Why We Hate Keto

Episode 32 of The Pound of Cure Weight Loss Podcast is titled, Why We Hate Keto. We cover a lot of material in this episode, including Pharmacy Benefit Managers, over-the-counter supplements for weight loss, Keto and the Lion diet, Glp-1’s, and avocado oil, just to name a few.

In our In the News segment, we dive into an article from The New York Times titled, The Opaque Industry Secretly Inflating Prices for Prescription Drugs. As the title suggests, there are behind-the-scene shenanigans going on that needlessly and greedily add to the cost of prescription drugs. It’s an intricate, and unfortunately, legal method of stealing money to the tune of billions of dollars a year. But there is something you can do to stop it. Tune in to find out what that is!

In our Patient Story, we talk to Laura who came to us from Phoenix. Laura gained weight later in life and struggled with the idea of surgery. It wasn’t until she retired and her plans to travel became more difficult, (due to the extra weight) that she really considered having bariatric surgery. After meeting with me she went ahead with a gastric bypass and lost 80 pounds in 10 months! 

In our Nutrition segment we explain why we hate Keto. You might think that Keto is a relatively new diet but it’s actually over 150 years old and intended to help treat patients with epilepsy. And, while Keto may actually help you lose weight, it wreaks havoc on your cardiovascular system causing poorer health. 

In our Economics of Obesity segment, we talk about over-the-counter weight loss supplements. We cover Chromium Picolinate, Berberine, Metformin, Inulin, Alli, and Hydroxycut. Do they actually work? We lay it all out for you!
 
Finally, we answer 3 of our listeners questions including, when to start GLP-1’s after a sleeve, our thoughts on avocado oil, and what we think about the Lion diet. Tune in for a deep-dive into the science behind many famous and infamous weight loss practices.

Transcript

Zoe: 0:17

Anybody who has done keto or who's known someone who's done keto. It only lasts for so long. You can only do it for like a couple months, because inevitably you want to eat a freaking banana, I don't know. Welcome back everyone. Here we are again with the Pound of Cure. Weight Loss Podcast, episode 32, why we Hate Keto.

Dr. Weiner: 0:42

Yeah, I've always kind of hated keto as a diet for mutations yeah, but we'll find out why a little bit later. I guess.

Zoe: 0:48

Yeah, we'll talk about it.

Dr. Weiner: 0:50

So, zoe, have you seen the South Park episode, the End of Obesity, the one on Ozempic?

Zoe: 0:55

You know I wanted to so badly. I went on YouTube and watched a bunch of different clips and so I've kind of pieced all together the funniest parts.

Dr. Weiner: 1:04

First of all, it was hysterical. I mean really laugh out loud, funny. I think it's on Paramount Plus. I want to say, but yeah, if you can access that, if you have Paramount Plus, or even if you like, do a trial or something. My kids are always doing a trial. It's like every time I turn around we get a new seven-day trial. But anyway, maybe there's a trial, you can get it and it is absolutely worth the watch. It is hysterical. The humor is so biting but also so accurate. I feel like they hit on everything, like the insurance industry and just the craziness of navigating the American health care system.

Dr. Weiner: 1:44

So in the episode there's one of the characters, cartman, who suffers from obesity, is trying to get on Ozempic and it really does a great job of kind of showing like how important it is and how much he's struggling. His motives are not necessarily that great, but you'll see that in the episode, but it hits on that. There's this whole. All the moms are doing it to lose 10 pounds and the shortages it hits on the compounding pharmacies. I mean all of it is really Big food, yeah, big food, right In the end, like Tony the Tiger's chasing after them. I mean it really is a riot. Definitely worth a watch and, I think, funny. But also some great commentary in there about our society and how all those epics affected us.

Zoe: 2:25

I like how they brought back the Oprah special too.

Dr. Weiner: 2:28

Yeah.

Zoe: 2:28

Like Oprah said so.

Dr. Weiner: 2:29

Yes, yeah, they referenced Oprah. All right, well, let's move into our In the News segment. So our article today is from the New York Times and it's titled the Opaque Industry Secretly Inflating Prices for Prescription Drugs and it talks about pharmacy benefit managers. We actually covered this in episode 10, and they hit on a lot of the things that we talked about in the past. But for those people who didn't catch episode 10 or have some questions about pharmacy benefit managers, this is, first of all, it's a group. Most people don't even know that they exist. But you really should, because they have a huge influence over your healthcare spending. But they're middlemen and they go back like to the 60s, and their job is to navigate between employers, insurance companies and the pharma industry to come up with the best and lowest prices. Insurance companies and the pharma industry to come up with the best and lowest prices. And the problem is that the PBMs are serving their own self-interest, not the interest of the employers, who are largely footing the bill for healthcare, or, of course, the people, the patients, who are the ones receiving the healthcare. So the New York Times, they interviewed like 300 people. They interviewed people who used to work for PBMs pharmacists, physicians, insurance company execs, employer HR people. This was a big investigative article that they put together and really, what they found is that PBMs act in their own self-interest and not yours, but they're given the responsibility of serving in our best interest.

