E71: Understanding Obesity Through Anesthesia and Beyond with Dr. Sarah Bodin

Welcome to the Get Healthy Tampa Bay Podcast with Dr. Kerry Reller! This week, I am joined by Dr. Sarah Bodin who delves into the challenges of anesthesiology in obese patients and shares her journey into obesity medicine. Dr. Bodin discusses her new telehealth practice aimed at managing obesity through personalized care plans focusing on diet, exercise, and behavior modifications. Additionally, we explore the significant influence of government policies and the food industry on obesity rates. The discussion offers valuable insights for anyone interested in the complexities and treatment of obesity.

Dr. Bodin is a Diplomate and Fellow of the American Society of Anesthesiologists, and a Diplomate of the American Board of Obesity Medicine. She maintains memberships in the Obesity Medical Association, the Florida Medical Association, the Florida Society of Anesthesiologists, and the American Society of Anesthesiologists. She earned a Bachelor of Science in Engineering at the University of Virginia (1991), her Doctor of Medicine at the University of Tennessee College of Medicine (1995) and completed residency in Anesthesiology at the Medical College of Georgia in 1999.  She has practiced in both academic and community settings in Florida, Georgia, Tennessee, and North Carolina, and is published in the field of Anesthesiology. She has a new boutique obesity medicine practice out of St. Augustine Florida, Quality of Life Physician Weight Management, serving Floridians via telehealth service.

Dr. Sarah Bodin is a board-certified anesthesiologist who has practiced both academic and community anesthesiology for almost 25 years. She has mastered pharmacology and physiology in her career, and the art of quickly developing a trusting relationship with her patients, while working in a variety of medical settings with many team members. She became interested in obesity medicine as a speciality after many years of treating people with obesity related diseases in the operating room, in addition to her own struggles with weight. She began studying obesity and its treatment in 2022, finding that the medical community as a whole has much to learn, and to overcome the unjust stigma that the disease carries.  

0:38 - Introduction to Dr. Sarah Bodin
0:47 - Sarah's Background and Interest in Obesity Medicine
2:50 - Challenges in Anesthesiology with Obesity
6:49 - Pre-op Clearance for Surgery
8:22 - GLP-1 Agonists and Anesthesia
14:01 - Starting an Obesity Medicine Practice
15:36 - Dietary Management and Obesity
21:58 - Impact of Government and Food Industry Policies
49:56 - Book Recommendations and Further Reading
55:00 - Closing Remarks and Future Directions

Connect with Dr. Bodin
Website: https://www.qualityoflifemd.com/
LinkedIn: https://www.linkedin.com/in/sarah-bodin-md-fasa-dabom-366631253/
Facebook: https://www.facebook.com/QualityOfLifeMD
Instagram: https://www.instagram.com/qualityoflifemd/
Tiktok: https://www.tiktok.com/@sarahbodinmd
LinkTree: https://linktr.ee/sarahbodinmd

Connect with Dr. Reller
My linktree: linktr.ee/kerryrellermd
Podcast website: https://gethealthytbpodcast.buzzsprout.com/
Facebook: https://www.facebook.com/ClearwaterFamily
Instagram: https://www.instagram.com/clearwaterfamilymedicine/
Clearwater Family Medicine and Allergy Website: https://sites.google.com/view/clearwaterallergy/home

Subscribe to the Get Healthy Tampa Bay Podcast on Apple podcasts, Spotify, Amazon music, iheartradio, Stitcher, Google Podcasts, Pandora.

Transcript

Kerry: 0:29

Hi, everybody. Welcome back to the Get Healthy Tampa Bay podcast. This is your host, Dr. Kerry Reller. And today we have a very special guest, Dr. Sarah Bodin. Welcome to the podcast.

Sarah: 0:38

Thank you. It's really exciting to be here. I appreciate you having me. Thanks.

Kerry: 0:42

And I always ask everybody, tell us a little bit about who you are and what you do.

Sarah: 0:47

Sure. I live in St. Augustine, Florida. So a little ways from you guys, but not too far, still in the same state. I've been here for about five years now. I am an anesthesiologist by training and been practicing anesthesiology for getting close to 25 years now. But I have more recently done training in obesity medicine as you know, got my certification with the American Board of Obesity Medicine back in, back last fall. So I'm beginning to ramp up a practice in that. So got interested in obesity medicine a few years ago. Well, I've been interested in it for a long time, but didn't really realize it was a specialty until more recently. But after treating people with obesity, both in the operating room and other procedural areas for so many years and seeing that we're treating people, we're treating the end effects of obesity over and over again in the operating room as well as medically. It was just getting very, very frustrating. And I just see over and over again. My goodness, if these Folks, had better treatment for obesity they might not be here for the problem they're here for today. So really got interested in obesity medicine at that point once I realized, it was also at the time when the GLP one agonist, you know, the more exciting new drugs that are so highly effective, we're starting to get a lot of attention in the media. And then I became aware of them and started paying more attention to them in the professional circles that I'm in and then realize, wow, obesity medicine is a specialty and started educating myself about it at that point.

Kerry: 2:13

Yeah, I mean, it's definitely interesting of how you entered the field and how so many of us were unaware of that obesity medicine existed, right? I think it's been around for quite some time, at least like 14 years, I think. And, you know, more and more people are getting board certified in it, which I think is great. And, you know, there's more and more people affected by obesity therefore, we need more people that understand it and can be good providers for it too. So what sort of things in anesthesiology did you see that was a problem with patients who have obesity?

