January 2, 2025 • 28 mins
Welcome to episode 58 of the Pound of Cure Weight Loss Podcast, where Dr. Matthew Weiner and Zoe Schroeder dive into cutting-edge obesity treatments like GLP-1 medications (like Ozempic and Mounjaro) and their role alongside bariatric surgery and nutrition. This episode delivers insights into new research, nutrition strategies, and the future of affordable Semaglutide production.
GLP-1 Medications vs. Bariatric Surgery: A Data-Driven Comparison
A recent study presented at the American Society for Metabolic and Bariatric Surgery examined 40,000 participants’ weight loss outcomes across three approaches: lifestyle changes, GLP-1 medications, and bariatric surgery.
- Lifestyle changes led to 7% weight loss but most of the weight returned within four years.
- GLP-1 medications like Wegovy achieved 15-22% weight loss, though over 50% was regained upon stopping treatment.
- Bariatric surgery offered the most durable results, with gastric bypass patients maintaining 25% total weight loss after 10 years.
Dr. Weiner emphasized that combining these tools often yields the best results, rather than choosing one in isolation. “When used strategically, they complement each other to lower your metabolic setpoint effectively,” he explained.
Addition vs. Restriction: A New Approach to Dieting
Most diets focus on restriction, which fails over time. Instead, Zoe advocates for an addition mindset, emphasizing nutrient-dense foods like vegetables, lean proteins, and healthy fats.
“When you focus on what you can add rather than what you must cut out, it naturally crowds out less healthy choices and fosters a sustainable, positive mindset,” she explained.
Semaglutide’s Global Impact and the Rise of Generics
Dr. Weiner highlighted a groundbreaking development in the global production of Semaglutide. Due to a favorable ruling in India, generic versions could be available by 2026, potentially lowering costs significantly.
“This could be a game-changer for millions who currently can’t access Semaglutide,” Dr. Weiner noted, though challenges like cold-chain transport and international legality remain.
Nutrition Strategies for GLP-1 Success
For those using GLP-1 medications, Zoe shares essential dietary tips to optimize results and minimize side effects:
- Prioritize vegetables, fruits, lean proteins, nuts, seeds, and legumes.
- Avoid greasy and processed foods that can worsen nausea or digestive issues.
“This unprocessed, nutrient-dense diet mirrors the advice we give post-bariatric surgery patients,” Dr. Weiner added.
Key Takeaways
1. GLP-1 Medications: Transformative but most effective when paired with proper nutrition and, in some cases, surgery.
2. Restriction Diets Are Outdated: Adopt an addition mindset to foster long-term, sustainable success.
3. Bariatric Surgery’s Durability: Surgery offers unmatched long-term weight loss results, especially when integrated with other tools.
4. Affordable Semaglutide Is Coming: Generic production in India could reshape global access by 2026.
Final Thoughts
Episode 58 reveals the synergistic power of combining GLP-1 medications, bariatric surgery, and the right nutrition strategies. If you’re ready to take control of your metabolic setpoint, this episode provides the tools and insights you need.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Zoe (00:00):
Let's say I need to eliminate sugar from my diet.
And it starts with thatchocolate at night.
And you're like, okay, I justcan't have that chocolate at
night.
Okay, I'm going to take awaythat chocolate at night from my
diet.
Okay, I can't have.
And you just focus on whatyou're restricting.
You're hyper fixating on it.
You're putting yourself in thatrestrictive kind of deprivation
(00:21):
mindset.
Instead of focusing on therestriction side of it, focus on
what you can add.
Welcome back to the Pound ofCure weight loss podcast.
A cut above surgery outperformsGLP-1 meds for durable weight
loss.
Dr. Weiner (00:38):
Yes.
Zoe (00:38):
That's the name of today's episode.
Dr. Weiner (00:41):
Yeah, we do everything in our office, right
we?
If you want to come and see usfor weight loss and just want to
work on your nutrition, we havea nutrition program.
Truthfully, you can do thatfrom anywhere in the country.
We write tons of prescriptionsfor these medications.
I think we write moreprescriptions for the
medications than any practice inTucson.
Zoe (00:59):
But what's different is that it's like the specialized
dosing versus like.
I just feel like I come acrossa lot of people who get it from
their PCP, yeah, and it's justlike all the dosings all over
the place and they don't reallyget the best results from that
because it's not as specialized.
Dr. Weiner (01:18):
I mean, I think this and we're going to talk about
the news article in just asecond but it's comparing
lifestyle and medications andsurgery, and in my mind they're
not three things to compare,they're three things to use and
combine as necessary.
Zoe (01:36):
They're not mutually exclusive.
Dr. Weiner (01:37):
They're not mutually exclusive, and so the problem
is doing any one of those thingsalone oftentimes doesn't work
out great.
It's only when you start tocombine them that you really see
all of the benefits of them.
And so you know the GLP-1 medsand people are going to wellness
spas or whatever and gettingthese meds and oftentimes will
(01:58):
initially have some decentresults.
But the long-term nutrition isreally what is going to allow
that weight to kind of staywhere you get it and give you
the tools so that you canmaintain that.
Weight loss Surgery withoutnutrition makes zero sense at
all and often people don't getwhat they want out of it and
(02:19):
sometimes we combine all three.
That's the most powerful.
Zoe (02:22):
Way's our pyramid, it's our pyramid exactly, um and so.
Dr. Weiner (02:26):
So anyway, I think you know let's, let's move into
this segment.
Um and so this this is a newsarticle.
It comes from medical newstoday and it says bariatric
surgery is better for weightloss than glp-1 drugs such as
ozempic, and this comes out of aresearch study.
This is a pretty common themewhere someone puts out a paper
that's interesting, and wecovered one of these a while ago
(02:49):
about Osempic making you goblind.
I haven't heard a word about itsince, like the 24-hour news
cycle that it hit, because it'sprobably nothing there and the
scientific article really wasn'ta particularly strong
scientific article, and so thescientific article kind of gets
caught by someone in the pressand they publicize it and
(03:10):
oftentimes the magnitude orimportance of that article is
outstated, overstated.
So this comes from it wasn'teven a peer-reviewed article, so
I think this is not publishedyet.
It hasn't been formallypeer-reviewed article.
(03:37):
So I think this is notpublished yet.
It hasn't been formallypeer-reviewed.
So I think that's a reallyimportant thing about any news
article and journal article isthat what happens is you submit
it to a journal and then,practicing, can join an
editorial board.
