education?
But I can also tell you talking about GLP ones online gets a lot
of backlash. I had posted just a quick little
tidbit about GLP ones because I honestly, the word micro dosing
is so triggering to me. I would say 30% or more of my
patients that come into my clinic for breast cancer
reconstruction are on GLP ones. And when I asked them, who's
prescribing it, does your oncologist know less than 10% of
them are getting these from doctors who or they don't even
know who the person is on the other end, presumably a medical
professional, but we don't really know.
And I'll say things like, well, do they know all the medications
you're on? Do they know you're on Keytruda?
Do they know this? Do they know that?
And it's a lot of skirting around the issue.
And when I asked them, does your oncologist know that you're on
this medication? Not everybody says yes because
they may have felt like their oncologist wasn't on board, but
maybe the oncologist wasn't on board because she doesn't, he or
she doesn't want you taking this medication while she's
prescribing other medicines, right?
And then they're getting this conflicting data online because
there's breast cancer influencers saying I'm on AGLP 1
and it reduces breast cancer recurrence rates and I feel
great. So they feel like they're
missing this golden opportunity because how desperate are all of
we, all of we, Jeez, all of us, how desperate are, are, is
everyone to, to pursue something that could decrease cancer risk,
especially if you've already been diagnosed with it.
So I, I see it really play out in real time.
And I, you know, have had patients not heal well from
surgery. I've had to cancel surgery
because they didn't disclose they were on the medication.
And it very much affects your GI function and the risk of
aspiration and the safe safety of anesthesia.
I've had patients admitted for severe pancreatitis because they
were on other meds at the same time and they weren't in ICU for
a month. So I see this sort of other side
of it where I feel like I'm capturing this subpopulation of
people that are prone to complications and it makes me
very wary. So I posted like AI think micro
dosing is a scam. And in retrospect, I felt like
it was a little bit of like a click baity kind of, you know,
everyone wanted to click. But my point, which I had put in
in the caption in the comments, was micro dosing is nuanced
dosing, right? If you are nuanced dosing, a
medication that should be coming from a specialist, Someone Like
You who's an endocrinologist who specializes in obesity medicine
that understands and can work comprehensively with your
medical team. Because chances are if you need
this medication, you've got other things going on.
You've got a primary care doctor, for example, and I find
it frustrating when people dive right into this, this magical
medication and they are not getting the adequate
comprehensive assessment and care from a.
Specialist, you are 100% right on all of that.
And actually, several years ago, I chose to go from being super
specialized in all of this to going back into primary care.
And so I do primary care as well as endocrinology.
And the reason is everything you're saying is that I felt
like I saw it coming, by the way, with these drugs and kind
of the explosion and how good they were going to be.
And I was like, I really need to make sure I'm taking full care
of people in order for them to be on this journey with me
because I am not comfortable just being involved in this
prescription because of everything you said, the, you
know, the supervision, the counseling on nutrition and
exercise, the really detailed guidance on stopping before
surgical procedures, before routine colonoscopies, before
egg transfers for fertility. There's so many things over the
course of a person's life that touches their health that this
GLP one just lingering in the background.
If they're getting it or buying it from, you know, buying it off
the Internet without supervision, it is a big
concern. And then they land in either
your office with something very serious and potentially could
have a surgical complication or they land in my practice have
been having been on these meds for a long time without adequate
support and that's not healthy either.
They're many things can be true at once.
And I think we said this on the phone together that these could
practically be miracle drug drugs, but has it gone too far?
Absolutely. Is there inappropriate use and
inappropriate prescribing? There are all of those things,
but when done right I think that these medicines can be life
changing not only for on label use, but certain off label uses
too. Yeah, absolutely.
So I want to bring it back to these platforms you are involved
and found, you know, we had been talking about Noom, how as a
consumer can someone that whether a platform is like
they're doing it the right way or if it's sketchy.
How does one know? Yeah.
I mean, do you interact with a clinician?
I would say that that is a big question.
