NEW YORK ENDOCRINOLOGY, P.C.

Episode Transcript
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Dr. Daria Hamrah (00:06):
All right, welcome back to the show.
I'm your host, Dr Daria Hamrah,and today's episode is going to
reshape how you think aboutweight loss, hormones and your
health.
Joining me is Dr RocioSalas-Walen, a triple board
certified endocrinologist andobesity medicine expert, based
in New York City.
She's a global voice inmetabolic health and obesity.

(00:29):
Today, we're going to talkabout hormones and hormone
disruptors, demystify GLP-1s,talk about why most diets fail,
unpack the myths around obesityand highlight how modern
medicine is empowering people totake back control of their
health.
So, rocio, thank you so muchfor coming on, and I'm gonna hit

(00:55):
it off with the first question.
We're gonna dive right into it.
What is actually obesity?
We all heard the word obesity.
People have this image of whatobesity might mean Probably a
really super overweight personand we hear it in the news.
That is kind of like thepandemic what 70% of Americans

(01:18):
are obese?
But what's the definition?
As an endocrinologist andobesity medicine physician, can
you please define it?
So, for the sake of thisconversation today we can have a
basis.

Dr. Rocio Salas-Whal (01:31):
Definitely , I think so.
Obesity is a disease of the fattissue.
Basically it's a.
It's a disease of adiposetissue, right.

So it's a medical condition.

Dr. Rocio Salas-Whalen (01:43):
It's a medical condition that the fat
there's an excess of fat tissuethat can cause or causes disease
, right?
Fat tissue is pro-inflammatory,so this can increase the risks
for metabolic disease, type 2diabetes, even more than 13 type
of cancers that are related tothis excess of fat tissue, of

(02:04):
what we call the bad fat right,which is like visceral fat.
And also the definition ofobesity is it's a chronic,
multifactorial disease, right?
And when we talk about chronic,meaning that is long-term, like
other chronic diseases that wehave type 2 diabetes,

(02:26):
osteoarthritis, hypertensionthey are not curable, they're
controllable, multifactorial,that there's many different
factors that can contribute forthis disease or for obesity and
this is a definition of obesity.

So a lot of people have heard of the fact
that fat causes inflammation.
But fat we have it in our body.
Can you clarify for people whatthat exactly means, that not
having fat is not a bad thing,but then too much of it, how too

(03:03):
much of the fat causes thistype of inflammation?
And then how do you know toomuch is too much?

So we have brown fat, which is what we
consider a good fat right, it'sthermoactive.
And then we have the white fat.
What is what we considerdangerous?
And fat tissue is an activetissue.
It's actually an endocrinetissue.
It can produce hormones,cytokines, so pro-inflammatory
chemicals, and an excess of thewhite fat tissue, also known as

(03:37):
visceral fat, increasesinflammation.
It's in a chronic state ofinflammation and I think the
best example, and that is morerecent in our minds, is COVID,
the COVID pandemic, right.
So people with obesity were theones having higher mortality or
the ones that were sicker ormore visits to the ICU, and it

(03:59):
was due to that chronicinflammatory state that the
person with obesity was in, tothat chronic inflammatory state
that the person with obesity wasin, and I think that was a very
palpable view of being in adiseased state for people with
obesity.
I remember in my practicepeople were coming and telling
me I don't want to die fromCOVID, I need to lose weight.

(04:21):
So I feel like people veryquickly got the message, versus
when we used to say in 20 yearsyou can develop type two
diabetes or complications if youdon't lose weight now, but came
a virus and it was somethingacute.

You mentioned COVID.
Do you think COVID?
Because I could tell, rightafter COVID almost this health
conscious movement started.
After COVID, almost this healthconscious movement started.
Now you've been practicingobesity medicine and
endocrinology for many years.
Have you seen a type of shiftin your patient's mindset, this

(04:58):
heightened awareness when itcomes to health and obesity, or
it's been always like that.
We just more aware of itbecause of the social media and
the internet?

no, I saw a completely shift and
incline on awareness ofsomebody's weight.
Uh, my, my practice when Iopened it six, six years ago my
private practice here inmanhattan it was more of a like
mix of endocrinology and weightloss.
But during COVID it made acompletely shift and I would say

(05:30):
95% of my patients now andcoming in is for weight loss.

What do you think created that shift?

So one the awareness that having
obesity put you in an acutedisease state or make you, put
you acutely at risk for otherdiseases to happen.
Right, that was one.
So the demand of, of awarenesswas there and wanted to change

(05:59):
it, and then it happened to bethat we actually had the
treatment for it for the firsttime.
So it was the demand was thereand the supply was there, or the
means to improve this was there, and that was like the boom.
I call it like the perfectstorm.
That is where we are right nowis where we are right now.

So at what point would you say I'm just
curious at what point did youactively make it your mission to
treat obesity during thispandemic I know 2020 it hit and
then we found out that obesepatients and patients with
multiple risk factor areobviously at heightened risk for
mortality from COVID.
At what point did you say okay,I really have to take obesity

(06:47):
even more serious than I havebeen and really get out there
and promote weight loss?

It was.

Do you remember that moment?

I remember I remember it was not a
a a single point in time, itwas it was a period of time when
I started having this influx ofpatients with obesity and me
interviewing them and theirappointment and and and talking
to them.
Um that I learned.

(07:23):
What I never learned in medicaland endocrinology fellowship,
or even as I was taking myobesity boards, is that patients
, every single one of them, wastelling me that they were eating
better, that they were countingcalories, that they were
exercising, that they will tellme a list of diets through their

(07:45):
life following recommendations.
They were aware some had chefs,some have private trainers,
they were doing everything intheir control to lose weight and
it was not happening.
So for me it was such an eyeopening to learn that patients

(08:05):
were actually listening to usand following our
recommendations, because beforewe used to think we give them
this, the recommendations eatless, exercise more and then the
patient would come back andthere was no weight loss.
And the first thing we wouldassume is the patient didn't
follow our recommendations,didn't do better, that if they

(08:27):
wanted it they would havehappened already.
So we doubted patients, right?
I mean, like, is he reallylistening to me when they tell
you I really eat very small.
We used to say, yeah, if I'msure if I go to your house I'm
going to realize and see howmuch you're eating.
That's our thinking as doctors,right?
Yes, and it was very humblingfor me to learn and to and and I

(08:48):
was very lucky to have theavailability to have that time
to really talk to patients.
Right, because in a 15 minuteappointment, in a in a 20 minute
conversation, you're not goingto dive deep, the patients won't
open to you in such avulnerable state, right?
they won't even trust you enoughto open up yeah to open up Like
you're going to judge them,you're going to misjudge them,

(09:09):
right.
So I had this great opportunityin my time that I designed my
practice in a way that it waspatient-centric, not
insurance-centric, not quantity.
I immediately said I wantquality care and through these
conversations that I had throughmy patients, I learned all of

(09:31):
this.
And that is the moment that Isaid, okay, we've got it wrong.
We've had it wrong all thistime.
It really is not working.

So it was not something you learned in medical
school or in residency.
It's something you learned inmedical school or in residency.
It's something you learned fromyour patients, once you spend
enough time talking to themwhere you realize there is more
to it.
It's not just you're lazy oryou're this or that, almost like
shaming them.
It's a much deeperpsychological issue and and

(10:03):
physiologic issue.

And I learned that some patients this
has been their life for decades,their life revolves around
their weight, around that platein front of them.
Like how is that going toimpact my weight?
Am I going to feel guilty?
What do I have to do later toreduce the calories that I
consume?
It's just like it was like 24,seven and and to me it was very.

(10:29):
I felt shame that I contributeas a doctor to that thinking
through my patients, because Ididn't have the knowledge Right
and and I asked I, I the firstquestion that I asked a new
patient is at what age were youconscious about your weight?
At what age was you consciousabout your weight?

There is such a thing that you have to pay
attention to.

Seven, eight, nine.
My mom put me on a diet at 10.
So it goes so far back, right.