A lot of times it's kind ofleaders and academics and when
they submit articles, you reviewthem and you say this is a good
article, or this is a badarticle, or you didn't explain
this and what about this?
And so there's this kind ofthis editing process that goes
(03:59):
on, that holds your science upto make sure it's up to snuff.
So if your science is flimsy,if your statistics are weak, if
they feel like you've kind ofmisstated something and you
don't really have the proof ofit, that gets pushed back to you
.
So that whole editorial processreally validates a paper and so
it ensures that you can't justwrite anything and get it
(04:21):
published in the journal andhave people start to follow it
and read it, and so that's animportant part of academics and
of medicine in general.
This has not been published yet,but it was.
They did present at a largeconference they presented at the
ASMBS, which is the AmericanSociety for Metabolic and
Bariatric Surgery.
I'm a very active member inthat group and it's really
(04:42):
honestly, it's a group of peopleI really have a lot of respect
for.
So there's a lot of greatbariatric surgeons out there, a
lot of very smart people who aredoing very good work, and so
I've always really loved being amember of that group and this
was a talk given at the nationalmeeting, and so this is someone
(05:03):
who comes and they put all thisstuff in front of a crowd of
two, three, four, 500 surgeons,and so that there's believe me,
you know if, if you put a bunchof crap up there, you're going
to get oh yeah, it's not goingto go well, you're going to get
torn apart, and I've seen thingslike that happen.
Um and uh.
It's not pretty.
Uh yeah, public evisceration isnot necessarily a pleasant
(05:26):
experience.
Um, it's, yeah, it's not, it'snot generally like that, but but
you know, there is certainly astandard, and if you violate
that standard you will hearabout it, and so so the fact
that this you know made it tothe podium and got that level of
attention really does show thatthere is some merit to this
study.
Um, I'm sure there'll be a fewtweaks, but probably no major
substantive conclusions will bechanged.
Zoe (05:49):
Before it's published Before it's published, right,
okay?
Dr. Weiner (05:51):
So this was a meta-analysis and we've talked
about meta-analysis in the past.
Meta-analysis means you take abunch of different studies and
you combine all of the data andlook at 20, 30, 40 studies.
What it allows you to do wherea normal study might be 100, 200
, 500, 1,000 people, this studyhad 40,000 people in it and it
(06:11):
looked at people across alldifferent treatment modalities
for obesity, so they had 40,000patients, which is makes it a
huge study.
And so with science, the morethe people, the larger the
number of people in the study,the more likely you're going to
get an accurate answer.
And something we say inmedicine and statistics is you
know, I can't tell you at allwhat's going to happen to one
(06:32):
patient, but I can tell you veryprecisely what's going to
happen to 100,000 patients.
And I think, that's an importantthing to understand when you're
both the patient and whenyou're reading these scientific
articles.
So 40,000 people, that's a lot.
It's a pretty good study and itcame out of my alma mater, nyu,
so that's where I did myresidency and it was a bariatric
(06:56):
surgeon, dr Megan Jenkins, whoput this out and she did a
meta-analysis and so there were18,000 patients who'd had a
gastric bypass, which isactually a lot.
Only 6,000 had a sleeve andthat really goes very much
against.
Certainly over the last 10years, what the ratio of you
know, there's been a lot moresleeves than bypasses, so I
think that's also interestingtoo in some of the conclusions.
My theory is, if it had been18,000 sleeves and 6,000
(07:20):
bypasses, they might not havecome to the same conclusion.
Zoe (07:23):
Oh interesting.
Dr. Weiner (07:25):
So there were 18,000 bypasses, 6,000 sleep patients,
723 lifestyle patients, 12,000semaglutide patients and 3,000
trisepatide patients.
So about 15,000 people on themeds, 24,000 on the surgery and
then a handful of lifestylepatients.
And another important thinganytime you want to know what
(07:47):
you need to know about, aboutresearch, figure out who funded
it, and so this was funded byMedtronic, and they are the
makers of the surgical staplersthat I use every day, and so you
know when the money's comingfrom the company that funds the
surgical staplers.
(08:08):
You could fairly accuratelypredict that there's going to be
some favorable things saidabout bariatric surgery yeah um,
you know bariatric surgery, um,volumes are down with glp1
medications and the surgicalstapler companies, the robot,
all their stocks are down as aresult.
So, anyway, so they showed 7%total body weight loss with
(08:33):
lifestyle change alone andalmost complete weight regain at
four years, and thatunfortunately mirrors what most
of us see.
And so when they looked atWeGoV, they saw 15% total body
weight loss.
The data that's out there isusually is around 15, 16%.
(08:53):
They showed 22% weight loss wasZepBound that syncs with what
we see in the Surmount trial and21% at one year and I think 25%
at 18 months is what most.
That's the numbers I usuallythrow out there.
And they said that half theweight was regained after
stopping the medication.
So they looked at people whostopped the medication.
(09:14):
I'm surprised it was only half.
Zoe (09:15):
I was going to say that too .
Dr. Weiner (09:17):
Yeah, my hunch is, if they followed it out long
enough, it's going to be morecomplete.
That's what we're generallyseeing.
It may take a year or two toregain all the weight, but when
you stop the meds you're almostalways going to regain a
substantial amount of the weight.
I think it also depends howmuch you lose, right?
If you lose 110 pounds, you'reprobably going to see a lot of
that come back quickly.
(09:37):
You lose 20 pounds.
It might be a little easier tokeep that off.
So they saw 29% total bodyweight loss for sleeve, 32% for
gastric bypass and for allbariatric surgery they
maintained 25% weight loss after10 years.
So that's pretty good.
You've maintained total bodyweight loss of 25% at 10 years.
They showed 22% weight losswith Zepbound.
(10:00):
So even at 10 years the weightloss after bariatric surgery was
better than it was at one yearfor Zepbound.
So this clearly shows and I doagree with this- it's kind of
what you've been saying allalong.
Surgery does, especially gastricbypass does provide better
weight loss than the medications, but you've got to have surgery
.
Zoe (10:19):
Well, yeah, and as we know, there's so many factors for the
individual that needs to takeinto consideration.
Dr. Weiner (10:26):
And I think the thing that we also often talk
about is this idea of a bellcurve of response and and you
know we talk about sometimes andwe've mentioned in past in past
podcasts about super complianteating, which is kind of the
hardcore vegan or near vegan,really, really almost perfect
lifestyle changes, super clean,not like they just don't eat a
(10:50):
lot of crap, but like they nevereat crap.