Dr. Weiner: 4:04

Now there's three big PBMs out there, and they happen to be owned, of course, by the large insurance companies. So there's Caremark, which is owned by CVS and Aetna, and just Caremark alone, and just Caremark alone, which is the largest PBM, for revenue, makes more money annually than Ford yeah, a massive company and yet they're actually just a subsidiary of CVS and Aetna, so they're not even the biggest company. They're owned by a larger company. Optima RX is owned by UnitedHealth and Express Scripts is owned by Cigna, and about 200 million Americans have healthcare decisions made by one of these three PBMs, so 80% of all prescriptions are going to go through one of these PBMs. And, starting in 2018, there's been all these mergers and acquisitions that have brought all these companies and made them gigantic entities, and essentially, they cause harm in really three ways, and this is what the New York Times pointed out. The first is that they steer patients toward more expensive drugs if they're more profitable for the PBM.

Zoe: 5:14

It's so sick.

Dr. Weiner: 5:15

I know, I know, and we keep acting surprised and outraged. But we really should just understand. This is our healthcare system. And our healthcare system right now is designed by the large companies that run at the insurance companies, and all of the rules and all of the things that are in place are designed to maximize their quarterly earnings, because they're all quarterly traded companies, uh, and their ceos get, you know, 100 million dollar salaries.

Dr. Weiner: 5:41

And so what happens is that a lot of times we go to the pharmacy and say, oh, you can't get this drug, you have to get this one. As a physician, I get these all the time I write a prescription I get in a little alert oh, don't write this drug, write this one instead, because this one is on the patient's formulary. So what happens is that the PBMs say here's the formula, here's the drugs we'll cover, and if it's not on the formulary, you got to get special permission, also known as we're never going to cover it, don't even try, but technically you can apply, but they never approve it. And so what happens is the doctors are kind of steered toward these prescriptions based on, and it all feeds in through the computer system. And so they talked about a patient who was prescribed a drug that cost $211 for their allergy drug when there was a very suitable equivalent alternative that was $22 at Costco. And so just because a drug's on the formulary it doesn't mean that it's there because it saves the patient money. It's likely there because the PBMs don't get more profit from that drug versus other alternative drugs, expensive drugs and often cancer drugs, because cancer drugs are kind of giving this oh it's cancer, like we got to pay for it. Oh my God, we'll do whatever it takes because cancer is such a terrible disease. And of course cancer is a terrible disease but that also makes it a real target for exploitation and driving a lot of profit out of it.

Dr. Weiner: 7:14

So there's a man in Oklahoma and the whole story of how this was discovered is kind of funny. So he has a. Most likely they didn't go into details, they said he has a GI cancer. But he was prescribed Everolimus, which is a chemotherapy agent which is used for a number of different tumors, one of which is a pancreatic neuroendocrine tumor. But anyway, so literally the dog ate his medication. So he had a package. He gets the package delivered every month. The dog ate. His neighbor dog ate the medication. So he had a package. He gets the package delivered every month.

Dr. Weiner: 7:44

His neighbor dog ate the medication and so he was like I want to get my medication, I don't want to die of this tumor. So the insurance company wouldn't give him a refill. They said, sorry, it's just like the teachers the dog ate your homework. It's not going to fly Apparently with insurance companies. The dog ate your package. It's not going to work either. So he went to.

Dr. Weiner: 8:03

He started shopping around, went to the the his, went back to them and said can I pay for it? They said it's 138 000 a year. Right, so by month that's a little over ten thousand dollars a month. Uh, and so he went to a local pharmacy and the pharmacist was like hey, you can get this drug wholesale for $14,000 for a year, so a little over $1,000. So he bought it from his local pharmacy.

Dr. Weiner: 8:30

Meanwhile, guess who's footing the bill for $138,000 a year? The state of Oklahoma, taxpayers of Oklahoma. And because most large insurance companies are self-funded, which essentially means you pay for the health care you need, so the state of Oklahoma is being charged $138,000 for a medication that you can get wholesale for $14,000. And so they're charging these steep markups on these drugs and, of course, where does the profit go? It goes to the PBM, and the last thing that they do is they charge billions of dollars in hidden fees. So the New York Times estimated in 2022, pbms charged $7.6 billion in hidden fees, and so we talked about this in the past.

Dr. Weiner: 9:19

There was this rebate system. So again it gets back to the, and we all know this. Like anytime, someone's like, hey, this costs a hundred dollars, but for you only 20,. It's like, oh, that's, that's too much. That's something sketchy about the, but it was never a hundred if it costs 20. Now that's just not realistic. So that's what was happening the drugs $15,000 a year, but hey, you get a rebate for $10,000.

Dr. Weiner: 9:45

But what was happening is that PBMs were charging the employer the $15,000 and then keeping the rebate. So that got exposed, and so there was all this legislation and a lot of that's largely illegal now, if not illegal, it's very targeted. The employers are onto it, but PBMs are smart. So they said what we're going to do is we're going to create these other companies called GPOs group purchasing organizations and we're going to negotiate that $15,000 down to $10,000. But we're going to charge you $10,000 for it, but we're going to charge you a $2,000 fee for that negotiation. So they just converted this rebate that they were taking into a fee. Fees are legal Keeping the rebate that they were taking into a fee Fees are legal, keeping the rebate is not, and so they just kind of changed it, but they still charge the same amount. And there's all these companies, and a lot of them are overseas, which means they're not paying US taxes, which is another issue. And so $7.6 billion, that's what was charged in just fees for negotiating drugs, and so I think you know what's the answer to this.