So what's the solution?
I mean, let's say you're a momwith two children and you see
it's not going well, how do youthen not, I guess, traumatize or
stigmatize things for yourchildren?
I mean, that's a very I mean, Iguess for one, the usual things

(11:26):
that we do, just a healthylifestyle and make sure they get
used and develop habits of ahealthy lifestyle, right?

yeah, but but again, it's not
lifestyle.
Only that's going to preventobesity right for children.

I'm talking about for children for children
too.

So we know now that the's weight
preconception can impact orpredispose the weight of their
children in their lifetime.
Right there's a lot of data, alot of papers, a lot of data
showing of.
So we have obesity, which couldbe monogenic and polygenic,

(12:04):
right, which could be monogenicand polygenic right.
So monogenic is a single genedisease and those type of
monogenic causes of obesity arevery severe and really showed in
very, very young age.
At two years old, at threeyears old, children have severe
obesity right.
Now we have the polygenic, whenit's just not a single gene
mutation, it's different genesand that is where heritability

(12:29):
comes into play, right.
So if the father is overweightor has obesity preconception, or
the mother, or in many casesboth, that can account to 50 to
70% heritability on thechildren's weight, right.
So also it's found thathyperpalatable genes are also

(12:52):
transmitted through theoffspring, right.
So we're learning more.
That goes even beyondpreconception that can
predispose somebody's weight.
So you have starting with thatfor children, obesity, right.
Or for children, they'realready coming in with a high
probability of struggling withtheir weight if their parents

(13:13):
also did.
Then we add to that foodindustry, right, the access to
good food is very low, to goodfood is very low, and even if
you have the access, it's stilldifficult to get good, healthy,
quality food.
And then we go intoenvironmental factors.

(13:34):
Living in areas that doesn'tpromote activity, right, doesn't
promote walking, sedentarism,and then food in schools, right?
I mean really, when you ask aparent to take it into their own
to control their kids' weight,it's almost like I don't want to

(13:57):
say mission impossible, butwe're set to failure, right?
So you really have to go toextremes to avoid that.
I'm not saying it's notpossible, I'm just saying the
environment that we live doesn'tmake it easy for us.

So I guess, is that why most diets fail, or?
I know you pointed out a lot ofimportant and interesting
points, from genetics toenvironment, to availability, to
education.
At which point, then, or wheredoes one start?

(14:38):
Because this, anytime you bringin the word genetic, I feel
people use it as an excuse andit's very dangerous.
It's a very slippery slope,because I feel, um, sometimes is
it's used as an excuse,although oftentimes and I don't
know the um, the statistics onthese obesity genes, how

(15:01):
frequently they are as far asepidemiology, epidemiology,
epidemiologically, how frequentit is disseminated in a general
population.
But at what point do you explainto the patient that it's even

(15:23):
though it could be genetics thatthey have to take
accountability and make somechanges?
How do you do that?
This?
This seems to me like such acomplicated thing and I guess if
it was so easy, we wouldn't betalking about it right now.
It wouldn't be the main toppingpoint of our society.
Where does one Like, let's say,someone is obese and they might

(15:49):
not even have access to you tocome to your practice, what is
recommendations that you cangive these people?

So we can talk about currently what we
can do with our givingsituation of this obesity
epidemic right, and we can talkabout what we can do in the next
generations to prevent this.
And I start with a patient thatcomes to me and tells me wants
to get pregnant right.
My biggest recommendation toavoid this being constantly

(16:25):
passed to generations is thatpreconception you start at a
healthy weight right.
If you're thinking of havingkids, of getting pregnant,
preconception, the best adviceis that you start in a healthy
way, because you're alreadycutting by half the chances of
your next generation to strugglewith their weight right.
Second is education rightEducating yourself about food

(16:58):
industry, about food choices,about what is the control that
you can still have right.
I mean eating a healthy dietexercising strength training and
then also the acknowledgementthat we have medications right.
But when you talk aboutaccountability, we go back to
the same idea that we just beguntalking about it.
Right, a patient can have 100%accountability and still not

(17:19):
lose weight.
And what happens in thosesituations is that to have that
accountability, that itinfluence their weight
completely, is usually somethingvery restrictive and not
sustainable long term.

Right.
Because, again, lifestyle is notjust the, which is why most
diets fail, in my opinion,exactly Because most diets are
restrictive, whether it'scaloric, whether it is
ingredients.
They're so restrictive and mostpeople can't sustain them
long-term.
And so that's a very good point.
But my question was where doesone draw the line between

(17:59):
genetics meaning factors thatthey can't influence and factors
that they can influence?
How does one?
Because to me, I've I've been umtreating patients for weight
loss in the past two years nowto prepare them for surgery.
So for my patients, if they areobese and they want to have a

(18:22):
some cosmetic surgery and that'show I got into obesity medicine
I felt like it's not safe forthem to undergo a six-hour
anesthesia, so they have to loseweight.
And the story was the same yeah, I've been trying for six years
.
And me then asking, well, howis it going?
He's like well, I actuallygained 40 pounds.

(18:44):
I'm like you gained 40 poundstrying to lose weight.
So that's how it got on my radar, where I said you know,
obviously the primary caresaren't doing enough to help
these patients or whoeverthey're seeing.
Obviously they're not gettingthe information that they need.
I need to educate myself so atleast I can help them, to guide

(19:05):
them in the right direction.
And when that happened I wentdown the rabbit hole.
And then the GLP-1s I cameacross the GLP-1s and the rest
is history.
But where does one draw theline between genetics
accountability andaccountability as far as
changing their environment orlooking deeper into their health

(19:28):
, whether it is hormones,whether it is other methods or
peptides or exercise, meaninghelp from the outside?
Where does one draw the line asto what they need to be doing?
Because I feel this is such awild west out there and people,
especially with primary carephysicians, becoming these

(19:49):
gatekeepers due to just lack ofknowledge and understanding,
even contributing to theconfusion of the population.

I am a very proactive type of physician
, so I would say I draw the lineearlier than later, right, and
we can talk even about treatingadolescents for obesity, right,
that early.
That is where I draw the lineis if we can spare somebody from
those years of struggle.
And I would say, when forsomebody, losing weight or

(20:23):
maintaining weight becomes afull-time job, that's where the
line needs to be drawn and Iwould say, why let them get to
that point?

right, it becomes counterproductive.

Exactly.
It becomes counterproductive,it takes control of their life.
It starts impacting mentalhealth right.
And when we talk about causesof obesity, it's not genetics
and lifestyle right.
We have hormonal changes, pcos,perimenopause, menopause,
hyperthyroidism, hypogonadism.
Then we go to aging right.
Aging also promotes weight gainby decreasing your lean muscle

(20:55):
mass, promoting or increasingvisceral fat.
And then you go intoenvironmental factors the food
industry right, is everywhere.
Industrialization of where welive, endocrine-disrupting
chemicals I talk about industryright is everywhere.
And industrialization of wherewe live, endocrine disrupting
chemicals I just talk aboutplastics right.
All of those are.
They mimic our own hormones andpromotes obesity, promotes
disease.

(21:15):
So it's not just genetics andlifestyle right, it's multiple
other issues.
And trauma, transgenerationaltrauma, can also promote obesity
.
There's research on that right.
So where we and I don't want tomake it feel like then we're
set to failure, right, becauseyes, it kind of sounds like it.

(21:37):
It sounds like that.
I'm sorry, but we have asolution currently, right, I
think, for the next generationsto not struggle as we struggle.
Different things have to takeinto place.
Change in the food industry,right.
We need, something, has tohappen for those.
Those are long-term solutions.

(21:57):
Those will be in the next threegenerations.
If it happens now, we'll seethe results.

If we start making changes now, we won't see
the difference immediately.
It will take generations, youthink.

Dr. Rocio Salas-Wha (22:10):
Generations for us to see changes in our
health.
If there's a change now, thenyou have all the things that you
can control.
You can control what you eat,how much you move and also
choosing or not choosingtreatment.
I like to say obesity is not achoice, but treating it it is

(22:33):
Right.
And also, as a society, if wetruly accepted obesity as a
disease, we wouldn't bequestioning treatment or we
wouldn't be looking at it as thelast resource.

