Dr. Gabrielle Lyon 00:00

From a firefighter study that showed that those that could do 40 plus push ups had an easy, 40% lower mortality risk, but had nothing to do with 11 it also was only men and it was only firefighters. Somehow, yeah, it was just so confusing.

Dr. Gabrielle Lyon 00:22

And

Dr. Gabrielle Lyon 00:24

I really like Brigham.

Speaker 1 00:27

Yeah,

Dr. Michelle Pearlman 00:31

I haven’t

Speaker 2 00:32

met him before,

Dr. Gabrielle Lyon 00:33

but he seems very pleasant. Yeah, everybody’s phone that’s, I’m so glad I asked

Dr. Michelle Pearlman 00:38

you. That’s crazy.

Dr. Gabrielle Lyon 00:39

So Saturday, if you guys want to do dinner, all of you, she’s like, Oh yeah, you’d like to do dinner, you can ask if Brigham would like to as well. What time is recording? He’s recording

Speaker 1 00:55

at 3pm Okay, could be early.

Dr. Gabrielle Lyon 00:57

Okay. Are you ready? We’re going. So whenever you’re ready,

Speaker 2 01:00

we’re going. So whenever you’re ready,

Speaker 3 01:02

I’m ready.

Dr. Gabrielle Lyon 01:03

Okay, if you say anything. So I often, frequently say really stupid fucking things. And if perhaps you do, although I highly doubt it, you could just pause and then say it again. We did have that one guy we’re recording right now. I won’t say anything. No, I’ve done that before, not exactly, not exactly. I also have one question for you, Matt, the intro. Are we going to record an intro? Yeah, with Michelle Pearlman. Is she going to be sitting there? Are we putting this in the teleprompter, and I am going to be doing this?

Speaker 2 01:46

Yes,

Dr. Gabrielle Lyon 01:47

afterwards, afterwards. So she is okay. You’re

Speaker 2 01:49

okay, right now, where you are

Dr. Gabrielle Lyon 01:51

great, yeah, right. I’m sure, like, my hair is a mess, looks great. I didn’t do it. Everyone’s phones off,

Speaker 2 02:03

yes.

Dr. Gabrielle Lyon 02:04

Dr. Michelle Perlman, welcome to the show.

Dr. Michelle Pearlman 02:08

Thank you so much for having me.

Dr. Gabrielle Lyon 02:09

You know, as I was thinking about today’s episode, we are going to talk about a gastro metabolic approach to health and wellness, because you are a gastroenterologist, for those individuals who don’t know what that is. And that field of medicine, how would you describe that?

Dr. Michelle Pearlman 02:27

In simplistic terms? I take care of everything from the mouth all the way down to the anus. So what does that mean? Well, it’s understanding digestion, absorption. You know, the things that we put in our mouth, how that affects the cellular health of our body and the gut microbiome, which, oddly enough, I never learned about in 14 years worth of medical training.

Dr. Gabrielle Lyon 02:49

Not surprising. It’s kind of this evolving field. You know, when we were talking before the camera started rolling, you had said that you were doing a ton of endoscopies, the little cameras that you swallow, and that’s a routine procedure done by gastroenterologists. Also you do colonoscopy, so you do both ends,

Dr. Michelle Pearlman 03:08

not at the same

Dr. Gabrielle Lyon 03:10

time. That would be impressive and very convenient, because it would really minimize the amount of time that one was in the operating suite, or whatever it is you had said something that I thought was really interesting from a medical perspective. Number one, typically, medicine isn’t about disease prevention. It’s about fixing a problem. And when you were scoping these people, they would finish their scope and say, I’m still not feeling well. You

Speaker 3 03:38

know,

Dr. Michelle Pearlman 03:39

it’s interesting. I went into gastroenterology because I’ve always been fascinated with nutrition, and I figured, okay, out of all the specialties available, which one would you assume would learn the most about nutrition? Well, a gastroenterologist came to my mind, because the gut and its food and our mouth and everything and absorption and digestion, and I’ll tell you throughout all that training in three years worth of Gastroenterology and Hepatology fellowship training, I learned pathology. I did not learn nutrition. I learned about celiac disease, I learned about Ulcerative Colitis and Crohn’s disease and steato hepatitis and reflux disease. But none of that training actually covered nutrition, and it was actually one of my attendings. One of my bosses in my training program told me when I was about to graduate, he said, Michelle, there’s no business in nutrition. I think you should just be a general gastroenterologist and do endoscopies and colonoscopies. And I said, I don’t buy it,

Dr. Gabrielle Lyon 04:39

okay? And now you in your own clinical practice. So you have a private practice, you combine both nutritional sciences with gastroenterology.