That you know.
You might see a little bit morethan 7%, and people who
maintain that behavior arelikely to maintain that weight
loss for a lot longer, notregain at all for years.
With the meds we see somepeople have these crazy good
responses.
We see some people not respondat all.
And the same thing with thesurgery we see some people
(11:12):
respond incredibly well.
We see some people not respondas well.
One of the reasons I tend tolean a little bit more toward a
bypass if someone's not going touse the medications is that the
bell curve for a bypass is morenarrow, meaning we have a lot
fewer poor responders.
And we still do see those superresponders with a bypass, but
(11:32):
we don't see those people losing20 or 30 pounds only after
surgery, like I've seen a coupledozen times after a sleeve, and
so, anyway, I think this was aninteresting article.
40,000 patients is a lot,funded by the stapler company,
so we got to take that with agrain of salt, um, but.
But it really shows us.
To me, I think this is what weall know, which is that
(11:53):
nutrition is the backbone of alltreatments, but when used alone
tends to not work very well.
It's when we add the meds orthe surgery that we get the good
results, and surgery works alittle better than meds.
So interesting news article Ithought it was worth mentioning.
All right, so what do we havefor nutrition today?
Zoe (12:11):
All right.
Well, I have two things kind ofprepared.
One is like a more tacticalnutrition tip, which I know a
lot of people like, and thenanother one is more of like that
mindset reframe that I findextremely powerful.
So I'm going to give them bothtake what you you know resonates
and leave what doesn't.
So the first one is coming fromwe had it on our group class
(12:35):
schedule for the nutritionprogram.
One of the sessions we have is arecipe swap party, so everyone
comes and brings a recipe thatthey've made recently and talks
about it.
So everyone comes and brings arecipe that they've made
recently and talks about it.
And so the one that I actuallywas talking about, because I've
been seeing online a lot thiskind of pizza dough or a dough
(12:55):
substitution, so I wanted to putmy own spin on it.
So, and I've actually used itin two different capacities now.
So it's like for the pizzadough, I used whole wheat flour
and plain nonfat Greek yogurtand some baking powder.
So for those of you who needthe exact like measurements, one
(13:17):
cup of the whole wheat flour,one cup of the Greek yogurt and
a one and a half teaspoons ofbaking powder and then a little
bit of salt.
So the recipes I've been seeingonline, as they say to use
bread flour, which makes sense,it's going to be a little
fluffier and whatever.
But, um, I don't have that and Idon't want it.
Um, so the?
(13:38):
So you, then you need it into adough and you, you know, like
kind of shrug it out, whateverthe word I'm looking for.
Spread it out, yep, roll it.
I didn't use a rolling pin, butyou spread it out and then I
built my, you know, pizzas on itand then baked it.
You can air fry it whatever,and it was great.
(14:00):
It held up.
I have my little sister's incollege.
She lives not too far from me,so she comes over occasionally
on Sundays and it's always thisfunny thing of like what do you
want?
Do you have any specialrequests?
And she's like nothing withkale, nothing with arugula.
She's like I'll eat.
You know, she's a pretty basiceater, but anyway she was like,
wow, even I like this, so itholds up.
(14:21):
The reason why I brought it tobring it up is because we talk a
lot or I talk a lot withpatients about how so many
things in nutrition are on thespectrum Right.
Maybe over here we have theDomino's pizza and then over
here we have your, you knowportobello mushroom crust pizza
or you know zucchini boatsinstead, and it's like, yeah,
(14:42):
that's a great option, but maybesometimes you want to make a
swap.
That's like not all the way onthat end of the spectrum, right.
And so I was really happy thatI had such great success with
this pizza dough.
I was telling people about itand it was great.
And then the other capacity inwhich I use is I made pumpkin
spice bagels out of that youlost me at pumpkin spice.
(15:02):
Oh, you don't like pumpkin spice.
Well, I'm sure that there willbe some people who like it.
So it's the same dough base andI just added a little bit of
pumpkin and pumpkin pie spiceand did it like that air fried
it.
It turned out great.
Dr. Weiner (15:14):
So you air fried the dough.
Zoe (15:17):
Yes, I cut it into four parts.
So it was the one cup of flour.
One cup of Greek yogurt makesfour servings.
Um, rolled it out into littlebagels.
I put a little egg wash on thetop, sprinkled a little cinnamon
air, fried it and they werefluffy, they were cooked, they
(15:37):
were great.
And then, like the next days, Icut in half, put it in the
toaster.
And then what I used?
I made a little spread withlight cream cheese, vanilla,
protein powder, pumpkin pureeand some more cinnamon and
blended that all up togetherjust to make like an extra
pumpkin-y spread that I'm sureyou would love.
(15:59):
But anyway, that's kind of mynewest recipe obsession.
I'm excited to kind of try insome other way.
Dr. Weiner (16:07):
That's interesting.
Yeah, I think it's a solidmiddle in the Solid middle.
Zoe (16:11):
Right, we don't want to be using flour all the time, but
the reason why I picked wholewheat flour is because it's
going to have more fiber.
It's going to have more protein, you know, slightly less
processed or stripped away fromnutrients than the bread flour.
So you know that was somethingthat I wanted to share.
Dr. Weiner (16:28):
I love it.
I love it.
Zoe (16:29):
So let's talk about the mindset piece, then, and it has
to do with this idea of additionversus restriction.
Okay, so when you are focusingon, let's say, I need to
eliminate sugar from my diet,right, and it starts with that
chocolate at night let's justuse that example.
Or you know, whatever it is andyou're like, okay, I just can't
(16:53):
have that chocolate at night.
Okay, I'm going to take awaythat chocolate at night from my
diet.
Okay, I can't have.
And you just focus on whatyou're restricting, you're hyper
, fixating on it, you're puttingyourself in that restrictive
kind of deprivation mindset andit's leaving that hole and it's
just going to backfire.
(17:14):
And so, instead of focusing onthe restriction side of it,
focus on what you can add.
So it's how can I add morevegetables, or add more steps,
or add more water, or add more,add more beans, whatever it is?
And then maybe you're stilltrying to take away that
chocolate at night but you'refocusing on the addition.
(17:34):
You're in an abundant positivemindset on what you can add.
Wow, Look at all these things Ican have.
And it naturally crowds outthose things you're trying to
avoid or restrict without kindof getting caught up in that
hyper fixation mindset about it.