Sure, well, we have a diagnosis for obesity.
Obesity is a medical diagnosis.
So, by definition, if we have amedical diagnosis, or the
reason why we have medicaldiagnosis, so that we can treat
it Exactly, so that has beenalready established, is it?

Dr. Rocio Salas-Wha (23:07):
implemented though.

It is not, and that's my question.
And why is it not implemented?
And why are patients beingshamed?

Yeah, because as a society, we see
weight loss and we've beentaught to see weight loss as
something external, right.
Yeah, as looking good, as beingattractive, as something
superficial, yes, not as ahealth concern, right, but if

(23:35):
you think about somebody withdiabetes, you wouldn't question
them being on treatment, right,good for you that you're
treating your glucose becauseyou were sick, you were not
feeling great and you can thislead to disease.
But for weight loss, if you, ifyou as a person, are thinking
of weight loss as somethingsuperficial, it's going to seem

(23:57):
bazooks to for somebody to takea drug for weight loss.

That's where the shaming comes in weight loss
.

That's where the shaming comes in,
that's where the shaming is andthat's where they call it the
skinny fat, the skinny injection, because you're thinking as an
individual and you were taughtthat, as in the society, in our
culture, that skinny issuperficial and that skinny is
not necessarily health, it'scosmetic.

I have to be honest with you, rocio, I'm so
disappointed and I don't care ifI get ripped on social media
for saying this, but I mean,someone has to say it I'm so
disappointed at our medicalcommunity, and for not only

(24:44):
gatekeeping these obesity drugs,peptides like GLP-1s that we're
going to talk about okay,because we're going to talk
about what they are and how theycan help and other benefits
that they have that we'refinding out every single day but
also for shaming patients ortelling them to do the things

(25:11):
that we and me and you justtalked about, that they've been
trying for decades and they havefailed.
Because it's more than justthat.
It's more than just exerciseand diet and diet because of
lack of education and lack ofknowledge and disseminating

(25:33):
incorrect information andconfusing the patients and
omitting them from a potentiallylife-saving treatment.
Because the reason why I'msaying that in our medical
community, obesity is adiagnosis Each diagnosis should
is a diagnosis.
Each diagnosis should have atreatment.
And when we choose a treatmentlet's say, for cancer we don't

(25:53):
just pick a treatment out of ourhat.
There is protocols, there isguidelines.
According to research, whetheryou do radiation therapy,
whether you do chemotherapy,there is guidelines.
You don't just pick randomstuff based on what your opinion
is.
Yet for obesity there is nospecific, unless you're a board
certified or an obesity medicinephysician or board certified in

(26:16):
obesity medicine.
You really don't know whatyou're doing.
And yet is the number onemetabolic disease, at least in
this country, or that'scontributing to then the number
two, three, four metabolicdiseases in the country, which
is diabetes, hypertension, allthe other metabolic dysfunctions
.
So why is that?

(26:38):
Why is it that they don't getbetter guidelines, they don't
get the boards of theirspecialty?
Boards aren't reallyreinforcing it enough, like what
is going on, like why is itthat influencers have a louder
voice than actual physicians?
It's so bizarre to me.

I'm going to tell you why.

Sorry, I just had to go on a rant.

That's fine and you are a surgeon and
you do plastic surgery, right?
So you don't deal with healthinsurance.
Yes, the other side of thoseprimary care family
practitioners, usually the firstdoctor that a patient can go I
would say 70%, 80% work withinsurance or in an institution

(27:27):
right, it's the healthcaresystem that doesn't.
It's how the healthcare systemis set up is not useful, is not
helpful for patients, is nothelpful for doctors.
You have a doctor, right, aprimary care that sees 30, 40
patients a day, that gets 15minutes with each patient.

(27:50):
What are they going to do inthose 15 minutes?
And if their primary carethey're dealing with their
hypertension, type 2 diabetes,high cholesterol and whatever
else is happening in a patienthappening in a patient In those
15 minutes, they're never goingto have the opportunity to talk
and learn from patients, as theexample that I gave of myself.

Yes.

Health insurance really controls the
time and how a doctor practices.
And I can tell you because Iwas in that spot many years ago
and I hated it and I said I cando so much more for my patients
if I have the time.
And that's the reason I wentinto private practice and that's
the reason I don't takeinsurance right.

(28:35):
And the reason that I'velearned all this knowledge and
that I'm here talking to you isbecause I took that leap of
faith on myself to work offnetwork out of network Granted.

So I would then say, well, they're victims
of the system.
Right, I get it.
But why do I hear, you know,not?
Once, multiple times, patientscome to me.
They ask me for GLP-1s and I'mthinking like this shouldn't be

(29:10):
my job.
I don't know how I got intothis, but this shouldn't be my
job.
And then when I ask them, well,did you discuss it with your
primary care doctor?
They say my primary care doctorwon't give it to me.
So now the first thought is okay, maybe their insurance doesn't
cover it or this and that.
And then I dig deeper.
I say, well, why does yourprimary care doctor not give it

(29:32):
to you?
He said I don't know myinsurance.
I actually checked with myinsurance and it's even covered.
I'm like okay.
And then they go.
My doctor says it's not good,it causes thyroid cancer.
It causes.
So basically, they tell me allthe things that this
fear-mongering in the media youhear, or these uh influencers on

(29:54):
social media do, thisfear-mongering for likes or
follows.
But even you hear it onmainstream media, the stuff
reporters talking about it, andyou're thinking, wait a second,
that's incorrect.
You know, this is just simplynot correct.
But when physicians tell it totheir patients.
That's where I draw the line.
So why, is that?

(30:15):
is there an excuse for that?

um, yes and no.
We doctors, we don't prescribewhat we don't feel comfortable
with right because you don'twant to deal with side effects.
You don't prescribe what wedon't feel comfortable with
right Because you'd want to dealwith side effects, you'd want
to create more symptoms on thepatient or make it worse for the
patient.
So we don't prescribe what wedon't know, or we don't
prescribe what we don't haveexperience with.
So most likely this whateverdoctor is not promoting or

(30:42):
prescribing this type ofmedication, glp-1s is because
they don't know how they work.
They don't really know the sideeffects, they don't have enough
expertise putting patients onit and having and seeing them
come with results or sideeffects and how to manage them.
Right, number one, second, Iwould say better off that they
don't prescribe it if they don'tknow how they work, because

(31:02):
then they'll create more sideeffects and bad headlines of
this wonderful type ofmedications.
But then we go to theaccountability part.
Right, that you don't knowdoesn't mean that somebody else
doesn't know.
So then you need to refer and behonest and say I don't have
enough experience with thismedication.

(31:24):
I'm going to refer you to anendocrinologist or I'm going to
refer you to an obesity boardcertified physician, right,
that's where we'll add the faulton the physician, right?
That they don't say, okay, Icannot prescribe it.
But what is the option?
What are you offering me?
Refer me to somebody else whoknows, guide me to where to go?

(31:45):
Right?
So that's where theaccountability should be
happening.

I'll be honest with you.
I think many physicians, justlike me and you, they're normal
human beings.
They let their own personalopinion about stuff cloud their
judgment and I think a lot oftimes and that's my feeling from
talking to my patients that'swhy they're not referring out to

(32:09):
an obesity medicine specialist,endocrinologist or someone that
is experienced in thosemedication I think oftentimes
which to me, it's not ethical tolet your opinion, your personal
opinion, which is completelyemotional, guide your judgment
and misinform the patient.
I see a lot of that going onand I hope that that will stop.

(32:33):
Thankfully, patients aregetting so smart because they
have access to information.
They have access to thesepodcasts, to information.
To have access to thesepodcasts and, with voices like
yours increasing, they will havea higher chance and higher
likelihood of hearing anotherside from an expert and then

(32:54):
questioning what their doctormight have told them based on
their personal opinion.
So I think, in turn, that'swhere social media is a good
thing.
People always demonize socialmedia.
I think social media is bothgood and bad.
It's like your kitchen knifeyou can cook food and live
healthy with it, or you canmurder someone and rob a bank

(33:16):
with it.
So but that then cheatingreally, because a lot of people
say that's cheating.
A lot of people shame patientsthat are on them.

(33:38):
At which point do you first ofall agree with them?