Dr. Michelle Pearlman 04:49

Oh, absolutely, because they are one in the same just like the mind and body, people often say that they are two different things. The whole gut brain access is such a power. Full connection that we have. And so when I would do, you know, let’s say 15 procedures in a day, I would have people that have been struggling with acid reflux and abdominal pain and bloating, diarrhea, constipation for decades, and they would wake up after the procedure and they’d say, Doc, what’s wrong with me? I’m miserable. And I learned a powerful lesson. I once, you know, I trained at the VA, and my patient woke up, and I said, Billy, great news. Everything was normal. And he said, Oh, Doc, so you’re telling me I’m bat X crazy. And I learned, don’t tell someone who’s suffering that everything’s normal. I think the phrasing is very important. And so endoscopies and colonoscopies are looking for structural things, but oftentimes when people are suffering from acid reflux and all of these other symptoms, it’s more of a functional process or a motility issue, and you’re not going to find that during a procedure.

Dr. Gabrielle Lyon 05:53

When you are seeing patients now, your practice is a little bit skewed. People are really coming to you for prevention, but for the general population, what is the most common symptom that people are seeking to solve for?

Dr. Michelle Pearlman 06:07

And so my practice has definitely evolved. Initially, I was seeing people mostly for weight management, so people who wanted to be able to lose a good amount of weight for overall health, not to see a six pack pack and walk around on South Beach, although I do have a couple of those, but most of my patients wanted to lose, let’s say, 10 to 15% of their body weight and be able to keep it off. And so that’s the initial practice. Was weight management. How things evolved is, you know, a lot of my patients were middle aged women, and a big part of my practice is using GLP one medications to improve cardio metabolic health and help with the weight loss process. Because most of the patients come to see me, it’s not their first rodeo. They’ve struggled for decades. The last thing they want is to go to a doctor and be told by just another person to eat less and move more because they’re really struggling. So I use all the tools in the toolbox to help optimize someone’s health when they come to see me, which

Dr. Gabrielle Lyon 07:02

is countertop, because most people

Dr. Michelle Pearlman 07:04

don’t

Dr. Gabrielle Lyon 07:04

go to a gastroenterologist, thinking I’m going to do nutritional work, yeah, thinking I’m bloated, I’m having reflux, maybe I need my scope, which is now 45 is when they’re colonoscopy, for colonoscopy. But

Dr. Michelle Pearlman 07:18

what’s interesting is so many gastro related issues, heartburn, bloating, pelvic floor dysfunction, constipation, are weight related. And that’s one of the other reasons why I pivoted in my practice, is because a lot of my patients were struggling with their weight. So they would have acid reflux, and I would do the endoscopy, and the endoscopy was normal, and I’d say, Okay, go on protonics or Nexium, or, you know, pick a random antacid where there’s a million on the market, why don’t we shut down your acid production? We would give out as gastroenterologist PPIs and other antacids like candy. But is that fixing the underlying problem? If someone is struggling with obesity and they have a lot of visceral fat, that extra fat around the midsection is just acting like an external corset. It’s increasing intra abdominal pressure, and they’re going to reflux, so no amount of antacid is going to fix the mechanical issue. So that was one of the main reasons for my pivot. The other main reason is the place I was working was not ready for a culture shift when it came to nutrition. So it’s fascinating. Within medicine, we talk about things at such a high level when we talk about innovation and technology and all these high level concepts. But I don’t know if you’ve seen and I’m sure you have, we are missing the low hanging fruit pun intended. One of the worst places that you can find Ultra processed food is the hospital.

Dr. Gabrielle Lyon 08:41

Oh yeah,

Dr. Michelle Pearlman 08:42

I would have patients wake up from their endoscopy. They would literally still be half asleep, lying almost flat, and the nurse would give them orange juice, or they’d give them a very high sodium turkey sandwich or a cookie or a muffin. And I would tell them, I literally just spent an hour with this patient talking about optimal nutrition. It really sends them a very confusing message to give them everything I told them to to limit,

Dr. Gabrielle Lyon 09:10

yeah,

Dr. Michelle Pearlman 09:11

you know, and I was told by the staff that I was too aggressive for asking for hummus and carrots and healthier snacks when my patients woke up from their procedure.

Dr. Gabrielle Lyon 09:22

That is shifting now we have the new dietary guidelines that are really targeting towards whole healthy foods. What percentage of individuals, if the majority of individuals are struggling with obesity or are overweight, but also a huge percentage of the population has reflux? What percentage would you consider, or do you think is the reflex related to say something like H Pylori or some kind of pathology, or maybe not pathology, but a parasite or something like that, versus weight?