Dr. Weiner (17:48):
And that's the essence of the Pound to Cure
program.
I mean, it's exactly what wetry to get people to do.
So, yeah, you're right.
I mean when you were talkingabout like the chocolate, and
you can't stop thinking about it, it's like the don't think
about an elephant.
Zoe (18:01):
Yeah, exactly.
Dr. Weiner (18:03):
All you can think about is a freaking elephant,
and so you want to get out ofthat kind of out of that
approach and this, really this,this is this idea of a cat, of
your calorie ratio, and sothat's something else I like
about that approach, which isthat if I, let's say, eat
something that I shouldn't beeating, and then I, so I'm like,
(18:23):
oh wow, most people are like,well, I'm not eating for the
rest of the day, which, ofcourse, sets you up to just do
the same thing over and overagain.
Instead, if you're thinkingabout, well, I just screwed up
my ratio, the only way to getthe ratio up is to add a bunch
of good calories into the mix,and that will bring your ratio
up, and so that, to me, isreally how I like to focus on
(18:45):
things.
No-transcript the more goodstuff you eat, the healthier
your metabolism is, the more itlowers your set point, the more
weight you lose and the easiertime you have maintaining that
(19:06):
weight loss.
So, yeah, I love it.
Those are two great tips.
So let's move into oureconomics of obesity segment,
and this is about something thatwe've been following pretty
closely for a while now.
We've talked in some pastepisodes.
I think it was episode 23, bigFood, big Pharma, big Lies.
We talked about semaglutide.
(19:28):
So just a quick reminder whenthese pharma companies file
these patents for drugs, theydon't just file like one patent.
They're not like here it is,here's the drug.
I have one patent.
Oftentimes around one drugthere may be five, six, seven
different patents, and now youthrow the injector pens in.
(19:48):
The injector pens each havelike 15 patents around them.
So there's a lot of patents anda lot of protection that these
drug companies rely on, and thepatents are the reason why
compounded medications are goingto come to an end, like we've
talked about once the shortageends, and the reason why the
medications are so expensive.
If there was no patent law thenanybody could be making
(20:10):
semaglutide and it'd probably beabout 50, 60 bucks a month to
be on semaglutide.
But we also have to incentivizeresearch and development, and
Eli Lilly and Nova Norris putbillions of dollars into these
drugs and they deserve to getsome of that money back.
And they also put billions ofdollars into drugs that never
made it at all and they nevermade a dime off of those drugs.
(20:32):
So we have that balance issomething we're constantly
trying to work on.
So there's two main patents forsemaglutide.
The first expires in 2026.
So a drug patent is 20 yearslong, and so it was filed in
2006.
And it really was the veryfirst version of taking the
(20:53):
GLP-1 hormone and adding acertain compound on it that made
it not get metabolized.
So if I just took GLP-1, theactual thing that circulates in
our body and I injected it intosomebody, it would last like
minutes, and so that's notuseful for a drug.
You need a drug to last muchlonger, especially one that
reduces your appetite and helpsyou lose weight.
So they started addingcompounds on and that slows down
(21:17):
the breakdown on and that slowsdown the breakdown.
And so the first one, thatexpires in 2026, is fairly vague
, and they just kind of use ageneral chemical compound that
they add to the GLP-1 molecule.
The one that expires in, Ithink, 2032 is very specific.
This is the actual molecule.
(21:39):
Here's all the carbons andnitrogens and hydrogens and
oxygen atoms, and here's exactlyhow it's made up, and so that's
the one that they're using toprotect the drug.
But you can make an argumentthat it was actually the 2006
patent.
That is the real patent andthis 2032 is just them playing
patent games.
(21:59):
So the thing is in the UnitedStates, the law shifts toward
the patent holder, so there'sdefinitely a bias to protect the
companies that hold the patents, but that's not true in every
country.
So India, it's really very muchthe opposite.
India has the law, favors thepeople and giving access to the
(22:21):
people and reducing prices andcosts and increasing people's
availability.
So there was a ruling in um inthe indian courts, um, that
basically the 2026 patent wasthe one they were going to
follow.
And so, um, there was actuallya company called Mylan and
(22:43):
they're a generic drugmanufacturer and they have.
They won the lawsuit and theirparent company, natco, now has
the ability to make semaglutidein India.
So, as of 2026, the semaglutidepatent is over in India the
semi-glutide patent is over inIndia.
Zoe (23:03):
Do you think they're like having the fact?
They're like producing it nowso that once the patent's over
they can start shipping out inmass quantities?
Dr. Weiner (23:09):
You know, maybe my suspicion is that this stuff is
not that hard to make.
It's been the injector pen, thefact that our market is flooded
with.
You know, I think 19 differentmanufacturers are making
semaglutide right now Right, sothat's not the issue.
It's not the issue, it's makingthe drug has never been the
hard thing.
Making the drug has neverreally been the cause of the
(23:31):
shortages.
Zoe (23:32):
Or the expensive thing.
Dr. Weiner (23:34):
It's the pens.
It's the stupid freakinginjector pens.
You know we've had vials andsyringes for 100 years and those
injector pens.
You know we've had vials andsyringes for a hundred years and
those are cheap and easy toproduce.
And you know, if this had allbeen done with vials and
syringes, believe me peoplewould have figured this out and
they would have figured out thedose and as much as this stuff
(23:55):
can cause some unpleasantness.
You know, even if you overdosed, it's really probably not.
It's not going to be fatal.
It might be pretty unpleasant,land you in the er, but it's not
going to cause any substantialdanger or risk for, except for a
very, very small group ofpeople, right, um?
And believe me, we see problemswith the injector pens all the
time.
People forget to take the capoff and they fire.
(24:17):
And then you know, there's allkinds of stuff that happens with
those too.
So so I think the question oneverybody's mind is so what's
this mean for me here in the USor in a country not in India?
If you're in India, you'regoing to be able to get
semaglutide pretty cheap, Ithink, within a few years.
What if you're in the US?
So this is what's where thingsare going to get a little bit
(24:39):
interesting.
So you know, we have patientswho want to use Zepbound and
they're on Medicare and so ifyou're on Medicare you can't use
that $650 coupon, so you got topay the full price, which is
like $1,100.
It's available in Canada forsomewhere between $600 to 800
(25:00):
bucks, depending on the dose.
Zoe (25:02):
A month, a month A month?
Dr. Weiner (25:03):
Yes, and so we write prescriptions to a Canadian
pharmacy and that Canadianpharmacy fills the medication.