Sarah: 2:50

Well, it's a lot of lot of different problems. I'd say the biggest one that sticks out the most for from causing us the most trouble and I struggled with it this morning with the patient I took care of this morning is folks with obstructive sleep apnea. And of course, that's one of the very common conditions that's associated with obesity. And unfortunately, it's very underrecognized too. There's a very large percentage of our population that suffers from obstructive sleep apnea, like around 20%, I think is the estimate. And a huge percentage of those, like over 75 percent don't even know they have it. So in the operating room obstructive sleep apnea even if it's treated, folks who have it tend to have more trouble with we have more trouble managing their airways, so putting breathing tubes in if that's necessary, or doing procedures like I was doing this morning where we're not using a breathing tube or giving sedation, and those folks are way more susceptible to having obstructed airways during, during sedation. So that's a big problem. Folks with sleep apnea are more likely to have high blood pressure. They're more likely to have heart disease. They're more likely to have sleep problems. So that's a real big problem for us in their anesthesia. You can start just back at the beginning, very simple things for patients who are having anesthesia who have Obesity. It's frequently a lot harder to place IVs, and we got to have IVs obviously for for anesthesia. If we're doing regional anesthesia techniques, things like peripheral nerve blocks or spinal anesthetics, it can be technically more difficult to place anesthetics that way. You know, the other comorbidities that patients have like diabetes or high blood pressure or heart disease, all of those things complicate our management a little bit by themselves, but they're more frequent with the anesthesia. Drug dosing changes with, with obesity as well. So it depends on type of drug and how it's characteristics as how well it binds to lipids versus water and what phase it goes into. So how much more susceptible people with obesity or less susceptible they might be to the effects of a drug and how quickly that drug clears out of their system. So that changes things somewhat. Folks with sleep apnea, again, kind of backtracking there a little bit, but folks with sleep apnea tend to be more sensitive to the respiratory depressing effects of a lot of anesthetics, particularly opioids, but other medications too. Opioids meaning things like narcotics for pain medicines sedatives like benzodiazepines, like midazolam is a benzodiazepine that we use frequently, but that's in the class of drugs like Xanax and Valium, things like that. Those are kind of the big ones that I can think of off the top of my head I'm sure I'm missing a few-positioning. So getting folks with severe obesity in particular positioned, finding sometimes procedural beds have weight limits to them, getting folks positioned for unusual like I was doing position cases today with patients positioned prone on their tummies. That can be a little bit challenging, getting them comfortable, getting them padded so we don't hurt them. They don't get hurt. And I had one other point I wanted to make, but it escaped me. Hopefully it'll come back to me.

Kerry: 5:50

Yeah, because oftentimes you're putting them to sleep when they're on their back. So if you have to reposition, usually having to, you know, do that when they're not aware. Is that sometimes true? Yeah.

Sarah: 5:58

Well, the cases I was doing today were, were heavy sedation cases. We actually had folks position themselves on their tummies while still awake, lightly sedated. And then I started the sedation after they were positioned. But most of the time, for instance, like a general anesthetic where we are putting a breathing tube in yes, we start with the Patient positioned supine or on their backs, place the breathing tube and then position after they're asleep.

Kerry: 6:20

So a question about the breathing tube. So as a primary care provider, I'm often doing a pre op on these things. And I mean, one thing I notice is often what we call the Malin Potti score. And you know, there's just really, you can tell that there's not a lot of room in the airway that it's just going to be hard to get a breathing tube down there. So when would it be a bad idea to clear somebody for surgery regarding maybe that or any of the other things that you brought up too.

Sarah: 6:49

clearance for surgery. That's a whole nother topic,

Kerry: 6:51

Okay, we don't

Sarah: 6:52

have Which is a great one. No, I love it. It's one of my favorite topics. I just didn't even think about it. I saw a quote, clearance form today. I put air quotes up because I find clearances meaningless. as an anesthesiologist, I would like to see from a physician who knows the patient well, is are their medical conditions optimized? What is the state of their medical conditions? Is their diabetes well controlled or poorly controlled? Is there anything you could do to improve the control before we do an elective procedure? Same thing with, say, heart disease or pulmonary disease. As far as airway you're not an airway expert so we wouldn't expect you to evaluate that or, or give us a, you know, unless you, you know, for instance, somebody who's got a large neck circumference, we know that's associated that if your neck circumference is greater than 16 centimeters is associated with a more difficult both intubation as well as mask ventilation. So giving us a heads up for that is, is nice. So you could say, you know, the patient has obstructive sleep apnea and a large neck circumference that may You know, be aware of that for airway management, and then we'll take it from there. But yeah, that's a really good question. Yeah, so folks with obesity more likely to have problems with, we're more likely to have trouble putting an airway in.

Kerry: 8:01

The other things you mentioned too, like the different drug dosings and things like that. I mean, those are really important to note as well. And sometimes I hadn't even thought of that one. I have to ask you about the new GLP ones and anesthesia, because the recommendations are just kind of coming out with that. So what are the current guidelines for the GLP one usage and anesthesia?

Sarah: 8:22

really great question. I'm really glad you brought that up. That's a big topic in anesthesia right now. Of course, in the American society of anesthesiologists did come up with some guidelines last year because of the number of case reports that were coming out with folks who came to surgery on the GLP one drugs and a lot of case reports of the, even though they'd held food and drink the way they were supposed to, when they had been recommended, which is at least at least eight hours for solid food two to four hours for clear liquids. They were fine. These folks still had a lot of. a lot of stuff in their stomachs. Partially digested food, stomach secretions, and some of them were aspirating, what we call aspirating. And that's why we have folks not eat and drink before surgery, of course. We want the stomach empty so that if there were any retching or things like that during surgery, that those contents don't make it up into the mouth and then down in the airway. So the sheer number of reports that were coming into different journals and newsletters and things like that being reported of aspirations, cause the ASA to come out and come up with a task force and come up with recommendations, which are that if you're taking a GLP 1 agonist that you hold, it's one of the weekly injectables like semaglutide, which is Ozempic or Wegovy, that you need not take it for a week before surgery, a full seven days, you hold the dose for the full seven days before surgery. But honestly, people are usually telling folks to hold it for two weeks, and I'll come to why in a minute, And also not just Ozempic or Wegovy, but also zepbound and, and mounjaro which is actually has a slightly shorter half-life, but they're still weekly injectables. So we're telling people that, or the recommendations are at least a week, and that means a full seven days. Honestly, it's probably better to take a little bit longer. There's some daily injectables as well. I'll be loraglutide is one, and which one is trulicity? Xenotide, I forget exactly which one trulicity is, but there's another couple of daily, or no, that one's weekly as well. Sorry, week trulicity is weekly as well. So that would be a seven day at least hold the daily medications recommendation is to hold for a full 24 hours. Semaglutide as an oral form. Ribelsis. Well, ribelsis, it's hard to say is also a 24 hour hold. So the first good retrospective study looking at the incidents. This was just published actually out of I believe the University of Texas, I believe in Houston, and they looked at they used gastric ultrasound to look at the stomach contents of the folks who were both on, well, they were all on GLP 1s, but they didn't have unusual hold times. They just came to surgery. They've been taking the medication as usual for the most part. Some of them had held it longer than others, and they found that anyone who was on a GLP 1 agonist had a 55 percent chance of having a significant amount of gastric contents compared to less than 20 percent for people who are not on GLP 1s. And that was both diabetics and non diabetics. So that was terrifying, frankly. And I would say clinically most centers are having people hold it for longer than one week, at least two weeks for the weekly