Dr. Michelle Pearlman 09:57

Yeah, I think it’s really hard to say I would. Say, you know, the new normal is being overweight or obese, where, if you see a normal appearing individual, oftentimes we assume there’s something wrong with them. I mean, that’s how scary it’s become with with just, just even on a global perspective, when it comes to weight, when it comes to being overweight. So I’m not sure I can give you that exact percentage, because if the majority of patients we’re seeing are overweight or obese, and I’m a gastroenterologist, I’m seeing a very skewed population, because most of those patients are coming in to see me for gastro related issues.

Dr. Gabrielle Lyon 10:33

Do you use PPIs?

Dr. Michelle Pearlman 10:35

I do. A lot of my patients come in because they’ve been on them for years, but my goal is attack the nutrition part, and not just what they’re eating, but the dietary habits are equally as important. How late they’re eating, how much they’re eating, how quickly they’re eating. You know, what is the volume at which they’re eating? Are they sucking down tons of fluids with a straw during their meal? So those dietary habits are equally as important. So I tackle those. Obviously, I want to try to help them get to a healthier weight. If they need a PPI or another antacid in the interim, by all means, I’ll use them. But my goal is not to just shut down someone’s acid long term, because we’re seeing longer term effects from these right? It is a survival mechanism, or it’s evolutionary, you know, based that we produce acid, because acid helps us break down food, which then allows for proper absorption. So it only makes intuitive sense that if I were to shut down all your acid production, could I be affecting bone density? Probably, I

Dr. Gabrielle Lyon 11:33

think there’s some pretty good data. Yeah, and this

Speaker 3 11:35

because

Dr. Michelle Pearlman 11:35

that affects vitamin D and calcium and all these things, that

Dr. Gabrielle Lyon 11:38

is exactly where I wanted to get to with this component of the show about PPI so proton pump inhibitors, things like Pepcid or antacids. One of the things very I remember, I used to live in New York City, by the way, and a very fit, more mature woman came in and she had fractured her femur, and this was close to 15 years ago, and based on everything that we looked because I was, you know, utilizing nutrition in my practice, I was like, Listen, this PPI used that you’ve been on chronic PPIs, this has affected your calcium, your vitamin mineral status. And man, her coach, her trainer, was furious at me, because they were like, I can’t believe that you told them that their PPI is affecting their bone density. Subsequently, years later, we’re starting to see a lot more data that these are even while they are available over the counter, these medications are available over the counter. It doesn’t mean that they’re safe.

Dr. Michelle Pearlman 12:39

Oh, and I would say some of the over counter medications, like ibuprofen, they give gastroenterologist job security when it comes to peptic ulcers, the number of patients that would come in hemorrhaging to death because they took a bunch of NSAIDs for, let’s say, orthopedic issues, more than I want to say. So oftentimes people equate over the counter was safe, and that’s not necessarily the truth.

Dr. Gabrielle Lyon 13:03

If you were to tell them, people listening, what’s up, guys, three things never to do. What would you tell them? Please don’t say carbonation. I know your sister is here, Dr Amy Pearl, and we’re not talking about sex toys just yet. But would it be, for example, I love carbonation. Please don’t tell me to stop drinking carbonated things. Are there a handful of things that you’re like, you know, when

Dr. Michelle Pearlman 13:30

it comes to acid reflux and acid

Dr. Gabrielle Lyon 13:32

reflux, or, how about gut health, just in general?

Dr. Michelle Pearlman 13:35

Okay, the first thing would be, you have to be able to identify the food, right? So if it’s something like bologna, it’s a hodgepodge of the odds and ends of who knows what that is. So even though it’s high protein, it’s very ultra processed, so that can definitely lead to dysbiosis of the gut. So I would say, try to minimize the number of ingredients. So calories are important. Macronutrients are important, but the quality of our food and the ingredients really, really matter when it comes to overall gut health and how people feel.

Dr. Gabrielle Lyon 14:09

How do we how do we know? Do we know that to be true? So we have randomized control trials that’ll elicit the information that if something is ultra processed there, so there’s a cause, a mechanism of action and an outcome.