So it's legal in the UnitedStates to write a prescription
to a pharmacy that's overseasthat can then ship you the
medication.
And so there's no, we don't getany kickback from the Canadian
pharmacies or anything like that.
(25:24):
We're not the ones selling it,but our patients can get it for
a reduced price.
So I can pretty much guaranteeyou someone in India is going to
figure out how to ship thisstuff over, and if we, if you
buy it from India and they shipit to your home, that's not a
patent violation because that'ssubject to India patent law.
(25:44):
Again, I'm not a lawyer.
We'll have to see how this pansout.
I might be wrong on this, butmy suspicion is that we will be
able to write semaglutideprescriptions for FDA approved
meds in India and have theprescription filled in India, in
India, and have theprescription filled in India,
(26:05):
which is probably a betterarrangement than every wellness
spa and every strip mall, youknow, selling a Chinese knockoff
of it.
So I think that's interesting.
We'll have to see.
The problem is keeping it cold.
Zoe (26:16):
I was thinking about that.
Dr. Weiner (26:17):
Yeah, that's going to be difficult.
Zoe (26:19):
Well, I guess we'll check back in in two years.
Dr. Weiner (26:21):
Check back in two years for sure.
So, anyway, interesting.
I thought that was interestingand we'll certainly be following
that and talk more about itlater.
Zoe (26:30):
Yeah, absolutely Well.
Thank you so much for listeningand we'll catch you next time.
Dr. Weiner (26:34):
Fantastic.
See you next time.
Let's say I need to eliminate sugar from my diet.
And it starts with thatchocolate at night.
And you're like, okay, I justcan't have that chocolate at
night.
Okay, I'm going to take awaythat chocolate at night from my
diet.
Okay, I can't have.
And you just focus on whatyou're restricting.
You're hyper fixating on it.
You're putting yourself in thatrestrictive kind of deprivation
(00:21):
mindset.
Instead of focusing on therestriction side of it, focus on
what you can add.
Welcome back to the Pound ofCure weight loss podcast.
A cut above surgery outperformsGLP-1 meds for durable weight
loss.
Dr. Weiner (00:38):
Yes.
Zoe (00:38):
That's the name of today's episode.
Dr. Weiner (00:41):
Yeah, we do everything in our office, right
we?
If you want to come and see usfor weight loss and just want to
work on your nutrition, we havea nutrition program.
Truthfully, you can do thatfrom anywhere in the country.
We write tons of prescriptionsfor these medications.
I think we write moreprescriptions for the
medications than any practice inTucson.
Zoe (00:59):
But what's different is that it's like the specialized
dosing versus like.
I just feel like I come acrossa lot of people who get it from
their PCP, yeah, and it's justlike all the dosings all over
the place and they don't reallyget the best results from that
because it's not as specialized.
Dr. Weiner (01:18):
I mean, I think this and we're going to talk about
the news article in just asecond but it's comparing
lifestyle and medications andsurgery, and in my mind they're
not three things to compare,they're three things to use and
combine as necessary.
Zoe (01:36):
They're not mutually exclusive.
Dr. Weiner (01:37):
They're not mutually exclusive, and so the problem
is doing any one of those thingsalone oftentimes doesn't work
out great.
It's only when you start tocombine them that you really see
all of the benefits of them.
And so you know the GLP-1 medsand people are going to wellness
spas or whatever and gettingthese meds and oftentimes will
(01:58):
initially have some decentresults.
But the long-term nutrition isreally what is going to allow
that weight to kind of staywhere you get it and give you
the tools so that you canmaintain that.
Weight loss Surgery withoutnutrition makes zero sense at
all and often people don't getwhat they want out of it and
(02:19):
sometimes we combine all three.
That's the most powerful.
Zoe (02:22):
Way's our pyramid, it's our pyramid exactly, um and so.
Dr. Weiner (02:26):
So anyway, I think you know let's, let's move into
this segment.
Um and so this this is a newsarticle.
It comes from medical newstoday and it says bariatric
surgery is better for weightloss than glp-1 drugs such as
ozempic, and this comes out of aresearch study.
This is a pretty common themewhere someone puts out a paper
that's interesting, and wecovered one of these a while ago
(02:49):
about Osempic making you goblind.
I haven't heard a word about itsince, like the 24-hour news
cycle that it hit, because it'sprobably nothing there and the
scientific article really wasn'ta particularly strong
scientific article, and so thescientific article kind of gets
caught by someone in the pressand they publicize it and
(03:10):
oftentimes the magnitude orimportance of that article is
outstated, overstated.
So this comes from it wasn'teven a peer-reviewed article, so
I think this is not publishedyet.
It hasn't been formallypeer-reviewed article.
(03:37):
So I think this is notpublished yet.
It hasn't been formallypeer-reviewed.
So I think that's a reallyimportant thing about any news
article and journal article isthat what happens is you submit
it to a journal and then,practicing, can join an
editorial board.
A lot of times it's kind ofleaders and academics and when
they submit articles, you reviewthem and you say this is a good
article, or this is a badarticle, or you didn't explain
this and what about this?
And so there's this kind ofthis editing process that goes
(03:59):
on, that holds your science upto make sure it's up to snuff.
So if your science is flimsy,if your statistics are weak, if
they feel like you've kind ofmisstated something and you
don't really have the proof ofit, that gets pushed back to you
.
So that whole editorial processreally validates a paper and so
it ensures that you can't justwrite anything and get it
(04:21):
published in the journal andhave people start to follow it
and read it, and so that's animportant part of academics and
of medicine in general.
This has not been published yet,but it was.
They did present at a largeconference they presented at the
ASMBS, which is the AmericanSociety for Metabolic and
Bariatric Surgery.
I'm a very active member inthat group and it's really
(04:42):
honestly, it's a group of peopleI really have a lot of respect
for.
So there's a lot of greatbariatric surgeons out there, a
lot of very smart people who aredoing very good work, and so
I've always really loved being amember of that group and this
was a talk given at the nationalmeeting, and so this is someone
(05:03):
who comes and they put all thisstuff in front of a crowd of
two, three, four, 500 surgeons,and so that there's believe me,
you know if, if you put a bunchof crap up there, you're going
to get oh yeah, it's not goingto go well, you're going to get
torn apart, and I've seen thingslike that happen.
Um and uh.
It's not pretty.
Uh yeah, public evisceration isnot necessarily a pleasant
(05:26):
experience.