Dr. Weiner: 10:47

I don't know what the answer to this is. I'm not, you know, I'm not a politician, but I do think it does come back to the government. I think the government right now is the only organization that is powerful enough to take on these insurance companies. Unitedhealthcare is the ninth largest company on the planet, and so you know, really, where this probably is going to come out is in the local elections and as much as there's so much, you know, craziness around our national elections, but our local elections tend to make much more sense and, honestly, most likely have much more honest people running tend to make much more sense and, honestly, most likely have much more honest people running, and so I urge all of you to really look carefully at your local elections and see and make sure that you understand where people stand on these items. Who's willing to take on the insurance companies?

Zoe: 11:37

All right, now it's time for our patient story of the day. We'd like to welcome Laura. All right, now it's time for our patient story of the day.

Dr. Weiner: 11:42

We'd like to welcome Laura. Yes, laura comes to us from Phoenix. Very successful gastric bypass patient really dialed in on nutrition and lifestyle changes. What I love about Laura and you'll hear more from her is that she's a postmenopausal woman who's built some muscle, and that's something that some people say can't be done, but I think Laura's proof that that is not true.

Zoe: 12:01

Yeah, Welcome Laura. Awesome. Well, Laura, thank you so much for being here with us today. We're super excited to chat with you.

Laura: 12:10

I'm excited too. It's good to catch up yeah.

Dr. Weiner: 12:14

Laura, tell us a little bit about your story. We did your surgery how long ago?

Laura: 12:29

What was your starting weight? Just kind of walk us through some of the decision making that came to bring you to us in the first place. Okay, I had my surgery on August 30th of 2023. And on that day I weighed 206, but my high weight was 217. And long before I ever met you, Dr Weiner, I had had two other general practitioners just suggest along the way that I should consider bariatric surgery. I had not been overweight my whole life. It really had happened since just a little bit before menopause began and I'm 61 right now and I just was not ready to consider that when that was suggested to me. But in the time between those suggestions and when I met you, I retired and I had a lot.

Laura: 13:24

One of my goals with retirement was to make my health a priority and the other goal was to travel as much as possible. And travel was becoming not impossible, but more difficult than it had been. You know I didn't need to use a seatbelt extender or anything, but it was just harder to carry luggage and I was having a harder time sleeping. I got diagnosed with sleep apnea and my life, you know, the retirement was not presenting in the picture that I had always dreamed it would be, and it was because of my weight. And so I, you know, looked into.

Laura: 14:08

I had dieted throughout my whole life. I've done every kind of diet. I had been successful at losing weight before, but I was really struggling this time and so I began to be more open to the idea of bariatric surgery. And then I found you and it made sense for me to work with you because of your private practice. So now it's 10 months later and I've lost 80 pounds. I don't think I'm done losing weight, but it'll be very, probably very, minimal. I think more it'll be changing body fat into muscle at this point, so I don't expect that the dress size that I wear will change very much.

Zoe: 14:55

May I interject?

Laura: 14:57

Please Sure.

Zoe: 14:58

I maybe don't expect the scale to move as much as you're used to, but the dress sizes. The more you change your body composition, the more that you build muscle, your body fat can definitely continue to go down, which means that dress size will certainly change as well.

Laura: 15:16

It's kind of funny because, although the weight loss has flown down, I will see friends that maybe you know like I'll see them every two weeks and even though my weight has maybe only changed one pound, they will just be astounded at how much thinner I look in two weeks.

Laura: 15:39

And I'm always surprised by that because to me you know that I don't see that change over that time and in fact I have to stop and think to myself have have I actually lost any pounds? I am not sure if I have in two weeks, but yeah, so that is happening. And strength training I was telling Zoe that I was not a fan of strength training in the beginning. I thought it was boring and I had done a lot of cardio exercise throughout my adult life, but I never stayed with strength training long enough to see results, stayed with strength training long enough to see results. And then Zoe encouraged me and I I stayed with it for six weeks and I began to see results. And so, and then I began to set some goals that it caused me to even increase the amount of strength training, not not the necessarily the amount of weight, but instead of just doing strength training for my arms, I added legs, I added core, so that actually has become a part of my life now.

Zoe: 16:50

Do you want to tell?

Laura: 16:51

us what those goals are. Yeah, so I always have been very interested in travel, but now that travel is much easier. In January, I am going to antarctica and peru, so I'll be kayaking in the antarctic ocean and and hiking around with the penguins, and then I'll be um climbing machu picchu and rainbow mountain in in Peru at altitude oh cool.

Dr. Weiner: 17:22

Dream trip.

Laura: 17:24

Yeah, it's exciting, but that takes training.

Dr. Weiner: 17:29

The coolest thing about that is that you're mixing travel and this great retirement that you always dreamed of with that physical fitness.

Laura: 18:30

Exactly and with setting health as a priority was the other goal.