Dr. Michelle Pearlman 14:24

So for instance, like deli meat is considered a class one carcinogen, increased risk of things like colorectal cancer and gastric cancer. So you had mentioned kind of the new screening guidelines for colorectal cancer. So really, since the beginning of time, it was age 50, but we are seeing metastatic colorectal cancer in 20 year olds. Why

Dr. Gabrielle Lyon 14:45

do you think that is it’s

Speaker 3 14:46

our

Dr. Michelle Pearlman 14:46

environmental exposures. These are people without genetic predisposition. And the interesting thing is, our genetics haven’t changed within the past couple of decades. Our environment, our environmental exposures have and. That changes the way our genes are expressed, or epigenetics.

Dr. Gabrielle Lyon 15:03

Do you think that it is the, say, for example, the nitrites, nitrates, or, do you think that it’s this constant exposure to chemicals from maybe fruits and vegetables, or just, you know, why colorectal cancer?

Dr. Michelle Pearlman 15:18

I think it’s all of those things, right? When I say environmental exposures, it’s whether it’s microplastics, whether it’s pesticides, whether it’s, you know, pollutants in the air, it’s so hard to say because you can’t do randomized, controlled trials. In that regard, I don’t know what people are being exposed to in their home. Let’s say with mold, colorectal cancer is very common, and it’s now becoming the leading cause of cancer under the age of 50 for individuals, and we’re seeing it at earlier ages. So in most other cancers, we are making progress when it comes to prevention and lowering prevalence, but we’re seeing more metastatic disease in younger individuals. And why is that? It’s because the stuff we’re eating right has direct contact with our gastrointestinal tract versus, let’s say, you know, our skin, you know that’s different. Our hair is different, our eyes are different. What we’re eating and our gut microbiome, our gut is our largest immune organ. So if, what if we’re putting in chemicals into our body and we’re stimulating this underlying cytokine cascade that has huge implications on just overall health and disease, but also direct contact with that gut lining. And

Dr. Gabrielle Lyon 16:30

is it because the colon is where, if someone is constipated, that that, you know, waste byproduct sits there?

Dr. Michelle Pearlman 16:37

Oh, yeah, I think that’s, I think that’s definitely playing a role. Now, does constipation increase risk of colorectal cancer? I don’t think we have the data to support that, but I’m sure you know, if those feces, which are, you know, basically waste matter, are sitting there, I imagine that probably can’t be good for the lining of the gut.

Dr. Gabrielle Lyon 16:56

Yeah, I just, I think, do we have, you know, the carcinogen? Classification has been a real challenge for me because, you know, there was that Annals of Internal Medicine, Bradley Johnston came out with, you know, basically, he looked at red meat, and he looked at the risk factors, and he used the grade analysis for you guys listening and will link these papers. I think they’re available to everybody, but basically the great analysis of how you know the quality of the evidence, and there, if you know, basically, if his whole read me, he didn’t find a relationship between cancer or heart disease, which makes me think, is it a weight problem? Is it, for example, if we’ve got 20 year olds that are coming in with metastatic cancer, I mean, it’s got to be pretty complex. And it’s probably also, from what I understand, one of the risk factors for colorectal cancer, if I’m not mistaken, is obesity? Oh yeah, no, absolutely. But what’s interesting about that is that hasn’t made it into the screening guidelines. So if, let’s say, I have a patient who has metabolic disease and obesity, I’m not screening them any earlier based on guidelines. I’m still waiting until I’m 45 I think that’s where the guidelines probably need significant improvement. If we know that you know diabetes or insulin resistance or fatty liver, if these things may play a role in development of polyps, then that should make it into the screening guidelines, to the point where, let’s

Dr. Michelle Pearlman 18:30

say you have someone who’s very healthy and they have a colonoscopy at 45 Do they need a repeat colonoscopy in 10 years? Maybe, maybe not. Versus someone who, let’s say, is diabetic and has other metabolic issues, maybe we shouldn’t wait 10 years, even with a normal colonoscopy at 45 I think that’s where there’s a lot of unknowns.

Dr. Gabrielle Lyon 18:48

When do you think would be appropriate to screen for colonoscopy?

Dr. Michelle Pearlman 18:53

I think 45 is appropriate, because if we were to lower that age, the question is, are people going to have access to the procedures we already have, depending on where you live. There aren’t many gastroenterologists in smaller towns. So if we end up lowering the screening age, are these people actually gonna have access to get colonoscopies? And colonoscopies do have risk, because you get sedation versus screening a larger population. There’s now a blood test that’s come out, you can do cologuard,

Dr. Gabrielle Lyon 19:22

which is, do you mean for this is really important, and I believe in early cancer detection, are you talking about the Grail test or the gallery test that looks at methylated DNA for various types of cancers, or cologuard, or something like