Um, it's, yeah, it's not, it'snot generally like that, but but
you know, there is certainly astandard, and if you violate
that standard you will hearabout it, and so so the fact
that this you know made it tothe podium and got that level of
attention really does show thatthere is some merit to this
study.
Um, I'm sure there'll be a fewtweaks, but probably no major
substantive conclusions will bechanged.
Zoe (05:49):
Before it's published Before it's published, right,
okay?
Dr. Weiner (05:51):
So this was a meta-analysis and we've talked
about meta-analysis in the past.
Meta-analysis means you take abunch of different studies and
you combine all of the data andlook at 20, 30, 40 studies.
What it allows you to do wherea normal study might be 100, 200
, 500, 1,000 people, this studyhad 40,000 people in it and it
(06:11):
looked at people across alldifferent treatment modalities
for obesity, so they had 40,000patients, which is makes it a
huge study.
And so with science, the morethe people, the larger the
number of people in the study,the more likely you're going to
get an accurate answer.
And something we say inmedicine and statistics is you
know, I can't tell you at allwhat's going to happen to one
(06:32):
patient, but I can tell you veryprecisely what's going to
happen to 100,000 patients.
And I think, that's an importantthing to understand when you're
both the patient and whenyou're reading these scientific
articles.
So 40,000 people, that's a lot.
It's a pretty good study and itcame out of my alma mater, nyu,
so that's where I did myresidency and it was a bariatric
(06:56):
surgeon, dr Megan Jenkins, whoput this out and she did a
meta-analysis and so there were18,000 patients who'd had a
gastric bypass, which isactually a lot.
Only 6,000 had a sleeve andthat really goes very much
against.
Certainly over the last 10years, what the ratio of you
know, there's been a lot moresleeves than bypasses, so I
think that's also interestingtoo in some of the conclusions.
My theory is, if it had been18,000 sleeves and 6,000
(07:20):
bypasses, they might not havecome to the same conclusion.
Zoe (07:23):
Oh interesting.
Dr. Weiner (07:25):
So there were 18,000 bypasses, 6,000 sleep patients,
723 lifestyle patients, 12,000semaglutide patients and 3,000
trisepatide patients.
So about 15,000 people on themeds, 24,000 on the surgery and
then a handful of lifestylepatients.
And another important thinganytime you want to know what
(07:47):
you need to know about, aboutresearch, figure out who funded
it, and so this was funded byMedtronic, and they are the
makers of the surgical staplersthat I use every day, and so you
know when the money's comingfrom the company that funds the
surgical staplers.
(08:08):
You could fairly accuratelypredict that there's going to be
some favorable things saidabout bariatric surgery yeah um,
you know bariatric surgery, um,volumes are down with glp1
medications and the surgicalstapler companies, the robot,
all their stocks are down as aresult.
So, anyway, so they showed 7%total body weight loss with
(08:33):
lifestyle change alone andalmost complete weight regain at
four years, and thatunfortunately mirrors what most
of us see.
And so when they looked atWeGoV, they saw 15% total body
weight loss.
The data that's out there isusually is around 15, 16%.
(08:53):
They showed 22% weight loss wasZepBound that syncs with what
we see in the Surmount trial and21% at one year and I think 25%
at 18 months is what most.
That's the numbers I usuallythrow out there.
And they said that half theweight was regained after
stopping the medication.
So they looked at people whostopped the medication.
(09:14):
I'm surprised it was only half.
Zoe (09:15):
I was going to say that too .
Dr. Weiner (09:17):
Yeah, my hunch is, if they followed it out long
enough, it's going to be morecomplete.
That's what we're generallyseeing.
It may take a year or two toregain all the weight, but when
you stop the meds you're almostalways going to regain a
substantial amount of the weight.
I think it also depends howmuch you lose, right?
If you lose 110 pounds, you'reprobably going to see a lot of
that come back quickly.
(09:37):
You lose 20 pounds.
It might be a little easier tokeep that off.
So they saw 29% total bodyweight loss for sleeve, 32% for
gastric bypass and for allbariatric surgery they
maintained 25% weight loss after10 years.
So that's pretty good.
You've maintained total bodyweight loss of 25% at 10 years.
They showed 22% weight losswith Zepbound.
(10:00):
So even at 10 years the weightloss after bariatric surgery was
better than it was at one yearfor Zepbound.
So this clearly shows and I doagree with this- it's kind of
what you've been saying allalong.
Surgery does, especially gastricbypass does provide better
weight loss than the medications, but you've got to have surgery
.
Zoe (10:19):
Well, yeah, and as we know, there's so many factors for the
individual that needs to takeinto consideration.
Dr. Weiner (10:26):
And I think the thing that we also often talk
about is this idea of a bellcurve of response and and you
know we talk about sometimes andwe've mentioned in past in past
podcasts about super complianteating, which is kind of the
hardcore vegan or near vegan,really, really almost perfect
lifestyle changes, super clean,not like they just don't eat a
(10:50):
lot of crap, but like they nevereat crap.
That you know.
You might see a little bit morethan 7%, and people who
maintain that behavior arelikely to maintain that weight
loss for a lot longer, notregain at all for years.
With the meds we see somepeople have these crazy good
responses.
We see some people not respondat all.
And the same thing with thesurgery we see some people
(11:12):
respond incredibly well.
We see some people not respondas well.
One of the reasons I tend tolean a little bit more toward a
bypass if someone's not going touse the medications is that the
bell curve for a bypass is morenarrow, meaning we have a lot
fewer poor responders.
And we still do see those superresponders with a bypass, but
(11:32):
we don't see those people losing20 or 30 pounds only after
surgery, like I've seen a coupledozen times after a sleeve, and
so, anyway, I think this was aninteresting article.
40,000 patients is a lot,funded by the stapler company,
so we got to take that with agrain of salt, um, but.
But it really shows us.
To me, I think this is what weall know, which is that
(11:53):
nutrition is the backbone of alltreatments, but when used alone
tends to not work very well.
It's when we add the meds orthe surgery that we get the good
results, and surgery works alittle better than meds.
So interesting news article Ithought it was worth mentioning.
All right, so what do we havefor nutrition today?
Zoe (12:11):
All right.
Well, I have two things kind ofprepared.
One is like a more tacticalnutrition tip, which I know a
lot of people like, and thenanother one is more of like that
mindset reframe that I findextremely powerful.
So I'm going to give them bothtake what you you know resonates
and leave what doesn't.