Kerry: 11:28

Yeah. I would say my experience is that they've been telling us two weeks mostly because if it's one week, it may just be due for the dose anyway. And that's how you know, the medicine work is its suppose to slow the gastric emptying. So it's a problem obviously with anesthesia. But if you're trying to feel full longer then that's when you know it's beneficial. But everybody needs to know about these, Potential side effects and complications that could happen if they're going to go under surgery for sure.

Sarah: 11:56

Absolutely. And I think those recommendations will change. And it may be that we have folks hold their food for a little bit longer, maybe closer to 24 hours rather than eight hours, things like that. We may come up with a longer hold times. We'll adjust. They're great medications. They're here to stay. We'll figure out a way to adjust. There are other medications we have to move around, Phentermine is another one that we actually have recommendations to hold for two weeks without great data. There's not great data about that, but folks who are on Phentermine, there were case reports about blood pressure and heart rate swinging wildly during anesthesia. And so kind of the generalized recommendations based on those case reports are for folks to come off their Phentermine for seven to 14 days before surgery,

Kerry: 12:37

Yeah. I was just doing a pre op today and the person is on phentramine and I had recommended that as well. The other thing was that you mentioned that they might have to hold the food longer. What's good about that if you're only on like metformin or the GLP one and not a drug for diabetes that causes hypoglycemia, That these drugs don't actually cause low blood sugar while the patients could be more prone to it. But if they are not, you know, if they have to hold their food longer, it's unlikely that they'll have low blood sugars, that they may feel different. So I think it's probably acceptable to do that.

Sarah: 13:11

And let's hope that those drugs will help more and more people come off of insulin and not have to take it.

Kerry: 13:16

Right. Yes, exactly. Yeah. Clearly if they're on insulin, that's kind of a whole other story, but we're not talking about that right now.

Sarah: 13:23

Different, different issue, for sure.

Kerry: 13:25

Yeah. Well, is there anything else you'd like to share regarding anesthesiology, mouthful, and obesity and the risks and, you know, any benefits or anything?

Sarah: 13:37

Any benefits to having anesthesia well not being awake during your surgery?

Kerry: 13:41

There you

Sarah: 13:42

No, sorry, I'm

Kerry: 13:43

And the ability to have their procedure, let's say it's a knee replacement or something like that, right? That would really make a difference in someone's life if they were able to get their knee procedure and then they can walk around more and have a better quality of life but I think that there is benefit, right? I guess

Sarah: 13:59

Oh yes,

Kerry: 14:00

If they're able to do the procedure

Sarah: 14:01

Absolutely. Yes. But in terms of if you know you have a procedure coming up and you want to optimize your health before surgery, some of the most important things would be to make sure that the medical conditions that you have are under good control. If you have obstructive sleep apnea be using your CPAP so that your blood pressure is controlled, your sleeping is good, you're less likely to have I don't know whether there's any proven benefits to using the CPAP versus not, but I do think blood pressure is definitely better controlled and untreated sleep apnea is associated with heart dysrhythmia. So if you treat it, you're less likely to have those heart dysrhythmias. Being able to lose weight before surgery would be great. Even though weight loss of five to 10 percent gives you significant benefits if you can make sure your diet is healthy, eating plenty of protein not mineral deficiencies, things like that, having a good protein background in your your diet, make sure you're able to heal well. If you happen to be a smoker as well, stopping smoking before surgery, even for a brief period of time, really has very good benefits for recovery from both anesthesia and surgery. But the main thing is making sure all your medical problems are treated as well, as you can get them treated before elective surgery.

Kerry: 15:09

Yeah, obviously really good advice and then you mentioned kind of post op. Those things are also helpful like stopping smoking, having good diabetic control so that your wound can heal or everything like that. So we were gonna talk about another fun topic today in the lieu of obesity medicine, and that was kind of about food policy and I guess food companies as well. Where do you wanna start with our discussion on this today? Mm-Hmm.

Sarah: 15:36

There's a lot of entry points there. Yes, that's, it's definitely something as I read more and more and become more aware of I've known about it for years. You can't live in the United States and not know about the influence of processed foods on on their diet and sugars. But it's interesting to learn about how the government influences our diets and a lot of the policies are not great. They could get a lot better. You know, there's a growing awareness in the government about how much money we're spending on health care. Obviously, we spend the most money of just about any industrialized nation on health care, and we don't get our bang for our buck. We do not have Great health or health care compared to other industrialized nations. And part of that, I think, is the fact that we don't emphasize good health prevention. We focus on stomping out fires once they've happened, treating diseases once they've come up. And obviously, as a family practitioner and obesity doc, that's what you do every day. And it, or hopefully you have some good influence with prevention. But if you look at the rise of obesity in the population over the past, I forget exactly when it started spiking, I want to say in the 80s, it really started spiking. It was maybe, it started before that,

Kerry: 16:45

know. Mm-Hmm.