Dr. Weiner: 18:36

My guess is, when you weigh 200 pounds, you never even thought about Machu Picchu.

Laura: 18:42

I thought about it. I will tell you I had a conversation with. Well, I will tell you that when I weighed 200 pounds, I walked the Camino through Europe and I walked 200 miles in 12 days. But it was difficult. And along the way on that walk I met a man who had done Machu Picchu and he wasn't a small man and I remember thinking. I asked him very specifically about his training and I remember thinking, boy, I bet that would have been easier for you if you had lost weight. And then I looked down at myself and I thought you know what this would be, this current hike that I'm on would be easier if I lost weight. And that I will say when I tell you that you know I was struggling and then opened my mind to bariatric surgery. That moment in time on that hike was one of the turning points for me where I I thought you know, I really have to be open to another way of conquering this problem in my life.

Zoe: 19:51

With you saying, you know, you didn't really enjoy strength training so much it was boring until you started seeing results and then it was like, oh, this is maybe a little bit, you know, more fun. It's a little bit more motivating and it does. It takes that consistency that you were able to put in and that time, um, which is a period of time that you don't necessarily see physical changes right off the bat. But in my experience that those first several weeks you experienced that internal change of feeling better, energy levels, sleeping better, all of that sort of stuff. So did you notice any, you know, non-body related results in those first couple of weeks that maybe propelled you to stick with?

Laura: 20:36

it I did. I mean, I could tell I was getting well, I could tell I was getting stronger because I could do more reps or more sets or a heavier weight. And so, even though you know I didn't see results, I was keeping track of that. I love data, so I keep track of a lot of things and that actually spurred me on. You know, I thought to myself well, you know, my arms to me still look the same, but I have increased my weight by 10 pounds, by by 15 pounds, in just you know, maybe three weeks. Remember I started very light. I did not want to be sore and so initially it was. It was that I also, throughout this whole journey, have taken my measurements and I noticed that my measurements were getting smaller. I started with just arms and I noticed my arms were getting smaller, even though I really did not notice muscle tone until really, I would say it was around the six-week mark.

Dr. Weiner: 21:46

I think that there's a couple of things that I think are really awesome about your story, laura, two in particular. The first is the timing of your surgery, which is right at the beginning of your retirement. And I've done that. You know, I've seen a lot of people come to me and with that exact same story it's like, hey, I'm retired, I worked my butt off for decades, I finally have an opportunity to really enjoy things, but I've neglected my health because we work so hard in this country and now I don't have the health I need to be able to enjoy that retirement. And bariatric surgery is kind of this like boom, you get your health back really quickly. And I love that that was your story, because to me that's like it makes so much sense and I love that. You know medicine has the ability to do that Like it's obviously not ideal. It's much better if you maintain your health throughout your entire life, but if you kind of fall and get into that point where you're like oh my God, what am I going to do?

Dr. Weiner: 22:44

I can't you know how am I going to enjoy my retirement? I worked so hard. Now I can't enjoy it because my health's terrible. But boom surgery and we can get you there. And retirement age sixties it's not too old for even a gastric bypass.

Laura: 22:58

It is not.

Dr. Weiner: 22:59

Yeah, and you got through it pretty easy right. It wasn't a rough surgery in any way.

Laura: 23:03

No, no, I didn't have any side effects. I uh even, you know, as I added back foods, you know, things went really really very smoothly.

Dr. Weiner: 23:15

I think the second thing that I really love is that you're you're really um debunking the myth that post-menopausal women can't gain muscle and shouldn't strength train.

Laura: 23:29

Oh, is that a thing? Thank God, nobody ever told me that.

Dr. Weiner: 23:34

It's certainly out there that a lot of postmenopausal women look at strength training and it's like, ah, you know, can I even do that? Is that even for someone like me? And it's probably the most important for you? For osteoporosis reasons, exactly, and muscle is the fountain of youth. The more muscle you have, the healthier you are metabolically, the easier it is for you to maintain your weight. So I really another part of your story that I really love is how you've just embraced the strength training as a post-menopausal aged woman. That's really to me, that's great. That's exactly the right thing to do, and been able to do it. After all this weight loss too, which is another thing. It's oh bypass. You lose so much muscle, but actually you probably lose more muscle from starvation diets than you do from bariatric surgery.

Laura: 24:21

I would agree with that. Yeah, I would agree with that.

Laura: 24:25

Yeah, I will say one thing that helped me is I invest and it's not even a big investment anymore into one of these scales that tells you your body fat, your muscle mass, your visceral fat, all the types of fat. But you know, initially I just used it to watch my weight loss, but now where I am working more on converting body fat to muscle, it's an extremely useful tool to watch that convert. It does take time, but you know, it provides you feedback so that you know that you're doing the right thing.

Zoe: 25:07

Well, your big trip is in January and we are so excited to see pictures from that and to get an update. We might have to have you back on and tell us all about your trip.

Laura: 25:19

Well, I would love to.

Dr. Weiner: 25:20

Fantastic. So good to hear from you, Laura. Congrats on your success. I love everything you're doing and it sounds to me like you're off to a great start with your retirement.

Laura: 25:31

Well, I feel like I am. Thank you very much. Thank you for helping me with it.