So the first one is coming fromwe had it on our group class
(12:35):
schedule for the nutritionprogram.
One of the sessions we have is arecipe swap party, so everyone
comes and brings a recipe thatthey've made recently and talks
about it.
So everyone comes and brings arecipe that they've made
recently and talks about it.
And so the one that I actuallywas talking about, because I've
been seeing online a lot thiskind of pizza dough or a dough
(12:55):
substitution, so I wanted to putmy own spin on it.
So, and I've actually used itin two different capacities now.
So it's like for the pizzadough, I used whole wheat flour
and plain nonfat Greek yogurtand some baking powder.
So for those of you who needthe exact like measurements, one
(13:17):
cup of the whole wheat flour,one cup of the Greek yogurt and
a one and a half teaspoons ofbaking powder and then a little
bit of salt.
So the recipes I've been seeingonline, as they say to use
bread flour, which makes sense,it's going to be a little
fluffier and whatever.
But, um, I don't have that and Idon't want it.
Um, so the?
(13:38):
So you, then you need it into adough and you, you know, like
kind of shrug it out, whateverthe word I'm looking for.
Spread it out, yep, roll it.
I didn't use a rolling pin, butyou spread it out and then I
built my, you know, pizzas on itand then baked it.
You can air fry it whatever,and it was great.
(14:00):
It held up.
I have my little sister's incollege.
She lives not too far from me,so she comes over occasionally
on Sundays and it's always thisfunny thing of like what do you
want?
Do you have any specialrequests?
And she's like nothing withkale, nothing with arugula.
She's like I'll eat.
You know, she's a pretty basiceater, but anyway she was like,
wow, even I like this, so itholds up.
(14:21):
The reason why I brought it tobring it up is because we talk a
lot or I talk a lot withpatients about how so many
things in nutrition are on thespectrum Right.
Maybe over here we have theDomino's pizza and then over
here we have your, you knowportobello mushroom crust pizza
or you know zucchini boatsinstead, and it's like, yeah,
(14:42):
that's a great option, but maybesometimes you want to make a
swap.
That's like not all the way onthat end of the spectrum, right.
And so I was really happy thatI had such great success with
this pizza dough.
I was telling people about itand it was great.
And then the other capacity inwhich I use is I made pumpkin
spice bagels out of that youlost me at pumpkin spice.
(15:02):
Oh, you don't like pumpkin spice.
Well, I'm sure that there willbe some people who like it.
So it's the same dough base andI just added a little bit of
pumpkin and pumpkin pie spiceand did it like that air fried
it.
It turned out great.
Dr. Weiner (15:14):
So you air fried the dough.
Zoe (15:17):
Yes, I cut it into four parts.
So it was the one cup of flour.
One cup of Greek yogurt makesfour servings.
Um, rolled it out into littlebagels.
I put a little egg wash on thetop, sprinkled a little cinnamon
air, fried it and they werefluffy, they were cooked, they
(15:37):
were great.
And then, like the next days, Icut in half, put it in the
toaster.
And then what I used?
I made a little spread withlight cream cheese, vanilla,
protein powder, pumpkin pureeand some more cinnamon and
blended that all up togetherjust to make like an extra
pumpkin-y spread that I'm sureyou would love.
(15:59):
But anyway, that's kind of mynewest recipe obsession.
I'm excited to kind of try insome other way.
Dr. Weiner (16:07):
That's interesting.
Yeah, I think it's a solidmiddle in the Solid middle.
Zoe (16:11):
Right, we don't want to be using flour all the time, but
the reason why I picked wholewheat flour is because it's
going to have more fiber.
It's going to have more protein, you know, slightly less
processed or stripped away fromnutrients than the bread flour.
So you know that was somethingthat I wanted to share.
Dr. Weiner (16:28):
I love it.
I love it.
Zoe (16:29):
So let's talk about the mindset piece, then, and it has
to do with this idea of additionversus restriction.
Okay, so when you are focusingon, let's say, I need to
eliminate sugar from my diet,right, and it starts with that
chocolate at night let's justuse that example.
Or you know, whatever it is andyou're like, okay, I just can't
(16:53):
have that chocolate at night.
Okay, I'm going to take awaythat chocolate at night from my
diet.
Okay, I can't have.
And you just focus on whatyou're restricting, you're hyper
, fixating on it, you're puttingyourself in that restrictive
kind of deprivation mindset andit's leaving that hole and it's
just going to backfire.
(17:14):
And so, instead of focusing onthe restriction side of it,
focus on what you can add.
So it's how can I add morevegetables, or add more steps,
or add more water, or add more,add more beans, whatever it is?
And then maybe you're stilltrying to take away that
chocolate at night but you'refocusing on the addition.
(17:34):
You're in an abundant positivemindset on what you can add.
Wow, Look at all these things Ican have.
And it naturally crowds outthose things you're trying to
avoid or restrict without kindof getting caught up in that
hyper fixation mindset about it.
Dr. Weiner (17:48):
And that's the essence of the Pound to Cure
program.
I mean, it's exactly what wetry to get people to do.
So, yeah, you're right.
I mean when you were talkingabout like the chocolate, and
you can't stop thinking about it, it's like the don't think
about an elephant.
Zoe (18:01):
Yeah, exactly.
Dr. Weiner (18:03):
All you can think about is a freaking elephant,
and so you want to get out ofthat kind of out of that
approach and this, really this,this is this idea of a cat, of
your calorie ratio, and sothat's something else I like
about that approach, which isthat if I, let's say, eat
something that I shouldn't beeating, and then I, so I'm like,
(18:23):
oh wow, most people are like,well, I'm not eating for the
rest of the day, which, ofcourse, sets you up to just do
the same thing over and overagain.
Instead, if you're thinkingabout, well, I just screwed up
my ratio, the only way to getthe ratio up is to add a bunch
of good calories into the mix,and that will bring your ratio
up, and so that, to me, isreally how I like to focus on
(18:45):
things.
No-transcript the more goodstuff you eat, the healthier
your metabolism is, the more itlowers your set point, the more
weight you lose and the easiertime you have maintaining that
(19:06):
weight loss.
So, yeah, I love it.
Those are two great tips.
So let's move into oureconomics of obesity segment,
and this is about something thatwe've been following pretty
closely for a while now.
We've talked in some pastepisodes.
I think it was episode 23, bigFood, big Pharma, big Lies.
We talked about semaglutide.