No, of course not.
But before we go into that, Iwant to say, also talking about
doctors and like you said, I'mgoing to say it, I have to say
it, somebody has to say it ishow many of us doctors are in a
healthy weight?

Hmm, you really want to go there.

Well, if we're talking about why we're
not having, why doctors are nothaving the conversation, then it
is really.
If you took into account whatyou're recommending patients to,
then you will be proof of thatright, 100%.
But doctors, we're humans,right, we struggle too.

(34:27):
Sure, but that's where you sayyour own personal experience or
bias is interfering in the careof somebody else.
So that's the psychology behindit.
But okay.

I'll throw okay.
So since you went there, I'llthrow you another good one.
I don't know where we're goingwith this conversation now, but
it's just happening.
What percentage?
What do you think?
If you would compare theprescription of antidepressant
compared to the prescriptionsprescribed for weight loss,

(35:04):
which one is being prescribedmore, in your opinion today Of?
course psych medicationsantidepressants, anti-anxiety
medications medicationsanti-depressants, anti-anxiety
medications, um, do you thinkwhere people mankind has gone
that crazy that psych medicineare some of the first.
I think it's the second mostoften prescribed drug I mean and

(35:27):
how much of it is?
how much of it do you think wecan treat with the things that
you talked about, with thepressures of lifestyle
improvement, where it feels likepeople are hitting a wall and
the wall is so tall that theycan't climb it and they
constantly be told well, youneed to climb it, no matter what

(35:48):
.
How much of that do you thinkis contributing to the need for
antidepressants?

I mean, I think we know all the
metabolic complications ofobesity, right, we built
specialties on it.
I don't think we know enough ortalk enough about the mental
health complications fromobesity.
If you're talking about a10-year-old that it's already
put on a diet, telling them thattheir body is not the right one

(36:17):
, that leads to anxiety,depression, suicidal thoughts,
right.
So that's.
I think that's one big part ofour mental health situation and
I think that's one big part thatI see improvement with GLP-1
once.
Is that peace of mind andpatients say for the first time
I feel control.

(36:38):
For the first time I feelrelief.
And also, when you explain to apatient that is not there full
that they were not causing 100%their obesity I can even see it
in their shoulders when I havethat conversation they relax,
right, it's just almost aphysical change when you explain

(37:00):
to them that, hey, if yourparents had obesity before they
had you, that it's alreadyputting you in a bad spot, right
.
And you know, what'sinteresting about weight loss
medications is that for themajority of patients I would say
all of them, I don't want togeneralize, but for the majority
of patients, if they have theright guidance, the healthy

(37:24):
lifestyle choices come afterthere's some weight loss or once
they're on that weight lossmedication.
It's incredible to see.
And when you talk about shamingon this medication no, because
this is not a self-induceddisease.
We wouldn't shame somebody whogoes on diabetes medication or
on a diuretic for blood pressure.

(37:45):
We wouldn't even think it twice.

I haven't.
I'm so glad you said that Ihave this amazing I'm.
I'm currently writing a bookand that story is in my book.
Yes, you too.

Oh my god yeah, I'm writing a book,
all right so.

So I'm gonna have to.
All right, so I'm gonna sendyou um manuscript.
I want you to read it and Iwant you to give me your opinion
and feedback on it, and I'll beglad to do the same, because
it's it's I want people thatknow so much more about me,
about this topic, to give meinsight than just some random

(38:23):
reader, and this is so importantfor me.
For me, this is this is goingto be the second half of my
career.
I'm so dialed in, so passionateabout this because I think we
can help so many people.
But let me tell you the story ofmy patient, jose.
He came to me a year ago, youngpatient in his 30s, for

(38:47):
liposuction of the chin and neck, and he just wanted a chiseled
jaw, which is after COVID.
This was the number oneprocedure people came to me for,
and that's how I became awareof this thing called obesity
People coming for liposuction.
And really handsome guy tall,he was 6'4".

(39:10):
He had beautiful facial anatomy, from the bone structures and
everything, because that reallyplays a role in how your soft
tissues drape over your facialbones.
If you have smaller bones,everything sags and it looks
more heavy, and if you have moredefined structures.
So he had very definedstructure.

(39:31):
And I looked, he was about 60pounds overweight.
So he had very definedstructure and I looked he was
about 60 pounds overweight.
And as he's talking to me,telling me about what he's
looking for, what his goals are,I couldn't help it but
constantly think that this youngman shouldn't be overweight.
Why is he overweight?
What is going on?
And I had this internaldialogue going on in my head

(39:54):
while he was talking and then Isaid I need to bring this up.
It's, it's always.
I don't know.
You're so much.
Probably better than thatbecause you do that for living,
talking about weight loss toyour patient, but for me, you
know, I always am veryself-conscious, so that I'm very
sensible, so I don't offendthem and I don't want to bring

(40:17):
it up before they have trustedme and opened up.
I feel, even though, as a doctor, it's our job to do that.
But I always try to approach itin a sensitive way because I
know they're probably insecureabout it.
And he had this desperation inhis voice that I said you know

(40:37):
what?
I'm just going to ask him.
And I said well, you can pay mea lot of money for me to do
this, but I can't help it tothink that at your age, losing
weight you're going to benefitmore from it.
It's going to be morelife-changing than you paying me
thousands of dollars to doliposuction.

(40:58):
And I feel like I really shouldhave had a different
conversation with you.
So I'm just going to say it.
And then he immediately stoppedtalking and looked at me and
goes like I've been trying tolose weight.
I just don't know how I've beentrying to lose weight.
I just don't know how I've beentrying everything.
And then his eyes got teary.

(41:19):
I felt this helplessness and itwas almost like he was so happy
that I brought it up and I saidlook, I could help you, but you
need to change a lot of thingsalso, one thing at a time.
So I spend about 40 times 40 40minutes with him 40, 40 minutes

(41:41):
of time with him to see whathis lifestyle is like.
So what I notice is that he'sbasically sitting in front of a
computer.
He has a very sedentarylifestyle sitting in front of
the computer.
He was a computer analyst of agovernment contractor and
sitting in front of the computerall day long eating potato
chips.
And so I said well, that's easy, because that is just some

(42:05):
minor modification.
So I gave him some tips and Isaid if you promise me to do
that, I will put you on GLP-1,and then we'll see each other
once a month and and then atfour months we're gonna see
where you are and then can stillmake a decision.
And and I didn't want to takehim the liposuction away from me

(42:26):
because he was really adamant Isaid I will do it, but give me
four months.
I will do it in four months, Ipromise you if you still need it
.
He said, fair, I literallyshook hands and I always make
this joke, I'm like handshakesor pinky promise.
And then he left.
So we put him on GLP once andyou know my nurses followed him

(42:48):
up, et cetera, and I saw himafter four months.
He came sat in a chair.
I didn't recognize him so Ididn't even know who he was.
So that's how much he hadchanged.
Uh, and I in, I introducedmyself like I'm seeing a patient
for the first time and he looksat me, he looks at my nerves,
kind of like, is he joking?

(43:08):
And I look at everybody, wasthis weird mood in the room.
I said, what's going's going on?
And he's like, well, you knowme, I'm Jose, and I'm like Jose
and I had to look at the chartand I had to literally read my
previous notes.
All of a sudden it hit me, hewas the way he looked.
He looked like a supermodel,Handsome, confident.

(43:32):
I did, I swear I did notrecognize, recognize him and I
had to sit down.
I was like, oh my god.
And he see that reaction on myface and he started laughing.
And then, right after hestarted laughing, he started
crying and he goes like youchanged my life.
I quit my job.
When I went home the next day,I quit my job because of you.

(43:56):
I'm like, oh, that's not good.
Like why'd you quit your job?
It's like I'm going to schoolfor nutrition and I'm becoming a
personal trainer and this iswhat I'm going to do for life.
I changed completely my.
I want to change my professionthis is.
I can't believe that within oneconversation, you changed my
life so much and I want to helpother people change their lives

(44:18):
too.
So he literally quit his job.
He went to nutrition school, heis becoming a fitness
instructor, and because herealized how important the
importance of lifestylemodifications are, which he had
done leaving my office, inaddition to the GLP-1s.
So when you said they canmotivate you, the GLP-1s can

(44:41):
motivate you to change your life.
The question is is it thechicken or the egg?
Does weight loss promote healthor health promote weight loss?
Which one is it?
Well, in this case it was aweight.
Weight loss promoted health,not the other way around, which
is what we were.
We were taught the other wayaround yeah so I want you to

(45:02):
talk about your experiences inthat and the importance of this
so people stop shaming thesedrugs and realize how we can
change people's lives with these.
I don't like to call them drugs.
They're really peptides, youknow Well they're hormones.