Zoe: 25:36

Okay, I just love Laura's story and I also really love how she's in Phoenix. She came down to have you do her surgery and that's a really real possibility for so many people who might be considering surgery and wanting to have you do their surgery.

Dr. Weiner: 25:54

Yeah, I mean we're happy we have quite a few people coming down from Phoenix. It's not that far. And the truth is, I think our complication they don't rank them, but knowing the numbers, I think our complication rate's got to be the lowest in the state for these procedures. And so in our nutrition program, there's no question it's the best in the state. So, yeah, if you're in Phoenix Come on down. Yeah, come on down, we can do probably 95% of your stuff through telemedicine. All right, zoe, let's move into the nutrition segment. What do you got for us?

Zoe: 26:24

Well inspired the title of the episode today, why we Hate Keto. Listen, keto had its moment and keto has also gotten plenty of heat from myself and you and Deidre, Deidre's like make sure you talk about keto.

Zoe: 26:45

So we are here to kind of talk about what keto is right and why it became so popular and why we don't like, why we hate it. I really hate the word hate, but I'm going to say I hate keto Go for it. So, yeah, let's talk about keto, the ketogenic diet. I'm sure you know this, but was originally made for children with epilepsy.

Dr. Weiner: 27:08

Huh, I didn't know that.

Zoe: 27:10

Yeah, so basically the diet itself was made to put children in ketosis so that it changed the energy pathway for their brain to help decrease the seizures that they were experiencing. Works? Great for that. Okay, decrease the seizures that they were experiencing.

Dr. Weiner: 27:25

Works great for that Okay.

Zoe: 27:27

But I think I'm not too sure how it became popularized in diet culture, but it goes way back.

Dr. Weiner: 27:33

It's like 150 years old oh yeah, I think they call it Banting diet or something.

Zoe: 27:37

Oh really.

Dr. Weiner: 27:37

Yeah, it was first described like in the 1800s. Oh, I had no idea. Yeah, yeah, no, it goes way back.

Zoe: 27:42

I thought it was just like a kind of a more extreme step from Atkins, kind of thing.

Dr. Weiner: 27:47

Yeah.

Zoe: 27:48

But anyway. So basically, the ketogenic diet, as it has been taken on by people trying to lose weight, is a mostly fat diet to change your energy pathway from using carbohydrates and glucose as your main source of energy to the ketones, and so by having basically 70% of your total energy intake, total calories that you're eating, to come from fat Wow, where, just for like reference, normal range is usually between 25 and 35% of your total calories coming from fat. So I'm sure you're listening. You're like oh yeah, I know keto and it's because keto eliminates carbs. But what do you get to eat? You get to eat bacon and you get to eat cheese and you get to put butter in your coffee and it's healthy. Oh, but, dr Weiner, it's healthy, right? A cardiologist's worst nightmare.

Dr. Weiner: 28:51

Right Animal fat.

Zoe: 28:53

Yeah, because you know I mean on top. Well, I'm getting sidetracked, so let me stay on track. So the reason why people see fast that's the key word there fast weight loss while being on the keto diet is because most of that initial weight loss that they see is water weight loss, because carbohydrates one gram of carbohydrates stored in your muscles in the form of glycogen is basically attached to three grams of water. So when you stop eating carbohydrates, your body then has to tap into that stored carbohydrates, muscle glycogen, and then that is used up for energy and then that extra water is also used up and whooshed away. Seeing that fast weight loss. So most of it's water weight loss right, but then you know maybe you're in a caloric deficit or you know you're extreme, you're cutting out a bunch of you know maybe processed carbohydrates, et cetera. So people see weight loss.

Zoe: 29:54

However, anybody who has done keto or who's known someone who's done keto, it only lasts for so long. You can only do it for like a couple months because inevitably you want to eat a freaking banana I don't know or have a piece of cake on your birthday maybe, or yeah, I don't know have fruit with your breakfast, and so it's just not sustainable. Our whole philosophy is creating that sustainable, durable, life long weight loss, and this is the keto and any other extreme fad diets that are out there that I know so many of our patients have tried, myself included back in the day. It just does not work in the long term and so that's why I hate keto and what I mentioned before about your blood work, your triglycerides, your cholesterol. Your health is not improving. The whole point of decreasing your weight is to improve your health.

Dr. Weiner: 30:57

Right.

Zoe: 30:58

Right, so anyway, it is tiring up there on that soapbox. Do you have anything to add?

Dr. Weiner: 31:07

You know, I certainly share the lack of enthusiasm for keto. It's been around a while and it does work a little bit, and I think the idea that you can somehow eat bacon, eat burgers, eat all this stuff and still lose weight is such an enticing idea. I mean, we're all kind of dreaming of that and we see this really with almost every weight loss style, right when we're talking about nutrition, the keto diet, which lets you eat a lot of garbagey delicious food and still lose weight Sign me up, right? People look at GLP-1 meds and say, oh, it's the med where I can still eat what I want and lose weight. Bariatric surgery oh, I can have the surgery and then eat what I want.