Sarah: 16:46

and 80s. It really paralleled the rise of sugar in the American diet. Sugar and saturated fats and things like that. But if you look at the processed food industry's growth. It ran, it ran a very close parallel course. And unfortunately, the government, even though they say they want to stop the obesity epidemic, or at least fight it, is really not doing everything they can to crack down on how much processed food and sugars and saturated fats we have in our diets. Or even alcohol, they're not even really cracking they're making some, some recommendations about alcohol but they're not as strong as what the evidence supports they should be. So there's lots of places you can start where what's the chicken and the egg. I don't know.

Kerry: 17:28

Yeah. We really don't know, like kind of what came first in, in truth, but I think there's been some policies over the years or recommendation and guidelines, right that have kind of led everybody astray. And I think, you know, we're starting with the food pyramid and thinking that that is bad. I mean, that's a really common entry point for when we started getting off on the wrong track and then the policies that were made around that right with the government subsidizing things So do you have any comment like kind of how the policy had created this obesity crisis

Sarah: 18:06

Yeah, that's a really good point. And I didn't really look back to the food pyramid, but I remember it. And I remember the bottom I believe the base was grains.

Kerry: 18:15

Yeah, like six to eight serving grains

Sarah: 18:18

didn't emphasize grains like crazy. And I don't think that was before we really knew that process grains were very, very different than whole grains. And even to this day the dietary recommendations that the USDA is putting out still doesn't recommend that you focus completely on whole grains. They're still saying it's okay to eat processed grains. Well, Not if you want to have good health. It's not. It's not okay.

Kerry: 18:39

Could you explain what a process grain is versus a process grain for the

Sarah: 18:44

And I'm not exactly, I'm not a food expert by any means, but to know a process grain is something like a wheat that's been ground very finely milled and the exterior hull of the of the grain has been removed, and that tends to be where most of the fiber and the nutrients are. When you take those out, you lose not only the fiber, but a lot of the other micronutrient benefits that come into the food. When you highly process that grain, the way it affects its absorption when it hits your intestines is different, and the hormonal responses to those foods change in a negative way, tend to promote inflammation, whereas whole grains, there are a lot of known health benefits. And I can't remember all of them other than of course the fiber is always good for creating a good environment in the gut and decreasing risk of colon cancer, things like that.

Kerry: 19:32

That was a pretty good explanation. I think you kind of nailed it. Like the outside of the grain is kind of discarded, wherein that's all the fiber and the nutrient. And yeah, yeah, that's the good part. So we kind of try to avoid those. Well, we should be avoiding the refined grains as best as we can.

Sarah: 19:48

Absolutely. And thankfully that food pyramid is has gone the way of the dodo. It's now been replaced with something called my plate, which I was looking at again today and I guess that's really aimed towards guiding people who are feeding children and taking care of children and kids and so it's got, you know, it's got some good parts to it and it encourages. I believe 50 percent of my plate to be filled up with vegetables and fruits. It says, you know, 25, roughly 25 percent protein is the other grains. It's still encouraging grains, but it's saying at least 50 percent of your grains should be whole grains. Honestly, it should be more than that. It also has a big chunk of dairy. Dairy is really controversial. Dairy is a huge source of saturated fat. we know that isn't good for a lot of different reasons. And yet the government is still promoting that as part of a healthy diet. That's got some caveats. Maybe it does, maybe it doesn't, but whole dairies, it's got some, it's got some risk factors that go with it.

Kerry: 20:44

Also for the, for the my plate they still have In their like sugar that they have a recommended, daily allowance to not go over and then they have that on the food labels too with added sugar. Whereas, you know, in truth, they don't need to have that. It shouldn't be there at all. And you can just say, you know, completely eliminated. But, you know, obviously, everybody's human. They're going to have some a little bit, but it shouldn't be on the, goal or anything like that of, you know, Added sugar for sure.

Sarah: 21:13

right. And I believe the name of the document, I didn't write it down as US Dietary Policy and their food recommendations are to minimize your processed sugars or added sugars to 10 percent or less of your diet. That's a lot. And evidently when making the most recent set of policy guidelines. They had a scientific advisory panel who recommended that it be much lower than that, and USDA ignored it and left it at 10%. So I wonder why that is. Lobbyists may well have something to do with it. So there's a big sugar lobby and corn lobby, a lot of external forces that are guiding policies that are not grounded in scientific theory, unfortunately.

Kerry: 21:52

So can you give an example of what's going on with that with the corn and the what was the other

Sarah: 21:58

Sure. Yeah. So, right. So the government subsidizes through the farm bill a number of commodity crops, the United States, which are, They make a lot of money for farmers, which is great. And they also provide corn, corn being one of them. Corn provides food not only for humans, but of course for the agricultural animal industry which is another whole story. Another topic we'll go into there too, but about 25 percent of the farm bill every year, which is billions and billions of dollars. I forget how many, not every year, every five years they, they redo the farm bill. Subsidies to help stabilize prices for these commodity crops, corn, soybean, wheat, cotton, rice, sugar really big products that have dubious value in a healthy diet are getting the lion's share of this, this, these subsidies, whereas healthier fruits and vegetables are not being subsidized or very little, very tiny percentages. And these, these industries are providing cheap fodder for the processed food industry, unfortunately. So that's again, probably parallels the increase in obesity in the country.

Kerry: 23:06

Mm

Sarah: 23:06

But those, those subsidies are there for a reason. And I'm no economist, but from what I understand, they help make sure that, obviously farmers don't go outta business. If there's a bad year, there's bad weather. The demands for these things fluctuate. You've gotta make sure that that supply is somewhat stable. So I understand the reason for it, but why we don't subsidize a healthier, the healthier components of our diet is beyond me.