How much of A medical history is required in order to get a
prescription? How detailed is the interaction
with the prescriber? So if you're using a platform
where you just have to fill out a form, somebody reviews it and
sends you the prescription, would you agree that that is
insufficient? I think that that is a different
type of care. So there are a group of
consumers that really do value price, speed and convenience.
The thing is what is that vetting process of deciding who
that patient is versus the more complex patient where that's not
adequate. So I would say that it depends
on the level of care you want. Is there an amount of?
What do you? Think that's safe?
Do you think it's safe if they're, because how is the
patient supposed to know that they are more complicated or
not? If they again, everybody's
looking for speed, convenience, obviously price is, is
important. And if they find you know,
because I see the stuff linked on breast cancer influencer
profiles and I'll go to the link and I am shocked at how easy it
is to get these medications. So to me.
I think people need to interact with a clinician.
Right, that's how I feel. I mean, do a virtual visit.
I do virtual visits with patients all the time, right?
We just hop on, we see each other, we ask some questions.
There's an exchange if you can just fill out a medical history
reform, send it off to somebody and they mail you medications to
me. That's not that's not it.
We've missed the mark if that's how it's going to be.
Yeah. Just something for our prior
conversation. So the whole like off label
thing, off label marketing is like technically not allowed by
the FDA just so we. Yeah.
OK. I wasn't sure if we like clearly
said that, I just wanted to. Keep it in there guys.
Whoever it the added team like we're keeping it in there.
The FDA does not approve of off label marketing and I think.
That doesn't the FDA is not against off label prescribing
between a doctor and a patient. But that's really important
because I'll tell you, I didn't know that.
Yeah, I didn't know that. Now I have not off label
marketed something. But if I could see how if I am
someone who does off label use certain things, for example,
this implant that I'm really excited to try in my
reconstructive patients again with a conversation, if that
implant company came to me and said, hey, you've had a year of
really good results, you have noticed an improvement in XYZ,
do you want to partner with us? I could see myself saying, yes,
I, I could. And I, I just think like we're
all so quick to attack, attack, attack.
And I find that sometimes, a lot of times it's really, we're not
giving people the benefit of the doubt, especially when again,
parcel by parcel, what this person said on the ad I don't
think was incorrect. I feel like I can factually pull
really good data. So I to me, if I had to boil
down that entire controversy into one action item, that
action item would be as physicians, we are not allowed
to advertise off label indications.
Now what about education? Are we allowed to talk about it
on our social media profiles because in a certain.
Way we're allowed to when we like do lectures and things like
that, we just. But what about social media?
Because social media is advertising in a huge way.
What if you talk about it but you don't link it?
I mean, do you see what I'm saying?
Like, how do we draw these guidelines?
Because I think that's where we're at as we probably need a
set of guidelines from like the AMA, you know, that come forth
and say, if you're going to be a medical professional, this is
what's OK and this is what's not.
And I, I think, you know, reimbursement obviously matters.
So when I do, when I did that neuromodulator collaboration, I
get paid a, a base amount to speak about that, that product.
And I literally use that product.
I swear by that product. And I use it both on label and
off label. But again, I have those
conversations with my patients, but I do not get paid for like
number of clicks or how many times I there's no kickback
involved, right? And that I think is critically
important. So if you're going to be an MD
influencer and in this case, the person is getting paid to speak
about a platform that he or she engages with about a medication
that they've personally used, again, I don't see anything
wrong with that. And I think villainizing
physicians for that, I don't think is it, I think we've
missed the market for villainizing physicians for
that. But I do think we can help the
public gain trust by being transparent on the on the
payment model. Hey, I got paid to talk about
this because these are all the reasons why, because I've used
it, because I'm a doctor, because I've prescribed it.
But also let me be very clear that there is no payment model
involved in this where I'm getting paid for number of
clicks or number of purchases. Totally.
And I mean, that is like the whole purpose of the Sunshine
Act, right? Yeah, yeah, exactly.
I mean it is publicly available data.
You can go look up how much your doctors get paid by industry.
Industry needs us guys. If you want innovation in
medicine, you need these pharmaceutical companies and
implant companies, whether it's orthopedic implants or a
pacemaker or a breast implant or chemotherapy or GLP ones, they
need to partner with doctors. We have to be on the advisory
boards. We have to be consultants to
help and also enroll for the clinical trials, but we should
also get reimbursed for our time and expertise.