Dr. Weiner: 31:49

And the truth is it's not true, not with any of these methods, and it's never going to be true, and we have to wrap our mind around that, that it really is. There's one clear, clean path, and that's fruits, vegetables, nuts, seeds, beans and this is going back to the stuff our grandmother would have told us to eat, right, and that's just. That's what good nutrition is. We've known it for a long time. It's not new, it's not sexy, it's not cool, it doesn't allow you all these indulgences and still finding the success. But it is sustainable and it is the way that actually works. And in fact what you find is that if you do something that kind of gives you the short-term weight loss but then you bounce back and gain more, it's much more painful and uncomfortable than if you just go kind of the less exciting pathway that is kind of more measured and stepwise in fashion. That's what works over the long run.

Zoe: 32:45

And also it might feel like, oh, this is taking longer, this is the long way to do it, but in reality it's the shortcut, because you're not spending years on, a couple months on this diet and then getting the weight back, and then going to this diet and then getting the weight back, and so it's like years and years and years versus okay, maybe this takes a year or really dialing in your nutrition for the long run. You know, habit formation and doing it the right way is not exciting and sexy, like you said, but it's what's going to save you frustration, it's going to save you time and and ultimately get you the best success.

Dr. Weiner: 33:24

Yeah, okay, so let's move into our economics of obesity segment. I'm going to play a little bit on the South Park episode. In the South Park episode, when Cartman couldn't get Ozempic because it wasn't covered by his insurance, he was given a prescription for Lizzo, and he was supposed to listen to Lizzo because it had a lot of body positivity and it made him not feel so bad about being overweight. And so I'm going to talk a little bit about some of these Lizzo-like drugs that we currently have out there that are actually available. They're not named Lizzo.

Dr. Weiner: 34:00

So the first is chromium, and so chromium has become pretty talked about now because it's the active ingredient in Lemmy Curb. Have you heard of Lemmy Curb? I have, yes, so Lemmy Curb is put out by the Kardashians, brilliantly marketed. But chromium is, first of all, lemmy Curb is about $40 a month. Chromium is maybe $10 or $15 a month if you buy it just as a supplement, but it's not in a purple bottle, but it's not in a purple bottle. It's not in a purple bottle, no, it's not, and it doesn't come with all the other extracts that they mix in there too.

Dr. Weiner: 34:34

But anyway, so chromium there was a study in the 90s that showed a substantial improvement in your A1c and a little bit of weight loss. Nobody's ever been able to repeat that study and most people acknowledge that chromium just doesn't have much of a weight loss effect a pound or two at the most. But it may have a little bit of effect on improving your blood sugar metabolism. But it really is a fairly inactive ingredient and pretty ineffective, and so I don't advocate the use of chromium for weight loss or even for blood sugar control. I think in my mind, if we're going to be focusing on using a medication, we want it to have some effect, because otherwise it just distracts us from making the nutritional changes and the exercise and lifestyle changes that are actually effective.

Zoe: 35:27

You can't out-supplement a bad diet.

Dr. Weiner: 35:29

You cannot out-supplement a bad diet. Absolutely Well said, zoe. So the next is berberine. We've covered this in the past, and berberine kind of works similarly to metformin, which is a diabetes drug, in that it does change your gut microbiome a little bit. There's some improvement in your lipid levels, there's a slight improvement in your A1C. It's definitely a little more effective than chromium, but there's very little changes in your weight, and so I think berberine is kind of a metabolic supplement to help with metabolic syndrome, lipids and sugar issues. It's helpful, but you're not going to lose a lot of weight for it, and then again you got to take it lifelong, and so taking a supplement for a very modest effect is probably not worth it, but it's a safe thing. So for 15, 25 bucks a month you can take berberine.

Zoe: 36:19

But it's not going to all of a sudden be this magic pill for you to lose a bunch of weight.

Dr. Weiner: 36:24

And that's really the problem with all of these is that is that, and that's why there's so much excitement over GLP-1s is because where GLP-1s they work and when they work, they can work amazingly well. All of these drugs, if they work, they work a little bit, and so metformin is not an over-the-counter medication, over-the-counter supplement, but it is. First of all, it's pretty much every doctor will prescribe metformin because we've been using it for so long and we know it's safety and it's dirt cheap. It's the cheapest option here. You can get metformin for five bucks a month, and so metformin also has shown.

Dr. Weiner: 37:00

You know, we've seen in that there's a small group of people who will lose up to 10% of their total body weight from metformin. Typically you got to ramp the dose up pretty high. Starting dose of metformin is 500 milligrams. We're talking 1,500 or 2,000 milligrams a day and that causes a lot of GI side effects and GI upset and that may be actually what's driving some of the weight loss, which, again, is not a favorable way to lose weight. But metformin also of all the things we're going to talk about, metformin is probably the one with the most evidence that it does drive some weight loss. What I like metformin for is to prevent weight gain, and so, especially if you're stopping a GLP-1 for a shortage reason, taking some metformin to kind of slow that weight gain down, to bridge you to the time you can get your prescription back or anything else, it can be helpful.

Zoe: 37:53

Could that potentially be an option for somebody who is maybe starting a mental health medication that might have the side effects of weight gain?