Kerry: 23:29

Right. I mean, obviously good to support the farmers, but it would be nice if you could have them grow things that were more useful and healthy for everybody, right? And subsidize that. So, I mean, yeah, it's hard. You got to change policy in order to change some of these things that are happening. But when you're subsidizing the corn and they turn it into corn syrup, or like you mentioned even corn feed for the animals, it's. Not moving in the right direction at all. The animals should be eating, you know, usually grass, not, not the corn. But the corn helps fatten them up more.

Sarah: 24:02

And there was, lots of lots of emphasis on eating less of those animals. Specifically, the red meat was beef, particularly, which is very high in saturated fat. goes back in the 80s and when that industry started turning, of course, the big beef farmers

Kerry: 24:16

Mm hmm.

Sarah: 24:16

were not happy about that. Understandably, a lot of lobbying money poured into that. And that means the beef industry is one of the biggest lobbyist groups. I think, I think I read that it is the biggest food lobbyist sector. in up on the hill. So they have a huge influence over U. S. policy. And we're eating way too much beef, way too much saturated fat. Still I love beef. It tastes delicious. I eat it too. I try to minimize

Kerry: 24:41

Right.

Sarah: 24:42

And dairy as well, particularly in cheese and things like that. cHeese and dairy have been subsidized heavily By the U. S. government for years, many, many years, decades, and we still eat too much of it. And it's still right there on MyPlate

Kerry: 24:55

Oh yeah. Yep. What about with the skewing of low fat diets from well, I guess I don't know what at the beginning, but once they determined things were low fat was better. So what happened with the low fat, right? They started taking those dairy products and then they sucked out all the fat and then they started making other stuff with it so that they could, you know, still have, you know,

Sarah: 25:19

cheese. They started making cheese.

Kerry: 25:21

The cheese. And then the other thing was I guess the less emphasis on the fat started putting sugar in all the other products too, right? So all of those the processed foods started all having sugar. And the other thing about sugar is that it's a preservative, right? So it helps those things last longer. So as we need this convenience and, you know, it's not convenience food for time, convenience food for preparation and other methods, I don't know if we're going to go into today, but like how everything tastes and things like that. That's why everybody sort of got hooked on these processed foods too, which I think also has led to, you know, kind of obesity worsening in our country, not just our country, but everywhere, really.

Sarah: 26:05

Oh yeah, definitely. Yeah. So I remember that distinctly back in the, this was the eighties, probably the eighties. I remember them the whole low fat craze. I remember that distinctly because my mother tried very hard to be clean. health conscious still does really got on the low fat bandwagon. And I remember buying all the cookies and things that were low fat. Remember the snack?

Kerry: 26:27

Snack wells. Yeah. I ate them

Sarah: 26:29

gosh, we had a lot of snack. Well, so

Kerry: 26:31

the devil's food snack wells. Yeah. Pure

Sarah: 26:34

I remember eating whole boxes of those things.

Kerry: 26:37

Yeah,

Sarah: 26:38

Because they still hit our bliss point, right? You mentioned that things taste really good and they still manage to. So the bliss point is the concept developed by a food scientist back probably in the 50s or 60s as they were beginning to develop processed foods and sell foods and groceries. Bliss Point kind of describes the optimum point of sweetness and texture, fat texture and salt to get the most happiness you can get out of a bite of food and the most addictive feeling and oh my gosh, I want more of that and I want more of it and I want more of it and that's exactly what the food scientists were going for then and still are was how to get A food to the right taste point where the most people would want to buy it over and over and over again. And we, you know, they learned early on, they already knew, I think, but certainly reestablished that sugar is probably more addictive than cocaine. There have been multiple studies showing that animals offered sugar will go for it more often than they will for cocaine.

Kerry: 27:41

Yeah. And our brain even lights up more when we eat sugar than with cocaine, right? The reward and addictive pathways in the brain light up more with sugar. It's crazy. So that bliss point, I mean, that is how those food scientists and engineers have created all these highly processed foods and tested and, you know, tested them on people to make sure that they got that just right. Right. Like even if it would. They've downgraded the sweetness if they thought it was too much in some cases, which is surprising and they've even studied kids, which is just kind of crazy to me.

Sarah: 28:15

They targeted the kids more than anything,

Kerry: 28:17

Yeah. And then they target them.

Sarah: 28:19

thing.

Kerry: 28:20

Yeah. And they target them with advertising and toys and characters. Like, I don't know, I was listening to something recently with Tony, the tiger character, you know, they wanted more, was it Kellogs? Right. Is that Tony the Tiger? Yeah. So they target the kids with all these things and make them want it and they get them addicted at an early age. Right. It's crazy.

Sarah: 28:46

So

Kerry: 28:47

of the problem, right?

Sarah: 28:48

some of those cereals are over 50 percent sugar. So you're just eating candy for breakfast and that's, and that's what children want. And then once that's the other thing that's been pretty well studied is once you've developed a taste for that sugar, you want more and more and more. A little bit's not enough. It's, you've got to have more So, and you know, and of course sugar found its way into everything that bliss point found its way into things that you wouldn't think should have sugar. And so now even if you're trying to avoid sugar and you avoid the obvious things this the sweetened cereals or cakes, cookies, candy, juices, soda, that's another whole topic, but it's an it's an everything process you open a package of anything and there's some sugar in it.

Kerry: 29:31

Even when it's supposed to be a salty snack, there could still be sugar. And the thing is, is that it's not always just called sugar, right? There's like 65 or more names for sugar. That you're, if you're not listening and educating yourself, that you're totally not aware of, and that's also, what's pretty scary. They also like to, you take the fat out of the yogurt and they throw a bunch of sugar in it. And then they say, Oh, it has a probiotic and then people buy it and they think it's healthy and it's got like 23 grams of sugar. It's just appalling.