Hormones .
Yes, I mean first is to haveempathy.
Number one, right, it's likeyou have to understand that when
you see somebody with obesity.
Number one, they know they haveobesity.
Number two, they don't want tohave obesity.
And number three, believe thatthey're trying, believe that

(45:42):
they're modifying, believe thatthey're listening and understand
that it's a health problem.
It's not a willpower problem,it's not a cosmetic problem.
It's a disease and there'streatment for it.
And it should be widelyaccepted.
And not let your own bias ofwhat weight is or what has

(46:06):
worked for you or not worked foryou shame other people from
doing it right.
And also like respect whenpeople are on a GLP-1.
And don't push food to it right.
And also like respect whenpeople are on a GLP-1 and don't
push food to them right.
And don't say, oh, that's allyou're going to eat.
Or stop saying, oh, stop losingweight, you look sick, that's
none of your business, right?
Or I mean, believe me, we'retrying to get to a health goal,

(46:29):
not for somebody to look goodenough for you, or that's enough
of weight loss for you for youfeeling comfortable, right?
I think that's another one.
And educate yourself about it.
And like it happened to you,like it happened to me.
Once you know, once youunderstand and once the
blindfold is taken away from you, your responsibility is to

(46:52):
share that knowledge and tocorrect.
When somebody says somethingnegative or ignorant about
somebody with obesity, oh, theywould have done it if they
wanted it.
It's just educate other people,right?
I think the more we educatepeople, the easier it will
become and it will be moreaccepted.

I love the way you put it and I think and they
will be more accepted.
I love the way you put it and Ithink, especially in certain
cultures, this is more extreme.
I know I come from a Persianculture and if you look, if you
have a perfect body compositionto your mom, you're underweight.

Yeah, Like your mom yeah.

It's like what's going on.
You look so sick, like why doyou have no meat on your bones
and you eat this, and it's acultural thing.
So, and for culture, I don'tknow how long it won't change in
decades, it will take centuries.
But let's talk about who is areal candidate for GLP-1s.
But before we talk about who isa real candidate for GLP-1s,

(47:57):
but before we talk about that, Ijust realized that we haven't
even told the audience whatGLP-1s are.
They've been hearing it for thepast 45 minutes and we haven't.
I know, I mean by now you wouldthink people know.
But just for the sake ofdefinition, how do they really
work?
Very briefly, in maybe one ortwo sentences how do they really
work?
Very briefly, and maybe one ortwo sentences how do they really
work?
And then, who is the idealcandidate and who should not be

(48:22):
taking these medications?

So GLP-1 is a hormone that we make in
our gut, in the small intestine,and it's secreted or produced
when our glucose raise up in ourbloodstream right.
Meaning after we eat, forexample, After we eat yeah,
after we eat, this hormone isproduced in our intestine, but
there's an enzyme, the DPP-4enzyme, that breaks it down

(48:45):
within two to four minutes,right.
So it's produced, but it has avery short-lived effect.
Glp-1 analogs what we know asOsempe Wegovi, monjaro the
commercial, the syntheticversion of it is a long-acting
form that is not broken down bythis enzyme.
Reason that it has a longerlife, right, like even a week,

(49:08):
like some aglutineinterceptatite and the way that
they work for weight loss.
I like to say that it targetsthe two reasons that humans eat
we eat for survival, for energy,and then we eat for our reward.
For the survival part.
What it does?
It increases your satietyhormones when you start eating,
so you get fuller with half ofwhat you normally would have

(49:30):
need to get full, and then inbetween meals it suppresses
ghrelin, your hunger hormones,right.
So you eat smaller through morecontent periods of time in the
day.
That's the gut level, which isalmost similar to bariatric
surgery, right?
But then we have receptors forthis hormone in our brain in the
amygdala, where the hedonisticeating and drinking area is,

(49:54):
where we eat for an anticipationof our reward or drink for
anticipation of our reward.
This hormone blocks thoseresponses.
So the behavior at thebeginning when you start on this
medication if the behavior isthere, you reach for it.
But there's a blunted effect.
You don't feel you don't getthe reward anymore for whatever
anxiety, depression, boredom,snacking, whatever you were

(50:16):
getting, anticipating thatreward, it stops it.
So you don't think about it.
You get hungry, you enjoy yourfood, but then you get full with
smaller portions through longerperiods of the day.
So that's how they work.

Wow, this was the best, most concise and
shortest explanation ever thatI've heard.
I'm going to have to memorizeit verbatim.
For those of you, you mentionedthe word amygdala.
This is for the audience thatis not in the medical community.
It's the center in your brain,that is in your limbic system,

(50:49):
responsible for emotions, flightor fight.
It's called the fear center.
Responsible for emotions,flight or fight is called the
fear center, and that's whatthat pressure, that's what kind
of drives, also habits, or ofeating, and so it the GLP ones,
also affect that part, and sothat's a dual function we were
talking about.
So now, who is a candidate andwho shouldn't be taking it?

(51:12):
Let's say, let me throw youthis one, dr Whalen, I really am
struggling to lose these last15 pounds and I really want to
get on these GLP-1s.
I've tried everything.
I'm going to the gym, I justcan't lose 15 pounds.
If I lose another 15 pounds,I'll be happy.

(51:34):
I don't have any medicalproblems.
I don't have diabetes.
I don't have any metabolicdisorders.
I just need to get into thesejeans that I used to wear when I
was 25, and I just need another15 pounds.
I will put her or him in a box,if not, I will go crazy and I'll

(51:56):
be depressed, and I'll throwyou this one too.

So usually what I?
Because I do body compositionson every single patient.
You walk through my door, youget a body composition.
Basically.
So if I have a, most of thetime that I have patients that's
like that oh, I only have 10pounds to lose, I only have.
Usually it turns out to be 20or 30, right, once we put
somebody on a body composition,the truth shows right.

Okay, let's talk about body composition then
also.

So so who's a candidate right?
So if we go by BMI, then 27 andabove with one comorbidity
meets criteria for weight lossmedication.
Or BMI equal or greater than 30without a comorbidity meets
criteria.
But if you go to that's, that'sa very outdated tool that I
don't.

Yeah, I mean, if you're like a bodybuilder,
you have a lot of muscles, youhave a lot of your BMI.

Yeah, that's not the I mean, that's,
that's the old thinking, becausewe rarely see that, I mean,
unless you're doing bodycompositions on WrestleMania or
something like that, right, butregular people, it's actually
the opposite.
You see, normal BMI with highpercentage body fat, high
visceral fat and low muscle mass.
So when you average it out, oh,it looks like a BMI of 21.

(53:09):
And no, you're under-muscledand overly fat.

So how do you know that?
That you're under-muscled andover-fatted?

I guess, Definitely, I mean, I think,
how would you know if you'reunder-muscled?
With sophisticated medications,we need to do sophisticated
tools right.
So I think anybody who'sjumping in this wagon of
prescribing GLP-1 medicationshould do it responsibly, with
body compositions, right,Because at the end of the day,

(53:39):
you don't know what the patientlost, could have lost 10 pounds
of muscle and 10 of fat, right,and you made him even worse,
metabolically unhealthy, 100%.
So definitely you need a bodycomposition.
So for that person that has 15pounds of weight loss to lose,
first, I would do a bodycomposition.
So for that person that has 15pounds of weight loss to lose,
first, I would do a bodycomposition.
Second, if it feels like afull-time job trying to lose

(54:01):
those extra 15 pounds and youneed it, and you need to lose
those extra 15 pounds youdefinitely will benefit from a
GLP-1 medication.
I mean, what else can you askfor the patient?
Right?