Dr. Weiner: 38:02

It might be. I don't know if there's any evidence to support it. It's a good thought for sure. But my experience with metformin is it slows the weight gain down a little bit, but that does not necessarily prevent it. Where I've seen it mostly, I used to use it pretty extensively in my sleeve patients who would gain some weight back. Another thing that we see is inulin. Inulin is essentially a soluble fiber. You buy it in a big pouch and it's kind of like a Metamucil type thing. There's some studies that show that weight loss when it's combined with nutritional counseling. But of course, was it the nutritional counseling or was it the inulin?

Zoe: 38:38

Yeah, or was it the increase of fruits and vegetables that the nutrition counseling? May have recommended to increase their fiber intake.

Dr. Weiner: 38:45

Yeah, there is some suggestion that inulin helps with weight loss plateaus. So if you're kind of plateaued and you want to try to get over that plateau, maybe adding some inulin. And again, it's cheap 10 or 20 bucks a month and it's certainly it's fiber, it's a harmless, safe supplement and that's actually what they put in poppy, and so the claim was that poppy had all these positive effects and they were really kind of leveraging what we see with inulin, but, as the class action lawsuit stated, they really wasn't much inulin in it at all. Another over-the-counter medication is Alli, and this one is it's more expensive it's about 50 bucks a month and it blocks lipase.

Dr. Weiner: 39:28

Lipase is an enzyme that breaks down fat, and so you don't break down fat, which means you don't absorb it, which basically turns fat into essentially Miralax or a bowel prep, right, and one of the side effects of Ally I think they call it anal leakage, which is a very it's probably the nicest way you can put what I think all of us now, what's coming to all of our minds right now, and that's because it just is high-volume diarrhea and it can result in incontinence, and so I think that's a drug that has not taken off for obvious reasons.

Zoe: 40:07

I can visualize their branding in my mind.

Dr. Weiner: 40:11

Interesting. In South Park, the Lizzo caused diarrhea to come out your ears. I think that was a little bit of a play on Ally. Then there's also Hydroxycut, which is about $20 a month, which is essentially just vitamins and apple cider vinegar and a bunch of just stuff that sounds like it would work but doesn't really. There's absolutely no evidence that it causes weight loss, but there actually is. There have been a few reports of acute liver failure, so I think I would recommend avoiding hydroxycut at all costs. In my mind, I think if we're looking at this list, metformin is going to be the most effective of them. Hydroxycut is the most dangerous and the one that I would avoid at all costs.

Dr. Weiner: 40:57

And really what we're seeing here is the placebo effect for sale for most of these products. The placebo effect it works. It's a real thing. If you take a pill and you think it's going to work, you tend to have a favorable opinion of it. You might even lose a few pounds or have some some of the outcome that you think will happen. That, to me, is I think it's a topic for another, for another day but the idea that your brain can somehow trigger some of these things just by believing in it. There's something there. Can you leverage that some other way besides taking a supplement? And I think the answer to that is yes, but maybe we'll talk about that later. Yeah, All right, so let's move on into our social media questions.

Zoe: 41:39

Sierra, what do you have for us today?

Sierra: 41:43

First question is from Facebook. This is from Monica. How long after a sleeve do you suggest starting a GLP-1 medication?

Dr. Weiner: 41:51

So that's a tricky question because there's a lot of elements to this. So, first of all, if you've been listening to the podcast, I think we talk a lot about weight regain, particularly after a sleeve gastrectomy, and the importance of using GLP-1 medications in conjunction with sleeve gastrectomy. And so the big question is, when do you start? Because we don't want to start people on it like at a week after surgery, because you're just trying to get your fluid in, your protein in. We don't want to be giving a medication that somehow slows down your ability to eat. And so there's some debate and there certainly isn't any widely acknowledged right answer. My general philosophy is, once eating is comfortable and you're meeting your fluid and protein requirements without much difficulty, that we can start that.

Dr. Weiner: 42:37

Now there's a little caveat to that, and that's that we can tell within a month or two how much weight someone's going to lose after surgery. So the idea that there's kind of this tortoise in the hair, where maybe the hair comes off and loses a lot of weight up front, but it's the tortoise who loses the most weight, that's probably not true when it comes to bariatric surgery, that if you lose a lot of weight in the first month or two chances are you're going to end up losing more weight than someone who loses a small amount of weight in the first few months, losing more weight than someone who loses a small amount of weight in the first few months. And so if you, in the first few months, are just doing amazingly well, losing tons of weight, hey, maybe you will be one of these people that don't require GLP-1s after surgery, and so I might hold off in that group and kind of see where we're going. Also, if they have 200 pounds to lose, well, we're going to need GLp1s we know it's a started early.

Dr. Weiner: 43:31

If they have 50 pounds to lose, then maybe not. Um, it also comes down to insurance coverage, right? You know some people have. We try to get people insurance coverage for these meds before surgery so that we can maintain them after surgery especially if it's like a onc kind of thing absolutely, especially we're getting approved for diabetes. Yes, and and go ahead.

Zoe: 43:52

Oh, I was going to say and we have a quiz actually on our website for people to see if they're, if they are considering surgery how much weight you predict they would lose with surgery, right?