Sarah: 30:01

yes. And a probiotic, all that means is, prebiotic, prebiotic, all that means is a fiber. So I see all these things being, yeah, the marketing, oh my gosh, the marketing that is so misleading is infuriating. And I just walked through the grocery store just shaking my head. Not to say I don't fall for some of it, but a lot of it. So prebiotics, you see things that are labeled on foods now, all that is, is fiber. You can get prebiotics by eating adequate fruits and vegetables with high fiber, but the marketing in particular, especially to children and they capitalize on any if once there started to be a little trend of what looks like that, you know, saturated fat or sugar, too much sugar is not yeah not healthy. So they started, you know, coming up with quote, reduced sugar formulas and marketing that as healthy, even though there still was tons and tons of sugar and other unhealthy things. And the misleading marketing is infuriating more than anything to me.

Kerry: 30:57

I agree. I think that without fixing the food industry, it's hard to fix the obesity problem. And I think that's kind of what this is about. But where else do you think that kind of food industry and government play a role? Is there any way out of this or what do you think?

Sarah: 31:15

So I was thinking about that, the whole my plate and, and those guys, you know, the USDA and Health and Department of Health and Human Services have the dietary guidelines. Who reads that? No one reads that other than other policy wonks. So that's, that's not what's affecting policy. It's, it's great to come up with recommendations, but people are going to eat what's put in front of them. So I really feel like changes and what More regulations and what is offered to the public is really important. But of course, people like freedom of choice. They want to be able to choose what they're eating. Just like we, you know, we stopped, apparently we're still subsidized tobacco, which is. How can we be subsidizing tobacco while we're treating all the health effects of tobacco? And it's exactly the same thing with the sugar. So there are some governmental policies that do try to limit sugar. The recommendations do say try to limit it. They don't limit it enough. There are local and state ordinances, mostly, I think there's a few city ordinances. Taxing, for instance, sugar sweetened beverages. That's a policy that's not real popular tends to work. There's evidence that that actually does. If you tax sugar sweetened beverages, whether it's soda or juices or all of the above. by the ounce, it does restrict consumption that the sales of those beverages do drop. So things like that work. Labeling menus, that sure makes a difference for me. If I go to a restaurant and the calorie counts are on the menu, I think twice. I think twice about what I'm ordering. So that's been shown to help too, but that's very localized and only certain places do that.

Kerry: 32:50

It is really nice when they put those kinds of things on the menu so people can make an educated decision. Mostly New York city is all I'm thinking of who does all this, the, these policies. I don't know what other places do, but I mean, I agree they work, but it is sticky situation with freedom of choice and everything like that.

Sarah: 33:08

Exactly, exactly. So not a lot of people are real open to the extra taxes are never popular, but those ones do work and if you can take the money gathered from those taxes and put them towards healthier programs, it helps. The other big chunk of the farm bill goes to 75 percent of it goes to nutritional assistance programs, and that's another place the government has huge influence on policy, you know, the W. I. C. Women, Infants and Children program, which helps supplement nutrition for low income women and their children SNAP, which is Supplemental Nutritional Assistance Program, same thing, providing nutritional assistance, and then there are increasingly healthy guidelines on what those programs provide, but again, they could be healthier. They can always be healthier.

Kerry: 33:53

Same thing. Like with the school lunch program, that

Sarah: 33:55

School lunches. Exactly. Same

Kerry: 33:57

that great. And even though I think Michelle Obama had tried, it's not,

Sarah: 34:01

from what I read that, you know, it got rolled back in the more recent presidential. Yes, exactly. And, and some of the progress that they made during the Obama administration really got rolled back during the Trump administration, unfortunately, and during COVID. And maybe that had some influence. Maybe it didn't, but it's time to start making progress again, instead of going backwards For sure. So what kids are eating at school, keeping advertisements out of schools, keeping sodas out of schools. And that's hard

Kerry: 34:28

soda industries I remember hearing is that they subsidize these school lunches. They have

Sarah: 34:33

that's when they're offering them money, they're bringing money in and these schools are underfunded as it is. It's probably really hard to pass that money up. lot of financial pressures there.

Kerry: 34:43

Have you seen some of, I don't know if it's social media or commercials or anything about how as these GLP one agonists have come about that the food industry Has gotten scared that they are not going to be selling as many as their highly addictive products as they were previously. Have you seen that?

Sarah: 35:02

I haven't, but that wouldn't surprise me even slightly. That's funny, but it's it's interesting. One thing that I did just read about gLP 1's a study about it, and to take it with a grain of salt, if you will. The study was sponsored by one of the pharmacy benefit managers, I forget which one, so take it with a grain of salt, it's that they had some interest in having, not paying for these drugs, because of course they're expensive drugs. They established that, I think they were looking at their patients who had been on Wegovy, prescribed Wegovy and, a very small percentage of them, not very small, less than half of them, it was more like 75 percent of them only took it for under a year, less than a year. So keeping people on it for a short term, they would lose weight and of course regain it, which is to be expected. We know that most people who take this medication for obesity, lose some weight. stop it most of the time, the way it's going to get regained, unless it's done really, really, really well. and also their conclusion was that they had no improvement in their healthcare costs during the course of that year. In fact, they had an increase in them and their costs. And I thought that was really interesting. Again, taking it with a grain of salt with who did the research, but I'm kind of not surprised because that's not the right way to use the drug, most likely to take it for short term and then stop. Of course you lose the benefits from it. If you have a chronic disease, you need to stay on the treatment for it chronically, forever. But the other thing is my impression is that there are a lot of, you know, there are only, you mentioned, this is just a growing number, but a fairly small number of physicians and other practitioners who have specifically studied obesity medicine and really are very familiar with how to use these medications. I think there are, and I've talked to a number of patients who, whose physicians have prescribed them one of these highly effective medications, but not giving them any real counseling about how to modify their diet, how to modify their behaviors, how to modify activity levels and really get the most benefit out of a weight loss program. They simply give them the medications and send them on their merry way. And, people are, As you know well, folks who are on these medications need to really concentrate on eating the right things when their appetite goes down they can't just eat, you know, they can't just eat a little bit of junk food and carbohydrates. They've got to really focus on fibers and proteins and micronutrients that are healthy. Or else they're going to lose too much muscle mass. They also really need to focus on their activity levels to maintain muscle mass. And People don't feel good if they lose a bunch of muscle mass and they're not eating well. So that's not the right way to use these medications.