I think the Sunshine Act is is important in bringing clarity to
how much we're making, but I think we can do even better by
forcing transparency on what the pay model is, because I think
you and I and all doctors would agree you should not be paid per
use. That's a kickback.
Completely. And I, I just, it's so hard
because I too am an MD influencer and I, I watch what
plays out and it helps me, you know, be accountable.
Even when I posted that I, I know you had reached out and
that's how we had originally connected because you said, hey,
there is a lot to micro dosing and this is where I use it.
And this is where it's not a scam.
This is where it works really well.
And I was like, you know what, you're right, I shouldn't have
said that. But I was speaking from the
point of view of someone who has a bunch of people in our clinic
every week saying they're getting micro dosing, but Lord
knows from where who's prescribing and they're they are
not connecting the dots of their own.
Health No, I I think I think you should have said something
because the word micro dosing has to a certain degree been Co
opted from like the recreational drug use culture and it's
created this impression that when you micro dose something
it's definitively safe, less serious yes, exactly right.
And so that isn't true. Like technically is taking a
smaller dose micro dosing, yes, literally you can say that.
But unfortunately that word has made it from like literally
recreational drugs to psychedelics to GLPS now it's
like a marketing word. And so it's like lost its true
meaning of are there populations of people that can benefit from
what would be considered sub therapeutic doses because they
don't have the full blown disease that was initially
studied. That is really what we're trying
to say. We also do across all
specialties and medications, changing the dosage of a
medication in a more new, I mean, we deescalate chemotherapy
dosages all the time based on toxicities and the side effects
that patients experience. That's a medical decision and a
clinical decision that's made together through informed
consent and conversation between the doctor and the patient.
And so I, well, thank you. I mean, I'm glad you reached out
about that post I made. It's funny, I actually had to
archive that post because so many people were linking GLP,
what's in the comments, literally posting links in the
comments. And I'm like, Oh my God, this is
literally what I was trying to warn against.
I'm not saying don't have a virtual appointment with the
doctor. I do virtual appointments.
But you should know who this person is, what their name is,
what their credentials are, and you should hold them to the same
standard as all of your other healthcare providers.
Do they meet with you regularly? Are they checking in?
Are they looking at biochemical markers?
And that, that was another sort of buzz term that I know ended
up being criticized of this new MAD.
But we do look at biochemical markers.
I mean, I, I think 1 should be if you're on GLP ones.
And I didn't see fault with that either.
I I had, I see no fault with checking labs.
I think that in the doctor world, that just means we check
labs, yeah. Right.
So I thought, you know, to see somebody come so full on attack
mode, I felt was unnecessary. And I, I really hate the
infighting that I see in the medical community because I find
that most of us are all on the same side.
And I think if you break it down and if you have a conversation
with someone one-on-one like we're doing, you can say, OK,
maybe there's one particular aspect such as off label
marketing is not something that is condoned by the FDA.
We should revisit that. But I even wonder, like this was
recorded months ago, how much was this person made aware of,
whether it was off label? Was it a disclaimer that was
added after the fact? We don't know.
We haven't given this person a chance to defend themselves or
talk about it. We're just ripping them to
shreds and then taking it 10 steps further going into all
sorts of other things about this person's reputation.
I actually would say you're doing a lot more harm if you're
the person attacking to that degree because you can have a
nuanced conversation. And also as we've shown in this
episode today, I don't think anything specific that was said
was necessarily. Incorrect.
I would not say something was scientifically incorrect, but I
think this person has been used as an example to, yeah,
highlight several confusions. Yeah, yeah.
Sort of like patient zero, right?
This person has now taken on the brunt of all sorts of
controversy and questions and speculation.
And again, the public, I think, in general struggles with this
degree of trust. And it is weird to have so many
doctors on social media. For a lot of people, they don't
like seeing us outside of their clinic.
And I think that's unfair. I think it's great to spread
good information, but I think unfortunately, this person
really was made an example out of to an extreme.