Dr. Weiner: 43:58

Right, we. What we need to do is update that quiz so that it has information about what if you take GLP-1s or what if you don't, but anyway, there's a lot of factors in, and again this kind of gets back to what Zoe talks about all the time, which is about individualized plans. So the answer to this is it depends. Yeah, it depends, but generally sooner rather than later.

Sierra: 44:20

Yeah, okay. Next question is from our website, from Raphael what do you think about avocado oil?

Zoe: 44:29

Well, I think avocado oil is great. We think about our healthy quote, quote fats, the unsaturated fatty acids, olive oil, avocados. So, falling into that category, we have the avocado oil. Actually, avocado oil is preferable to cook with, even though I personally don't, because I haven't bought any yet, but that's besides the point. So avocado oil has a higher smoke point, which means you can actually cook with it, safer than olive oil, because it can be heated to a higher temperature before it starts smoking. So the idea is that it's healthier for your body and so, yeah, avocado oil can be used to cook with.

Zoe: 45:12

It can be used for making your own little vinaigrette for a salad, however you want to use it, just kind of going back to that idea of we're not counting calories but we want to have calorie awareness, where we have unlimited vegetables because they're high volume, high fiber, low in calories. Similarly, with the oils, we want to be aware of the serving size that we're using. So, on the metabolic reset diet, we keep it to a tablespoon a day of olive oil or avocado oil, whatever kind of oil you're using, because, going back to that concept of calorie density, it's low volume but high calories. So we do want to make sure you're not willy nilly, pouring that oil over everything because you can. It can add up pretty quickly.

Dr. Weiner: 45:56

Yeah, so you know, a lot of people have heard of trans fats and trans fats are like Crisco is kind of the classic trans fat? I don't know if Crisco still has trans fat.

Zoe: 46:04

They banned trans fat right.

Dr. Weiner: 46:06

Yeah, I think they've been restricted. But trans fats it's because they cause heart attacks and metabolic syndrome and diabetes. I mean they're very damaging. So unsaturated fats, when you heat them, have the potential to flip and become trans fats, and so that's why the smoke point is so important. And so avocado oil having a higher smoke point means less of that oil, less of that fat is gonna be converted to a. Why the smoke point is so important. And so avocado oil having a higher smoke point means less of that oil, less of that fat is going to be converted to a trans fat. But when you cook with unsaturated fats that smoke, some of that is being changed over to a trans fat and there is some negative health consequences as a result. Interesting, all right. Last question, sierra.

Sierra: 46:46

Okay, this one is from our YouTube video on lipoedema and lymphedema. What do you think of the lion diet?

Dr. Weiner: 46:54

You want to go first. So you know actually what is the lion diet? Why don't you first Well, you know.

Zoe: 47:00

I have not had very much run-in with the lion diet. Most I know that it's all meat.

Dr. Weiner: 47:06

Yeah. You eat like a lion eat and eat meat, and I think it's mostly like organs and height. It's like higher fat. I think it's a and fur I don't know about the fur.

Dr. Weiner: 47:19

I would hope not just kidding. Um, you know, there's the carnivore diet and I think the carnivore diet, and again I think the carnivore diet, and again these are all the constructs. It's not like it's a real thing. This is just like somebody made it, whether it was social media or whatever. Sounds cool, sounds cool. I think the carnivore diet. They can eat dairy and cheese and some other eggs, right? And I think the lion diet. You can't even eat that stuff. It's like just the meat.

Dr. Weiner: 47:49

And you know, animals will lions will preferentially eat the organs over the meat, because of the nutrients, because of the nutrients and the fat. But that works great for lions. And I mean, listen, lions are pretty ripped right. Yeah, they're looking good these days, lions. I just don't know. Humans aren't lions. We don't look like lions. I I just I have so much of a problem that ignores our omnivore status, our body.

Dr. Weiner: 48:13

We are omnivores. We eat meat, we eat fruit, vegetables, nuts, seeds, beans. We can eat all of these things. Our body was designed and evolved in order to mix everything up together and when you just pick one versus the other, you're kind of ignoring 100,000 years or longer of evolution of what our body was designed to do and everything kind of works when we give it a nice balance. And when you distort that balance, either by being like a strict vegan or a strict carnivore, you ignore the best of what we are metabolically, and so I just worry about that. As a you know, using the lion diet for that it works you probably lose some weight up front for some of the things you talked about with keto.

Zoe: 49:03

Right, I wonder how long would you be able to follow the lion diet?

Dr. Weiner: 49:07

Yeah, I don't know. I think if anybody's out there and has tried the lion diet, let us know how it goes. We might get some some some haters, because we kind of trash keto and lion diet and there's a lot of yeah, there's a lot of there's a lot of zealots behind these, anyway, all right. Well, I think that wraps up this episode. Why don't you take us out, zoe?

Zoe: 49:26

All right, this podcast is produced by Sierra Miller and Rhiannon Griffin and the editing is done with our folks over at Autogrow. And please check us out on social media. We are on all of your favorite platforms Instagram, facebook, tiktok. You can send your questions directly to our website if you'd like, and please consider joining our online nutrition program or Pound of Cure Platinum program if you want that personalized assistance in helping you achieve your long-term weight loss goals. See you next time.

Dr. Weiner: 49:56

Bye-bye.