Dr. Michelle Pearlman 19:37

that? So it’s actually a different company. It’s a different company that recently came out. So it’s separate from, like, the gallery test, and specifically is looking for, like, higher risk polyps in the blood. So that’s a separate test. Yeah, yeah, that’s how you get more people screened, right? A screening test is only effective if you’re doing it in a large population,

Dr. Gabrielle Lyon 19:58

and how specific. Like, how sensitive are those tests? And yeah,

Dr. Michelle Pearlman 20:02

you’re still going to have false negatives and false positives. But if someone is willing to do a colonoscopy with a positive blood test, versus they’d say, I’m never doing a colonoscopy. Which

Dr. Gabrielle Lyon 20:15

patients like that, and I’m sure

Speaker 4 20:16

at least

Dr. Michelle Pearlman 20:17

they’re going to get screened. Now, would you offer the blood test if they said, even if it’s positive and not getting a colonoscopy. Not sure in that regard, it’s going to be helpful, but sometimes it will lead someone to get a colonoscopy. If they say, okay, you know, I need to take this more seriously, because it was a, you know, a positive test, but yeah, you can still have false negatives and false positives. Colonoscopy is technically the gold standard, but not everyone has access to colonoscopies, and not everyone is willing to do that as their first step.

Dr. Gabrielle Lyon 20:44

What would you say are the clear Yeah,

Speaker 2 20:47

so you asked her the three things you labeled one, if we could kind

Dr. Gabrielle Lyon 20:53

of finish

Speaker 5 20:54

that, yeah, and

Speaker 2 20:56

then you can go into that question.

Dr. Gabrielle Lyon 20:58

I’m just so interested in that, yeah. Okay, okay, so I’m gonna ask it again. Were the three things that you would tell people never to do? You have them in your

Speaker 3 21:06

mind?

Speaker 2 21:06

So you hit the question,

Speaker 3 21:08

I’m

Dr. Gabrielle Lyon 21:08

gonna have her say all three, yeah. And

Speaker 3 21:10

then

Dr. Michelle Pearlman 21:11

Ultra processed food. So when it comes to gi health, yeah, in particular,

Speaker 2 21:16

exactly the whole conversation you had right now, you also kind of display or talk about the time of when you should go get your colonoscopy. So that would also be one of the three, if you if you wanted

Dr. Gabrielle Lyon 21:30

1. So basically, what Matt’s doing? Have you done a ton of podcasts? He’s doing pickups right now? No. So this

Speaker 3 21:34

is good. Also,

Dr. Gabrielle Lyon 21:35

you’re doing great.

Dr. Michelle Pearlman 21:36

I would say the second would be never, never ignore warning signs. Okay?

Dr. Gabrielle Lyon 21:41

And then, do you have the third and because we’ll have her say, but why don’t we have her say all three? Yes,

Speaker 2 21:45

that’s fine. And then we’ll ask it, and she can hit it,

Dr. Gabrielle Lyon 21:47

yeah. Do you have your third one?

Speaker 2 21:50

You said, Never ignore warning signs.

Speaker 3 21:51

Yeah,

Speaker 1 21:52

never believe the claims on a marketing

Dr. Michelle Pearlman 21:59

package for okay, I can do that.

Dr. Gabrielle Lyon 22:00

No, no.

Dr. Michelle Pearlman 22:02

Eloquently,

Dr. Gabrielle Lyon 22:04

save what.

Dr. Michelle Pearlman 22:05

Eloquently,

Speaker 1 22:06

never believe that all the mark.

Dr. Gabrielle Lyon 22:08

But do you okay? So you know what? David Barr, how about that? I mean, that’s that’s interesting, also risky,

Dr. Michelle Pearlman 22:13

yeah.

Dr. Gabrielle Lyon 22:13

I mean, also, if

Speaker 2 22:16

you can stay away from

Dr. Gabrielle Lyon 22:19

them, no, but, so recently, because of FTC, are you familiar with how the USDA and then how the FTC runs food labeling laws?

Dr. Michelle Pearlman 22:28

I don’t know the nuances. So

Dr. Gabrielle Lyon 22:30

there’s about a 20% rate, yeah, for example, right,

Dr. Michelle Pearlman 22:32

but I saw how the macros didn’t add up, and their EPG and all that stuff, yeah, yeah,

Dr. Gabrielle Lyon 22:37

yeah. But they can legally do it because under FTC, as opposed to USDA, deals with commodities. What

Speaker 3 22:44

would

Dr. Gabrielle Lyon 22:45

be a third one? Let me think you mentioned

Dr. Gabrielle Lyon 22:49

the ultra processed

Dr. Michelle Pearlman 22:54

foods. Yeah, never ignore warning signs. Yes. Do you want

Dr. Gabrielle Lyon 23:00

to say, don’t believe the labels on the

Dr. Michelle Pearlman 23:02

packaging, or never believe something if it seems too good,

Speaker 6 23:09

that kind of confuses that. Yeah,

Speaker 2 23:12

because I’m like, Okay, I don’t believe anything.