For those of you who are rolling their eyes
and saying oh God, please, youknow, just stop eating potato
chips or go to the gym.
For 15 pounds, for God's sake,you know, do you really have to?
Can you please explain to themwhy?
Because you said somethingimportant.
I think it got lost.

(54:35):
Can you explain to them why youconsider them a candidate and
why it is important Because itis consuming their lives and
infecting them in a negative way?
Can you kind of dive a littlebit into it?
Explain it for the biggestdoubters out there?

Because if it was as easy as just eating
less, they would have lost italready, right?
I mean, we cannot assume thatsomebody who has 15 pounds and
hasn't lose them are ignorant.
They don't know what they'retalking about.
They don't know how to countcalories.
They haven't read a diet book,right, uh that.

(55:12):
That's another thing that Ishould say, because you don't
struggle with weight, or becausemaybe you do lose weight if you
restrict yourself, doesn't makeyou better or more intelligent
than somebody who's trying andit's not happening.
I think that's one thing thatwe have to stop.
Don't assume that the persondoesn't know what they're doing,

(55:33):
hasn't tried or is notcurrently trying.
But so if they need to losethat amount of weight or more or
10 pounds, but it's a full-timejob in their life, they require
weight loss medication.
Otherwise, if they didn'trequire the weight loss
medication, they would have lostit already.
If they didn't require theweight loss medication, they
would have lost it already,Meaning that there's so many

(55:54):
other things in theirenvironment, in their age,
hormonally, that is not allowingthem to reach that goal.

Yeah, and I think the psychological impact
is totally underestimated.
It's so funny that we're soquick to prescribe
antidepressants so quick, like.
I'll tell you a story as anendocrinologist.
You will be shocked.
I went with my wife to thedoctor.

(56:21):
She was a new doctor that shewent to, her insurance changed
and she was going to pick up herthyroid medication, have them
refilled or have themre-prescribed, and the doctor
she was telling the doctor askedher about their symptoms.
She's like, yeah, I'm kind oflike tired and this and that.
And she was back then in herearly 30s and the doctor said,

(56:42):
yeah, I think this sounds likedepression.
I'm going to prescribe youantidepressant.
And I was sitting in the room.
I was like what, I was sittingin the room.
The doctor didn't know that I'ma doctor, so I didn't say I
usually don't like to sayanything, I just sit there.
I don't like to interfere.
I like I want I'll have them dotheir job and I thought I heard
it wrong.
I said, and then I saw my wifelooks at me with a question in

(57:04):
her eyes, like and she's like,I'm not depressed, I'm actually
very happy.
I actually very happy, I justneed my thyroid medicine.
I have Hashimoto's and I'mhypothyroid and my levels show.
I mean, did you look at my labs?
And the doctor says, yes, Iknow, but your symptoms are very
suspicious for depression.

(57:25):
And my wife, she lost it and Ihad to calm her down and I'm
like calm down, just it's okay.
She's like well, what is goingon here?
And, long story short, thereason why I'm mentioning it.
This is not just one event.
This is an event where I wasinvolved.
There are events of patientstelling me or they're on

(57:45):
antidepressant and I asked themwhy an antidepressant?
And then I'm not a psychologistso I'm not qualified to even
diagnose or question a diagnosis.
In my wife's case I knew I wasable to because I live with her.
But the psychological impact isnot often talked about and I

(58:08):
see it a lot on my patients.
They completely in the case ofJose and and in case of other
patients just like him, it hassuch an underrated psychological
impact which then has thistrickle-down effect.
I mean, when you look at howdepression can affect your other

(58:28):
metabolic function of yourother organs, from your fat
composition, all kinds oftrickle-down effect.
When someone has 15 pounds or 20pounds overweight and they've
tried everything desperately andthey just can't do it.
They've been on every dietunder the sun.
They go to the gym seven days aweek, which I don't even go to

(58:51):
the gym seven days a week.
I have usually one or two offdays and I'm a gymaholic.
And they want to lose.
Give them the 15 pounds, forthe love of God, because then
there will be happier people andthen they can go on with their
lives.
And so the indications.
They're much broader than thedefinition of obesity, in my

(59:12):
opinion.
Now, I know insurance companieshave the reasons for that.
That's great, but I don't thinkwe should necessarily have
insurances guide our treatmentobjectives.

And also , I think, for what I see a lot
clinically, a lot of the peoplethat saying it's 10 or 15 pounds
that I cannot lose and I'mdoing more, or I'm doing exactly
what I was doing, is usuallypeople that didn't struggle with
obesity growing up, right, it'speople that were in a healthy
way most of their life and nowthey're in perimenopause.
Now they're in menopause or nowthey had a kid and they cannot

(59:48):
get the weight back.
So usually it's people thatlive the healthy but at the time
that it happens, theirenvironment, their hormones,
their age is not helping them asthey did before, right, because
if you have somebody withsevere obesity that had 80
pounds overweight and 90 poundsoverweight 60, those 10 pounds

(01:00:08):
doesn't make such an importance,right, but usually it's people
that were always in a healthyweight and then something
shifted and now they cannot getback to what they know their
healthy weight is.

Dr. Daria Hamrah (01:00:21):
So you mentioned hormones and
perimenopause.
I know it's a whole differenttopic, which I covered with Dr
Mary Claire Haver in my lastpodcast, but I want to bring
this up, especially since you'rean endocrinologist.
But I want to bring this up,especially since you're an
endocrinologist how do youbalance the prescription of
GLP-1s and adjustment of hormonetherapy?
Do you do them at the same time?

(01:00:41):
Do you do one first and thenthe other?
What's your approach?
And how do you see thecontributor of the weight issue?
Do you see it more in thehormone side or do you see it in
a more genetic lifestyle side,or is it just a combination of
all of it?

Dr. Rocio Salas-Whalen (01:01:05):
I mean, as I said, everything in
medicine is very individual,right, it's depending on the
patient, but it will be what arethe most pressing symptoms?
Right, but it will be what arethe most pressing symptoms,
right?
Let's say they have obesity orthey are overweight, but they're
also in their mid-40s andthey're not sleeping right
because of perimenopause.
Then that's a person that I maywant to start both medications

(01:01:27):
at the same time.
But let's say I have somebodyin their early 40s and they're
saying their waking morely dueto perimenopause, but they're
not fully symptomatic, they'renot having the hot flashes and
night sweats, the travelsleeping.
Then I may start with weightloss medication and then see
what improves, right, even sexdrive.
Many patients with low sexdrive can improve with weight

(01:01:48):
loss, right.

Can you explain that?

that's interesting yeah, because uh,
self-confidence right, I think,for many patients more of a
psychological impact, more of apsychological impact.
They don't feel comfortable withtheir body, so that can
suppress their sex drive.
Just because of that of of poorself-confidence, that for many
patients once they lose theweight, that improves.

(01:02:13):
But let's say somebody who'sfully menopausal and they can
lose weight but their hormonesare below zero, then definitely
adding hormones will help themright?
Also, there's some patientsthat are very sensitive to
medications and if a patientlike that, you don't want to put
three new drugs on a patientright Because she won't like how
she feels and she may droptreatment completely.

(01:02:35):
So for those patients, again,what's more pressing is that the
night sets the travel, sleeping.
Then I'll start with hormonereplacement therapy and then in
their next visit in six or eightweeks, then we can start a
GLP-1 or vice versa.
Right so again, it's verydependent on their current
symptoms weight, age, preference.

Gosh, I could tell you one thing from what I
just heard from you I wonder howmany marriages and
relationships these things cansave, thinking of how many
relationships get disrupted, howmany and I talked to Mary
Claire about this the percentageof relationships that break up

(01:03:17):
because of you know all of theseissues.
That's to me anothercontribution of these drugs to
our society, in addition to themedical aspects of it.

But Well , I see what GLP wants.

I see divorces happening more than well, yeah,
I mean that, but but there hasto be another um yeah, going on
prior to that.
Yes, something underlyingthat's just exposing something
that was yeah, that's actually,that's exposing something that
was going to happen eventuallyyes, but I'm just going to talk.
I meant relationships andmarriages.