Kerry: 37:30

no, yeah, no, I agree for sure. I think that it's interesting with, you know, most of the government policies for insurance are not covering any obesity medicines. Although I know there was one. I don't know, some other state that not Florida, but Medicaid was covering it, but only for a year. So here's your Wegovy because this is for obesity, not for diabetes. So here's your medicine for a year. like what you were saying with that study, they're not really proving anything because the chronic problems that may develop from having obesity are not going to necessarily be immediate if they don't have that yet. Right. So it would take years to develop and that's the idea of preventing it. But once you have your, Great time losing weight while on the medication for a year, then they rip it away and you can't get approval. And they obviously can't afford it. If they're probably using Medicaid, then their weight is going to come back. It'll be harder to lose weight in the future. You know, their metabolic rate is kind of all messed up. It's just a really. Ridiculous thing that they would allow for the prescription to be for a year, but then not like, well, then what, you know, I think it does more harm than good

Sarah: 38:40

Right. Absolutely. I agree. It's almost like a teaser. And then also not only just a teaser, but actively harmful to these people's health. So to have lost a significant amount of weight and then regain it.

Kerry: 38:50

I think another problem is that, you know, that we don't only the AMA has recognized obesity as a disease, whereas the other. Authorities, I guess, haven't, and they aren't really going to cover medications to help treat it unless, you know, they're recognizing it as a chronic disease. And I think that that's part of the limitation that not everybody has accepted it yet. There are definitely more on board than it is, but, you know, nobody's, everybody's way behind the AMA.

Sarah: 39:17

Right.

Kerry: 39:18

and I know we were talking before and I had watched that Oprah special. I haven't watched the follow up after the show, but she had discussed about like, everyone was like, it's so surprised that obesity was a disease in the show they like didn't know. And it had been 20 years since that, you know, They, the guy, the expert on there had been treating obesity for 20 years and had considered it a chronic disease and Oprah was like, where was I, you know, she was going to the same medical institution that he was working at. And she had no idea that she was struggling with the disease of obesity all of this time. And it was, it's, you know, a really sad story. And she did a great job showing you know, the blame and the shame and that's kind of what she called the show, which I think is very appropriate. And then how effective these GLP one receptor medications are for people and kind of life changing. So I think it was really good, but I think one thing that it's missing is all the stuff we talked about today, which is that the food industry, the food policy is a mess as well, I don't think they talked about the food, which is also not their fault, right? Those are the foods that they were exposed to, had access to. And we're eating and addicted to, and it's certainly not their fault. But that kind of part wasn't brought up. Now I said, I haven't watched like the after the show part, so I don't know what's coming there, but I thought that was one thing missing, but otherwise it was short, short, she probably couldn't have included all of that to make it one little 40 minute episode. So I think it was a really interesting Show and it was it was well done as well. So I would recommend everybody see it. I saw it on Hulu I think it's on ABC or something like that, too. But yeah,

Sarah: 41:05

wait to watch it. Like I said, I was hoping maybe tonight might be able to watch it tonight but but you touched on that insurance, most insurers, because obesity is not roundly accepted as a disease throughout every organization the way it ought to be and we're working on that. But that keeps insurers from wanting to pay for it. As you mentioned, Medicare pays some for the treatment but it won't pay for any anti obesity medications right now. And of course all the other private insurers follow Medicaid's lead. And one one really important act that's we've been trying to we I say we the whoever sponsoring the bill and I don't even know who it is, the, an act to get through Congress called the treatment of treatment and care of what is the name

Kerry: 41:47

I know what you're talking about But I don't know the

Sarah: 41:49

treat and reduce obesity act. I've been trying for 16 years to get that bill through Congress supported by those who recognize that obesity is a disease. It's up again this year. The point of the bill is to try to expand Medicare to cover treatment of obesity recognition of it as a, I think Medicare does recognize it as a disease, but they won't pay anything to treat it right now to expand Medicare coverage to cover anti obesity medications. As well as to expand who can treat it as well because I believe Medicare will only pay primary care physicians right now, or primary care physicians versus providers. I read that just recently to that they're trying to get to expand it so they will pay for other providers. Also, obesity specialists of different sorts. Oh shoot, if they'll just pay primary care providers, that would be a good start.

Kerry: 42:39

Yeah Yeah. Yeah.

Sarah: 42:41

If medicare will cover anti obesity medications, then the other insurers will cover it. But for Medicare to cover it would be a huge, huge increase in spending right off the bat. The whole point of it would be to cut costs downstream by treating obesity and cutting costs related to obesity. We got to do it the right way. So thank goodness. I hope that that goes through. Thank goodness. People are supporting it. Fingers crossed that goes through this year.

Kerry: 43:08

Well, I don't have a solution or anything and I don't know how to fix it, but I do think, you know, the problem really does lie within the food industry and policies around it and all the economics around it. And there's, I don't know how to fix it. I feel like it would cause a crash in the economy if we somehow had the right policy. So I don't know what to do. But I know at least. You know, everybody can educate themselves and we can educate our patients on avoiding the highly processed addictive foods. And it doesn't mean you can't have'em for like at all, but, you know, definitely reduce consumption unless someone really does identify with a true addiction to them. It might be better to just abstain. Yeah. Mm-Hmm.