Dr. Gabrielle Lyon 23:15

What about, what about excessive use of over the counter?

Dr. Michelle Pearlman 23:18

Oh, never believe that over the counter things are,

Dr. Gabrielle Lyon 23:21

are

Dr. Michelle Pearlman 23:21

always, are safer than more control, yeah, let’s say things I would

Speaker 2 23:26

say, like, be stay cautious of,

Dr. Michelle Pearlman 23:28

yeah, yeah.

Dr. Gabrielle Lyon 23:30

Anything else? Cleanses, cleanses, detoxes. I mean, that’s all bullshit,

Dr. Michelle Pearlman 23:37

right? I mean, never protect your natural detox. Never believe the hype or something or,

Speaker 2 23:44

Oh, you were saying, don’t just rely on me when lifestyle is actually the truth. Oh,

Dr. Michelle Pearlman 23:51

never skip foundation. Never skip the foundation. I’ll say, Never skip the foundation. Yeah, okay,

Dr. Gabrielle Lyon 24:00

meanwhile, my fucking hamstring is killing

Dr. Michelle Pearlman 24:05

1. But how would I word the first one about the ultra processed food?

Dr. Gabrielle Lyon 24:09

I don’t actually agree with that.

Speaker 2 24:11

Well, you did talk

Dr. Gabrielle Lyon 24:12

because

Speaker 3 24:13

protein

Dr. Gabrielle Lyon 24:14

shakes are ultra processed.

Dr. Michelle Pearlman 24:15

No,

Speaker 3 24:16

I know. I know,

Dr. Michelle Pearlman 24:17

yeah, but yeah, it depends on how we define processed. Everything, technically is processed. If there are chemicals our body doesn’t recognize,

Dr. Gabrielle Lyon 24:27

you should mention that,

Speaker 2 24:28

yeah, ask it again from the top. The three questions are the three things, and then you can kind of better off, or if you want to, yeah,

Dr. Michelle Pearlman 24:34

can we maybe just change the way we ask? Because I hate saying never, maybe just three things, you would caution patients or something

Dr. Gabrielle Lyon 24:44

caution. We’re doing it for you, because we’re going to push this out. Yeah, it’s, it’s three things. So I’m gonna say, what are the three things that you would and then you say, Well, I never. Say, never, yeah,

Dr. Michelle Pearlman 24:55

yeah. Okay.

Dr. Gabrielle Lyon 24:59

So we. Make the episode so you get the best visibility. So that’s where some of these questions

Speaker 3 25:05

come

Dr. Gabrielle Lyon 25:07

from. Three things that you would tell your patients to never do for gut health,

Dr. Michelle Pearlman 25:12

okay, I never say never. But the first one is to avoid, or try to at least limit Ultra processed food.

Dr. Gabrielle Lyon 25:23

Number two.

Dr. Michelle Pearlman 25:24

Number two is never, well, I guess I do say never, almost never, never ignore warning signs. I

Dr. Gabrielle Lyon 25:31

think that that’s a really good never do, because as physicians, I think that we’re also focused on the nuance. And it’s very difficult to say, Okay, this is black and white, but that is something that I would say people should never ignore warning signs. I think that’s really important,

Dr. Michelle Pearlman 25:49

yeah. And I think we’re seeing it, you know, in the celebrity realm, where people are coming out. James Van Der Beek with Colorado, that’s what I was thinking, Yeah. And how,

Speaker 3 25:58

by the way,

Dr. Michelle Pearlman 25:58

didn’t have a weight problem, yeah, no, but he had some symptoms that he probably said, Oh, it’s probably nothing. And there has been several celebrities and professional athletes that have died from colorectal cancer over the past few years. And so it used to be that if a 25 year old person came into my clinic and said, I’ve had rectal bleeding, most gastroenterologists would say you’re too young for colorectal cancer. It’s probably just hemorrhoids. And then we realized it’s not just hemorrhoids in a lot of people. And so anyone with any sort of rectal bleeding, even if it’s just rectal bleeding with wiping, I recommend a colonoscopy. So we don’t want to avoid those warning signs. What are some of those alarm signs? It would be unintentional weight loss, nausea, vomiting,