(01:03:56):
Yes, marriage and relationshipsthat broke up because um, um,
um, maybe, um, there was lack ofself-confidence, lack of sex,
drives like, uh, just moodswings, uh, because of
everything is just too much.
And, in addition, the hormonalfluctuations in perimenopause

(01:04:17):
that are not being addressed,which is still baffles my mind.
That what, 25 years after thestudy came out?
That still physicians out thereare not well-informed, which is
a whole different topic that wealready covered.
That's another gatekeeping yes,another gatekeeping yes,
another gatekeeping.

Only four percent of women, or four
to six percent of women four tosix percent of women in the us
is are on hormone replacementtherapy.
What, even with all theinformation?

that right for four to six percent of
perimenopausal women, or alltotal women of all ages total
women of all ages.

Total women of all ages Okay Are only
four to 6% are taking hormonereplacement therapy.

And if you think about how many percentage
of the total women are 50%.
Candidates are 50%, right, holyshit, oh my God.

That low , I mean it's yeah.

Wow, I would have guessed like, by now, at
least half of them.

And that's another one that I mean
and you had that conversationwith the wonderful Dr Marie
Claire Haver, but that's anotherthat I see as an
endocrinologist is like have youever been talking about hormone
replacement therapy?
No, they told me.
No, it causes cancer.
That's another one that islacking a lot of information in
the medical community of thebenefits of it and that it

(01:05:46):
doesn't increase breast cancer,right, I think.

Yeah well, I don't even know enough doctors
in my area, in the Washington DCarea, that I can refer my
patients to.
I know two or three physiciansthat I know, so if you know any
endocrinologists in the DMV areahere in DC, please, let me know
, Dr Rachel Rubin, she's not anendocrinologist, she's a

(01:06:09):
urologist but she prescribeshormone replacement therapy.
I just had a patient last week.
She gave me that name, rachelRub.
She's a urologist but sheprescribes hormone replacement
therapy.

I just had a patient last week.
She gave me that name, RachelRubin.

She's amazing she's there in DC, perfect,
perfect.
So next question why are thesedrugs so expensive?
I don't want to create apolitical conversation, but very
briefly, in maybe one or twosentences why are they just so
expensive and why can people getthem in other countries so

(01:06:38):
cheaply?
Is it just simply price gouginghere in the US or does it have
other complicated reasons?

I mean I think they're so expensive and
they charge so much for it herein the United States because
they can.

So okay.
So it's price gouging.

I mean it's because they can.
But also I think that the penitself is an expensive mechanism
to deliver the medication,right?
If in other countries, like inMexico, monjaro is now available
, but it came only in vials, sojust the substance syringes, so
that cuts the pricesignificantly?

(01:07:13):
Right, in Europe they have asingle pen for a month of
Monjaro, so you're only usingone pen versus four pens.
Also, right, why?

don't we have it here?
Why don't we have a single penhere?

When the pens of Monjaro came out.
When Monjaro came out, I spokewith the general manager.
I actually called him and Isaid I am fixing something,
obesity, but I'm worsening ourenvironment.
They're not recyclable, theycannot be burned, they go to
landfill.
So it's like imagine a pen perweek, per patient, millions of

(01:07:49):
people using these pens.
Plus, it increases the price,increases the production.
They have to build newfactories just to produce the
pens.
So I think the pen itself is anexpensive process and expensive
to make.
But that's not the only reason,because Wegovi, let's say in

(01:08:09):
Europe, it's also a third ofwhat is here for the same amount
of pens.
Right, so I think it is the pen, but I think also it's because
they can, here in the unitedstates, they can get away with
it interesting.

So what is the ?
What is the issue with justgiving vials?
And yeah, I guess itlogistically will be a little
more difficult because you haveto educate the patient handling
syringes etc or having to cometo the office once a week to
just get an injection.
But how do we do it withinsulin?
That's how we do it.
I mean, they inject themselveswith syringes.

(01:08:44):
They don't have necessarilypre-filled.

I think we're going to move into that.
I think it's going to take somepatient adaptation to that idea
of having to inject themselveswith a substance I think with
the pen makes it but how to?

how do um um diabetics do with insulin?

well, also, it comes in pens, right.
I mean rarely we use a vial andsyringe.
I mean we haven't used that inI don't know how many decades,
because even insulin comes inpens, right.
So it's.
But it's just, we can learn, wecan re-educate ourselves right.
And if the cost goes from$1,200 to $300, believe me, many

(01:09:22):
patients say, yes, I will learnhow to do it right.
Occasionally I have a patientthat says I cannot deal with
seeing the needle, I'll just,I'll rather do the pen.

Interesting.
So we mentioned, we talkedabout in the very beginning of
the podcast about hormonedisruptors.
You mentioned hormonedisruptors.
There is this.
It's almost like a buzzwordthat's going on with all these
influencers on social media.
Everything is a hormonedisruptor.
Can you kind of like as anendocrinologist who is an expert

(01:09:54):
in hormones and hormonedisruptors and endocrinology,
tell us what are hormonedisruptors?
How do they affect our body,our metabolism, and where is it
in currently today, in ourenvironment?
What are the typical things?
I'm not talking about this onething in one part of the world,
like every day american in theirdaily lives, what they should

(01:10:18):
look out for, what they shouldavoid.
Just at least, um, tomorrowthey can, or even today, after
listening to the podcast, startum living a healthier life
without having their hormonesdisrupted so endocrine disrupted
chemicals are a real thing,they're completely real and they
completely can affectnegatively our health so it's

(01:10:39):
not fear-mongering oh no.

And when I talk about environmental
causes of obesity, uh, we cantalk about it's endocrine
disrupting chemicals promotingobesity.
Right, endocrine disruptchemicals.
They are substances orchemicals that mimic our own
hormones, so they go into thereceptors that our own hormones

(01:11:03):
would normally go and don'tallow them to do their proper
function.
Right.

So they're blocking the receptors.

Blocking the receptor of our natural
hormone by mimicking our ownhormones.

Which hormones are those in specific?

Estrogen .
Estrogen is one of them, andcortisol testosterone.
There are many types ofhormones.
They can cause infertility.
We can see infertility fromendocrine-resorpting chemicals.
Just yesterday there was a veryinteresting article published
in Biomedicine that it was alarge study that started here at

(01:11:37):
NYU.
They looked at 370,000 deathsdue to phthalates, which is
plastic.
So worldwide, 13% ofcardiovascular disease deaths
are caused by in 2018, just in2018, they were caused by
endocrine disrupting chemicals,specifically for phthalates that

(01:12:00):
are found in plastic.

What is the number one source of phthalate
today in our environment?
Like what?
Like bottled water.

So food packaging can be on it food
containers.

But everything is packed in plastic today.

Well and that's why we have the problem
that we have, right, thatendocrine disrupting chemicals
promote metabolic disease.
Right, they promoteinflammation, they put ourselves
in oxidative stress.
And it's found in plastics,pesticides, painting in our

(01:12:43):
walls, fabric, vinyl I meancleaners cosmetics, right, I
mean it goes.
The list goes on and on.
We cannot, I always tell mypatients, unless you go and live
in a farm in the middle ofNorway where there's nothing
around, then that's the best wayto avoid it.
But we live in anindustrialized world.

(01:13:04):
But there's some things thatyou can control, starting in
your home.

So let's talk about that yeah.

Get rid of plastic containers.
Okay, I've done that.

Yeah, get rid of plastic containers.
Okay, I've done that check.

Move to all glass containers right.
Get rid of all plastic bottlewaters.

Done.

Do glass or stainless steel?
Never, ever.
This is like the if one thingyou can do never heat in the
microwave anything in plastic,because the heat makes the BPAs,
the phthalates, spill into yourfood or into your water.
Good Right, whenever I walkhere in New York and I pass

(01:13:44):
through a pharmacy outside andin the window you have the boxes
of plastic bottled water andthe sun hitting it.
I'm like, oh my God.
I'm just like I know I can likeoh my God, I'm just like.

I know I can't escape it anymore either.