(19:28):
So just a quick reminder whenthese pharma companies file
these patents for drugs, theydon't just file like one patent.
They're not like here it is,here's the drug.
I have one patent.
Oftentimes around one drugthere may be five, six, seven
different patents, and now youthrow the injector pens in.
(19:48):
The injector pens each havelike 15 patents around them.
So there's a lot of patents anda lot of protection that these
drug companies rely on, and thepatents are the reason why
compounded medications are goingto come to an end, like we've
talked about once the shortageends, and the reason why the
medications are so expensive.
If there was no patent law thenanybody could be making
(20:10):
semaglutide and it'd probably beabout 50, 60 bucks a month to
be on semaglutide.
But we also have to incentivizeresearch and development, and
Eli Lilly and Nova Norris putbillions of dollars into these
drugs and they deserve to getsome of that money back.
And they also put billions ofdollars into drugs that never
made it at all and they nevermade a dime off of those drugs.
(20:32):
So we have that balance issomething we're constantly
trying to work on.
So there's two main patents forsemaglutide.
The first expires in 2026.
So a drug patent is 20 yearslong, and so it was filed in
2006.
And it really was the veryfirst version of taking the
(20:53):
GLP-1 hormone and adding acertain compound on it that made
it not get metabolized.
So if I just took GLP-1, theactual thing that circulates in
our body and I injected it intosomebody, it would last like
minutes, and so that's notuseful for a drug.
You need a drug to last muchlonger, especially one that
reduces your appetite and helpsyou lose weight.
So they started addingcompounds on and that slows down
(21:17):
the breakdown on and that slowsdown the breakdown.
And so the first one, thatexpires in 2026, is fairly vague
, and they just kind of use ageneral chemical compound that
they add to the GLP-1 molecule.
The one that expires in, Ithink, 2032 is very specific.
This is the actual molecule.
(21:39):
Here's all the carbons andnitrogens and hydrogens and
oxygen atoms, and here's exactlyhow it's made up, and so that's
the one that they're using toprotect the drug.
But you can make an argumentthat it was actually the 2006
patent.
That is the real patent andthis 2032 is just them playing
patent games.
(21:59):
So the thing is in the UnitedStates, the law shifts toward
the patent holder, so there'sdefinitely a bias to protect the
companies that hold the patents, but that's not true in every
country.
So India, it's really very muchthe opposite.
India has the law, favors thepeople and giving access to the
(22:21):
people and reducing prices andcosts and increasing people's
availability.
So there was a ruling in um inthe indian courts, um, that
basically the 2026 patent wasthe one they were going to
follow.
And so, um, there was actuallya company called Mylan and
(22:43):
they're a generic drugmanufacturer and they have.
They won the lawsuit and theirparent company, natco, now has
the ability to make semaglutidein India.
So, as of 2026, the semaglutidepatent is over in India the
semi-glutide patent is over inIndia.
Zoe (23:03):
Do you think they're like having the fact?
They're like producing it nowso that once the patent's over
they can start shipping out inmass quantities?
Dr. Weiner (23:09):
You know, maybe my suspicion is that this stuff is
not that hard to make.
It's been the injector pen, thefact that our market is flooded
with.
You know, I think 19 differentmanufacturers are making
semaglutide right now Right, sothat's not the issue.
It's not the issue, it's makingthe drug has never been the
hard thing.
Making the drug has neverreally been the cause of the
(23:31):
shortages.
Zoe (23:32):
Or the expensive thing.
Dr. Weiner (23:34):
It's the pens.
It's the stupid freakinginjector pens.
You know we've had vials andsyringes for 100 years and those
injector pens.
You know we've had vials andsyringes for a hundred years and
those are cheap and easy toproduce.
And you know, if this had allbeen done with vials and
syringes, believe me peoplewould have figured this out and
they would have figured out thedose and as much as this stuff
(23:55):
can cause some unpleasantness.
You know, even if you overdosed, it's really probably not.
It's not going to be fatal.
It might be pretty unpleasant,land you in the er, but it's not
going to cause any substantialdanger or risk for, except for a
very, very small group ofpeople, right, um?
And believe me, we see problemswith the injector pens all the
time.
People forget to take the capoff and they fire.
(24:17):
And then you know, there's allkinds of stuff that happens with
those too.
So so I think the question oneverybody's mind is so what's
this mean for me here in the USor in a country not in India?
If you're in India, you'regoing to be able to get
semaglutide pretty cheap, Ithink, within a few years.
What if you're in the US?
So this is what's where thingsare going to get a little bit
(24:39):
interesting.
So you know, we have patientswho want to use Zepbound and
they're on Medicare and so ifyou're on Medicare you can't use
that $650 coupon, so you got topay the full price, which is
like $1,100.
It's available in Canada forsomewhere between $600 to 800
(25:00):
bucks, depending on the dose.
Zoe (25:02):
A month, a month A month?
Dr. Weiner (25:03):
Yes, and so we write prescriptions to a Canadian
pharmacy and that Canadianpharmacy fills the medication.
So it's legal in the UnitedStates to write a prescription
to a pharmacy that's overseasthat can then ship you the
medication.
And so there's no, we don't getany kickback from the Canadian
pharmacies or anything like that.
(25:24):
We're not the ones selling it,but our patients can get it for
a reduced price.
So I can pretty much guaranteeyou someone in India is going to
figure out how to ship thisstuff over, and if we, if you
buy it from India and they shipit to your home, that's not a
patent violation because that'ssubject to India patent law.
(25:44):
Again, I'm not a lawyer.
We'll have to see how this pansout.
I might be wrong on this, butmy suspicion is that we will be
able to write semaglutideprescriptions for FDA approved
meds in India and have theprescription filled in India, in
India, and have theprescription filled in India,
(26:05):
which is probably a betterarrangement than every wellness
spa and every strip mall, youknow, selling a Chinese knockoff
of it.
So I think that's interesting.
We'll have to see.
The problem is keeping it cold.
Zoe (26:16):
I was thinking about that.
Dr. Weiner (26:17):
Yeah, that's going to be difficult.
Zoe (26:19):
Well, I guess we'll check back in in two years.
Dr. Weiner (26:21):
Check back in two years for sure.
So, anyway, interesting.
I thought that was interestingand we'll certainly be following
that and talk more about itlater.
Zoe (26:30):
Yeah, absolutely Well.
Thank you so much for listeningand we'll catch you next time.
Dr. Weiner (26:34):
Fantastic.
See you next time.
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