Dr. Gabrielle Lyon 26:39

how much weight loss, 5% 10%

Dr. Michelle Pearlman 26:42

there’s no percentage. It’s just it would be unintentional. So because it depends on what your starting weight is, if someone’s 200 pounds and they lose five pounds, I probably wouldn’t be so concerned. If I have a patient who’s 120 and they lose five pounds, that could be a big deal if there is no other explanation. So unintentional weight loss, nausea, vomiting, abdominal pain, if it’s getting worse or if it’s not improving. So not just a run of the mill. Gastroenteritis, if something is prolonged or getting worse, that would be a warning sign. And then rectal bleeding, or blood in the stool,

Dr. Gabrielle Lyon 27:15

avoid Ultra processed never. Ignore warning signs. We got you to say never. And then the third one

Dr. Michelle Pearlman 27:21

I forgot.

Dr. Gabrielle Lyon 27:26

Never skip the foundation. Never skip, never skip life day the third, what is the the third thing, and basically we were like, what would you tell your patients? Never to do so, never ignore warning signs. Yeah, avoid Ultra processed foods.

Dr. Michelle Pearlman 27:43

Yeah. And the third one I would say is we can’t skip the foundation, with all the hype with peptides and GLP ones. And GLP ones are a big part of my practice, and all the technologies and innovation that are coming out within the medical and the and the wellness industry, we cannot skip the foundation, which is optimal nutrition, getting our protein, as you know, moving our bodies on a daily basis, no amount of medication will replace those things, sleep, stress, management, that social network, all those things are incredibly important for overall health and wellness.

Dr. Gabrielle Lyon 28:16

Talk to me about GLP, one use, and also, there’s various delivery systems for GLP ones.

Dr. Michelle Pearlman 28:25

You know, it’s fascinating the GLP ones, because in my years of training, I had very little exposure. So these medications, oddly enough, have actually been around, some of them for about two decades. A lot of people just remember the ozempic Jingle that came out a few years ago. Oh yeah, oh yeah, oh yeah. There’s a jingle. I have a terrible voice, so I’m not going to sing it, but it was on all the commercials all over TV, but, but some of these medications have actually been out for about two decades, so they are not brand new, and they’ve been doing research on them for a long time. It’s just the initial medications didn’t pan out in clinical trials, but none of my training really, really talked about GLP ones because they didn’t, kind of reach the press and the media, and they weren’t more accessible until around 2018 when ozempic or semaglutide came out for diabetics. So my first exposure actually to these medications. So I was a GI Fellow at the time, and I actually got exposure to this medication outside of my own training program. So I was already very fascinated with weight management and cardio metabolic health. So I asked someone who ran the weight management program at UT Southwestern, he’s an endocrinologist, and I said, I’m a gastroenterology fellow, but I would love to rotate through your endocrine What’s that Dr Jamie almond does? He is phenomenal. He is the man who changed the trajectory of my career, not even within my own training specialty. So I rotated through his clinic, and that was my first exposure to watching a dietitian talk to a patient. It was my first exposure to see. Doctor, talk to a patient about, what does their family unit look like? What does their budget look like? You know, what are their health and wellness goals? What is their nutrition intake, what is their movement? And then give them a realistic plan on all the foundations of health and wellness nutrition movement, but then also introduce medications when they were appropriate. And to the point that he inspired me. I kind of created my own little weight management clinic as a trainee, and I was actually teaching my attendings at the time.

Dr. Gabrielle Lyon 30:27

You

Speaker 1 30:28

bring

Dr. Gabrielle Lyon 30:28

up a really good point. The misconception about GLP ones is that they are new medications, but they have been around and have been FDA approved for type two diabetes. Then 2018 they are then available to be used for weight management. And I think that that’s probably the biggest shift. Would you agree? Because the medications were around,