It's that.
And then also like choosechemical free cleaning supplies
right, we have everything, evenless BOCs, which are chemicals
in your paint, because thenyou're inhaling them right in
your pain, because then you'reinhaling them right.
Fabrics, those like stainrepellent they are very high in

(01:14:18):
chemicals and things, heavychemicals that are going to be
endocrine disrupting chemicals,right.
So there's little things thatwe can do in the day to day.

That have a great impact yeah.

Yeah, that can impact our health right
At least the things you cancontrol.

I mean, there's things that we can't
control because, as you said, welive in a society that it's
just the way it is.
But you can start at your ownhome.

Yeah, you can start at your own home
and even when you do groceryshopping, right.

I don't think I agree with you on bottled
water.
I mean, you never know wherethat bottle was.
It was sitting in the sun For24 hours, yeah.
So every time I see someonedrinking out of a plastic bottle
, I really cringe and I have tohold back to tell them no, don't
do it, you know.

There's pictures of water too.
There are glass for filteringwater and the filter comes in
stainless steel.
So I mean it's an investment.
But then you're filtering thewater in a glass container with
zero plastic, then you put it ina stainless steel bottle or a
glass water bottle and then youare really avoiding there and

(01:15:24):
that makes that it is impactful.
I mean I don't know why thisarticle, that it was so well
done and it showed such a highpercentage of cardiovascular
cardiometabolic death.
It's not a headline rightBecause it's not sexy.
But whenever we're talking orpeople say, oh, why are you just
prescribing medication?

(01:15:44):
What are we doing about thefood industry?
Then this is, this is proof.
These are these are things thatyou think are minimal can
impact really and preventdisease.

Yeah, well, I think the reason is because
right now, we don't have areplacement for all this.
We don't have a replacement forplastic.

Well, cardboard, a lot there's,
cardboard there's other things.

No, as far as mass production, as far as scale
production of like, how do youbring water?
How do you sell water?
I mean, you have to to.
Economically, it's not evenfeasible.
You know, they have to reallyinvent something new.
It's like this.
This shift can't happen.
I think that's why the mediadoesn't talk about it enough,
because if they start disruptingthe whole system now without

(01:16:27):
having a replacement alternativefor it yet, um, it's going to
create chaos I'm going to sendyou the the their account, their
handle.

It's a company that a guy from spain
and a guy from, I think, germany.
They created a membrane madeout of made of algae, of of
seaweed that is compostable, forwater container food they're
like.
Now they're mass producing it.
So it's like those things.
One should invest on thosethings, right?

(01:16:57):
No kidding, because they can't.
They're packaging food, they'repacking water.
Actually, in the new yorkmarathon they were giving them
out.
They were like little packagesof this membrane with water or
or electrolytes, and they justand they ate it.
So you can eat it also becauseit's made of algae.
What?

yeah, it's amazing you finish drinking your
water and then you eat thebottle just pull the whole thing
in your mouth it's like remindsme of a guacamole.
Hat you just I?

mean but things like that.
People are finding solutionsfor that right and but the but
the industry doesn't or investon it.

They don't think it's well because it's
it's because it's disrupting alot of other powerful people.
You know, money talks, I meanthe for uh.
For every one lobbies for that.
There is 100 lobbies for theother companies.
So that's an uphill battle andI think us as people can do

(01:17:51):
something about it by pressuringour constituents and pressuring
our government to pull throughwith these changes.
Otherwise I don't see ithappening in a short period.

Yeah, I was looking for the link because
I found it so interesting andthey won so many awards now for
this creation.

Any other suggestions on avoiding hormone
disruptors?

I mean we talk about organic food right
and non-organic, and people say, oh, it's not healthy.
But I mean pesticide-free, it'shealthier, right.

Start off with that easy.

Start off with that, but that's why
that.
I mean, I went to a farm oneday and the process to not have
pesticides in the crops is sodetailed and that's why it's so
expensive to really it's again,it's cheaper to have the mass
production and just swipe themwith pesticides, right, but

(01:18:53):
avoid eating the skin of fruitsand vegetables, right, because
that's where the pesticidesmorally condense.
Buying from your local farmsalso grass-fed meats,
wild-caught fish, those areother things.
Nothing that is farm.
That's another important thing,because you don't get those
hormones for the mass productionPasture-raised poultry,

(01:19:18):
pasture-raised eggs so there'slittle things that you can do
that if you put them together,they impact.

I know.
So thank you so much for that,because I think I feel like,
personally, even though I knew alot of the stuff, I feel so
overwhelmed and, um, I wanted toleave it.
Leave this conversation on aout, on a positive note, um, and
not on a doomsday note, but allof these things we've talked

(01:19:50):
about, they are true.
So someone needs to bringawareness to these things.
First, we have to acknowledgethat issues exist so we can make
changes.
Right, I mean, we have to talkabout it.
Like, if we don't talk about it, who's going to talk about it?

Exactly, and I think it's not a doom.
It's where we are right now asa country, as a, as a in the
2025,.
We live in an industry.

Not just a country, everywhere.

We live in an industrialized world,
right, we have all thistechnology, we we're we're
living smarter, but it comeswith some consequences, right,
and I think you having theeducation about how, how much
you can control and what you cancontrol, is our best way to

(01:20:40):
trying to get out of this in agood, in a good way, right, and
live healthy.

And it's empowering.
It's empowering, yeah, yes.

Yes, yourself, and that's your
biggest weapon against foodindustry and just
industrialization of itself.
We cannot say, oh, we'revictims of our society, of where
we live right now.
We have some power, and the waythat you can control and regain
power is with education 100%and to that point kind of like

(01:21:08):
to end our conversation on thatnote.

if someone listening to this entire podcast
who feels really overwhelmed,ashamed or lost or helpless,
what's one thing they can dotoday to just take back control
of their health, Like, wherewould you have them start?
And I know you talk to hundredsof patients and literally give

(01:21:34):
them that advice, but for ouraudience here, um, what would
you say?
That one thing would be wherethey would start I would say
three things okay, three thingsfair one, build muscle.

If you build muscle, muscle is an
endocrine organ too.
It releases hormones, myokines.
Muscle is your bestanti-inflammatory organ that you
have in your body.
And if you're building muscle,you're losing body fat.
We don't say that by losingbody fat, by you losing body fat

(01:22:10):
, you're not gaining muscle.
But if you concentrate on onething, and that's building
muscle, you drop body fat.
By you losing body fat, you'renot gaining muscle.
But if you concentrate on onething, and that's building
muscle, you drop body fat.
So you're already in ametabolic healthier state, right
?
Second, get rid of plastics asmuch as you can, right.
And third, educate yourself.

Thank you.
This was, I think.
Now it comes down to execution,and I really hope that the
audience takes this to heart,and thank you so so, so, so much
for sharing your knowledge,your story, your compassion.
I feel so much enthusiasm andsincerity and every time you

(01:22:56):
talk, that is inspiring to me assomeone that has been on this
path for several years now.
And for those listening guys,health isn't about perfection,
okay.
It's about reclaiming controlover your life with the tools

(01:23:18):
available to you.
And if you've been judged,dismissed or just frustrated
with your weight journey, knowthat science is on our side, you
know, and support is out there.
And for those of you who are inthe New York City area but I

(01:23:38):
know Dr Sal as well and she alsodoes virtual consultations and
calls follow her online, sharethis episode with someone who
needs to hear it and we will puther information in the caption
below.
And yeah, until next time.

(01:23:58):
Say, stay curious, stay strongand keep pushing forward.
Thank you, rocio.
It was such a pleasure to notjust get to meet you, but to get
infected by your passion forwhat you're doing, and I can't
wait to read your book, and so Ihope that it be.

(01:24:24):
I'm pretty certain it willbecome a bestseller, because I
don't think there is any morepressing and important topic
than this in our society thanit's ever been.
So thank you for all you do andkeep inspiring our colleagues
and keep pushing forward.
Thank you, Thank you so much.

(01:24:45):
Thank you so much.
All right, guys.
I hope you enjoyed this podcast.
Please leave me a review soothers can benefit from this
episode, and also you can onSpotify, leave comments down
below and I'll be happy torespond to them.
And yes, until next time.

(01:25:07):
Bye-bye, bye.

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NEW YORK ENDOCRINOLOGY, P.C.

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