And I hope podcast episodes like this can help sort of breakdown
the nuanced aspects and instead of marking someone with a
scarlet letter, giving everybody an opportunity, opportunity to
talk about like, what's really the issue here?
Yeah. I mean, I think you did a great
job of kind of summarizing the issue on your own platform
because again, for those of us that didn't have contacts, and
that was even me, I just happened to have a busy week
with patients. I didn't know what was going on.
And then you made a 16 minute video explaining the whole thing
and I was like, OK, I have to figure out what's going on.
And then you happen to also reach out, which I mean, I think
that that was great. Like you literally were like,
OK, let me just call an expert on this and figure out what what
was scientifically incorrect, if anything was.
And really it wasn't. It was more all of these other
issues that this person was, you know, being raked over the
coals. For yeah, absolutely.
Like, thank you for joining me last minute on a Sunday, but a
very special day because it's International Women's Day and I
am so, so grateful for women like you who have a voice, share
such good educational content real quick for everybody, say
your handle out loud so they can all follow you.
For all of the incredible endocronology content content
you share. Of course I'm I'm at Doctor
Rekha Kumar on Instagram. I was so happy to be here for
you on a Sunday and I hope I can like be as glamorous on social
media as you are talking. To any would anyone believe that
this woman has teenagers as children, you need to drop your
skin care routine. I will bug you for that offline,
but I will also add her handle to the posting so you guys can
all see it. And I'll link your associate
professor page at the university as well in case anybody's
interested in seeing you as a patient.
Thank you so much for your time. Do you have any parting words?
Parting message? It doesn't even have to be about
GLP ones or endocrinology. It could be about anything.
I mean, I just would, you know, want everyone that's listening,
patients, consumers, just people who watch to know that we are
like at a real turning point in medicine.
I think that there are so many new innovations that are really
going to change how we see our health and how we take care of
people. So I do hope that people
understand that we had this conversation to say that, you
know, there's a lot of really exciting stuff happening in this
field and science, and I hope people can find doctors they
trust to have these conversations.
I love that. I love that.
All right, guys, that is inside thoughts out loud.
I will check all of your comments.
I will make sure Doctor Kumar is listening in as well.
Thank you all and until next time.
So we just heard from Doctor Rekha Kumar, an absolute icon
and expert in the fields of endocrinology about GLP ones.
But we didn't only talk about the medication, which of course
could be many podcast episodes by itself.
We also talked about the weight that physicians and healthcare
providers hold and carry when we are also on digital platforms.
What does that responsibility ability look like?
What is taking something too far?
When are we being attacked unnecessarily?
And I really think the lesson that I learned from all of this
as a physician who is also on social media is that we really
do need to be kinder to each other.
You know, we don't know the back story necessarily.
We don't know what that person was told or not told or prepped
with, or what information has come to light about the platform
or medication since these are conversations we can have in
nuanced ways and in high IQ kind ways with each other to hold
each other accountable without just throwing attack after
attack. Not to mention, just because
somebody criticizes somebody else doesn't mean that person is
100% correct either. We also heard today that
factually the things said in that video are independently
verifiable with scientific data. So I really want to leave my
listeners with this. I think we should hold each
other accountable. I have been held accountable and
thankful for that. But I'm grateful for the fact
that when people do speak out about content that I put out,
it's it's done in a way that is that is kind and factually
based. And it isn't just full on attack
mode. Because when you start
undermining somebody's credentials, their skill set,
their abilities based on one singular item, I find that it's
personal. It's like a vendetta.
It's really not actually holding somebody accountable in a way
that can actually make for a good change.
You're just trying to bring somebody down and that we are
not into that. So thank you so much for joining
me on this. Again, I'm going to say it's
like an emergency episode of Insight Thoughts Out Loud
because I really wanted to get this conversation out there.
I can't wait to hear your comments.
Let me know and if you guys want another follow up episode, if
there are any other questions you've had about GLP ones, I'm
sure I can get Doctor Kumar to comment on those.
So let me know and we can always follow up with another episode
if that's something you guys want.