Sarah: 43:50

then unfortunately, the costs of, processed foods are inexpensive and fresher, more healthy foods tend to be more expensive. That doesn't always, that doesn't always hold. There are ways to do it less expensively, but not everyone has equal access to those sorts of foods and those disparities are glaring in communities with, less money, lower socioeconomic, lower socioeconomic level communities tend to have more obesity and that's probably part of it is less access to healthier foods and the processed unhealthy stuff is what's inexpensive and that's what they can afford and sometimes you don't have a lot of choice so I get really frustrated when I hear People with bias towards those with obesity saying, well, I can, I can eat healthy. I can go to the gym. Sure you can. Yep. You've got access to a gym. You have money to do it. You have money to go to the Whole Foods and buy whatever healthy foods you want to buy. Not everyone has that. In fact, you're among a very small percentage of Americans who do have those privileges. Making the good options available to everyone is really important.

Kerry: 44:53

Definitely difficult as well. And those foods were designed for packaging convenience, time convenience, you know, pop it in a microwave, whatever it is, and then making it last longer and things like that, too. So, it's hard to, it's hard to beat that. And that's what they were, that's where they were designed, right? That and the Bliss Point, right? So, it's, it's real hard to beat that. So we've been talking a lot and you are just tell us about your practice or what's coming for you in St. Augustine. I lived there for a little bit, by the way, and it was fun. But yeah, so tell us about what you're set out to do.

Sarah: 45:31

Well, I am starting. Thank you for asking about that. Since I'm an anesthesiologist and I don't have an office or a ready made patient population, like maybe somebody who's been in either primary care or OBGYN or endocrinology, some of those kinds of folks maybe have a little bit more natural transition point to help treating people specifically for obesity. I don't have that so I'm starting with the telehealth practice because that's pretty low, low cost as far as startup and convenient, not only for me but especially for patients. you can reach me at my website at www. qualityoflifemd. com.

Kerry: 46:10

I love that.

Sarah: 46:11

because I want to help people increase their quality of life. So that's how I picked the name of the practice, which is quality of life physician weight management. I'm not going to take insurance to start with either because that's another huge ball of wax, as you know, well Taking insurance is a nightmare. So I'm starting with what we call a direct care practice which actually turns out to be pretty cost effective for a lot of people. Even paying out of pocket may turn out to be less than buying insurance. And again, many insurances don't cover. Obesity care anyway. So I'll be treating people via telehealth. I will, you know, they can use their insurance for medications and for lab work. Just paying me that way. I will be focusing on not medications, even though we've talked a lot about medications, there's way more to treating obesity. Focusing on a goal, focusing on a health goal is probably the most important thing. Having a why, why do you want to get healthier How can we help you get there? What is your goal to get off of medications? Is it to be able to move more easily so you can travel or play with your grandkids? What's going to increase your quality of life? Do you want to live longer? You want to decrease your health risks from things like cancer or heart disease? Focusing on those goals and the four pillars of obesity treatment are going to be what I work with. So not only the nutrition, helping people improve their nutrition a little step at a time, they're not going to go on a rigid, strict diet right off the bat. We're going to work together to figure out how do we, eliminate the unhealthy things or at least cut way back on them, not eliminate them and start replacing them with healthier, healthier habits. Activity, helping folks change their activity levels gradually and finding the activity that's fun and sustainable. So there's your life, lifetime habits, identifying people who are using food maybe for unhealthy reasons. I'm one of them. I do it sometimes, emotional eating. There's a high portion of people, proportion of people who struggle with obesity who have eating disorders. And I'm certainly not a psychiatrist and not, that will not be my area of expertise, but I can help. people identify if that's something they're struggling with and try to help them find treatment for that, appropriate treatment for that. And then medications, when it's appropriate. So not only going over the medications they're already on and perhaps identifying if there are medications that are contributing to weight gain or other conditions like sleep apnea, not only does sleep apnea result from obesity that can also lead to weight gain. So treating conditions like that that are linked to obesity digress there. Medication management when it's appropriate. Prescribing, prescribing the appropriate anti obesity medications. We've mostly talked about the GLP ones, but there are a number of other medications out there. They're very expensive if your insurance does not cover them. So there are, are, are alternatives that work well, if maybe not quite as well as those. But, that's part of coming up with a personalized plan for every patient is what's the right fit.

Kerry: 49:05

Yeah, I definitely, you know, agree with your approach as I do something similar. My favorite thing is definitely de prescribing or getting people off of their medications. Yeah. So,

Sarah: 49:14

low hanging fruit, right?

Kerry: 49:15

yeah. So one thing I want to just tell the listeners is that one of the, I had a couple of books to recommend reading if they wanted to, you know, learn about some of this stuff. And one is Michael Moss's Salt, Sugar, Fat. If anybody wants to read that, he's the one that really Goes into the food engineering companies and discusses what has been done, what have been researched, what they did and how they defined and create that bliss point. And then another one would be fat chance by Robert Lustig. He really goes into the historical perspective of that as well. It's an excellent book as, and I would recommend that too. Is there anything you can think of on that regard.

Sarah: 49:56

Well, I was just working on the salt, sugar, fat that you recommended, and that was, that's, I'm not quite all the way through it yet, but wow, it's been, it's really fascinating.

Kerry: 50:05

I'll throw out. I'm reading glucose revolution right now by I forget her real name, but she goes by the glucose goddess. And while that's not really on this topic today I think it's a great read and definitely easy for anybody to read and really just talks about balancing blood sugars. And everybody, I think every book I read lately is always talking about how the Recommendations of eating too many carbohydrates in the past has been a problem with the low fat craze. So I think she begins her booklet a little bit with like that too, but what were you going to say?

Sarah: 50:36

I have not read a lot of books on these. I do a lot of podcasts and I read a lot of things online, but I can't think of any books that I've, I've read.

Kerry: 50:43

Okay, well so we want to include all your information and the show notes but Dr. Bowden, thank you so much for coming on the podcast. It's a pleasure to meet you virtually. And I know you're going to have a great successful practice. So if everybody wants to reach out to Dr. Bowden for any help, she's local in St. Augustine, but definitely can see people via telemedicine in Florida. And I also do obesity medicine and family medicine and allergy and asthma. If anybody wants to reach out to us at Clearwater Family Medicine and Allergy. thank you for coming on today and listening to us everybody. Tune in next week.