Dr. Michelle Pearlman 30:50

yeah. So the initial medications, Victoza was initially FDA approved for type two diabetics. They started seeing that people were losing weight. They did additional clinical trials, and that’s when sexenda came out. So these are daily injections, and that’s loraglotide is kind of the generic name now liraglutide, or six Senda for weight loss, only gave you about five to 6% weight loss. So it’s something but for overall cardio metabolic health, we typically want to hit around seven to 10% of weight loss. It’s not 100 or 200 pounds, it’s seven to 10% so it was helping. The good thing also about it is a lot of the other diabetic drugs on the market, like insulin, which we used to use a lot, were weight promoting. So it wouldn’t be fair to the patients if we said, you know, Hey, Sally, you got to lose a bunch of weight, we have to start insulin for you because of your diabetes. My goodness, we just made it a lot harder for Sally to lose weight because we’re giving her insulin, which is a fat storage hormone. So at least we had medications that were targeting both the diabetes management but also helped them lose weight. And then ozempic came out in 2018 so that is a once per week injection. So the other name for that is semaglutide, but actually wegovy, which is the same medication, but different dosing, came out in 2021 so it actually wasn’t until 2021 that we had medication FDA approved for weight management, and people with a BMI of 27 or above with a comorbid condition, weight related or 30 and above, and they didn’t need a comorbid condition. And then, more recently, is trezepatide. So terzepatide, we have ze found for non diabetics, and we have monjoro for diabetics. So a lot of people think ozempic is the only medication out in the world, and that’s not true. There’s really the two kind of main ones, which is semaglutide and terzepatide. It’s just there’s a lot of other names because of FDA approvals and indications, but it goes way beyond weight loss and diabetes control. I actually went to a recent longevity conference locally in Miami, and one of the cardio metabolic specialists, he’s a lipidologist. He was speaking on GLP ones and longevity. So GLP ones are now actually entering the whole longevity space, which I think is amazing. He made a very interesting phrase. He said, We need to stop saying these are weight loss drugs and diabetes drugs. These are metabolic reprogrammers. And I love that

Dr. Gabrielle Lyon 33:16

the sexenda would give an individual daily injection, 5% or so arguably, could be good for liver, but not necessarily effective for cardio metabolic health. In terms of reasons why someone wouldn’t try these medications, what are those reasons?

Dr. Michelle Pearlman 33:40

I think there’s a lot of fear mongering out there. So with social media and the digital age, obviously it’s an incredible resource for information. But when it comes to GLP one medications, it is very stigmatizing. You have people who are pro and you have people who are anti, and there’s not many people in the middle ground, which is kind of fascinating to me. It’s also a big stigma for patients themselves. I have many patients who will not tell anyone, even their husbands or their wives, that they’re on the medication, because oftentimes they think it’s a failure on their part, because they couldn’t lose the weight, quote, unquote, on their own, which I think is really awful. You know, these medications act in probably 50 different mechanisms, most of which we don’t quite yet understand. I think a lot of people have this thought that they just shut down your appetite, which is not the only mechanism. Yes, they delay gastric emptying, so they slow down the rate at which your stomach empties. Takes a normal stomach about four hours to empty a standard meal, like an egg sandwich. These medications slow down that process so that maybe the meal stays in your stomach for five hours or six hours. So it helps, in particular for people who eat a meal and they don’t feel satisfied, or they feel satisfied and then they have hunger one or two hours later, that’s where it can be very helpful. It also, you know. Body naturally makes this hormone, GLP, one right? People talk, oh, I want to go on a peptide. I go, Listen, you’re already on one glucagon, like one peptide, right? So this hormone, when food goes down into our intestine, our body releases this GLP, one hormone. It sends signals back to our brain, and it says, brain, I’m full. But our body also has an enzyme that breaks that down pretty quickly. So for people who say, Oh, just take Berber in or take all these other supplements that enhance your natural GLP one well, they may, but they’re not preventing the quick breakdown of it. So these medications like semaglutide or chirzepatide, they are synthetic versions of that hormone. So they stay in the body longer. They help get you fuller sooner. They keep you fuller longer. We also have GLP one receptors in the brain, so it works on the cravings and the pleasure pathway. Now, what I tell people all the time, my goal is not to shut down your hunger. It’s not to create food aversions. I want you to feel hungry, because when you work out, if I were to shut down your hunger and you don’t eat after your workout. Is that a good thing for muscle growth?

Dr. Gabrielle Lyon 36:04

I mean, I feel like I’m gonna throw up, but

Dr. Michelle Pearlman 36:08

I imagine you probably eat something to fuel within a certain period in the day, yeah,

Dr. Gabrielle Lyon 36:14

within the day, not necessarily post training, but definitely within the day,

Dr. Michelle Pearlman 36:17

yeah. But fuel is very important for muscle protein synthesis. So what I tell people all the time is my goal is not to shut down your hunger. I want you to get that hunger cue so that you eat something, but you eat your protein, you eat your fiber, and then you feel satisfied, and you kind of get rid of that the food noise in between meals.

Dr. Gabrielle Lyon 36:35

What about the nausea? There’s a lot of discussion around nausea, vomiting, reflux. People are afraid. I also, before we get to what happens, side effects the patient, yeah, we really appreciate what you said about there’s a lot of stigma.

Dr. Michelle Pearlman 36:48

Yeah,

Dr. Gabrielle Lyon 36:49

we’ve only, I would argue, we’ve only seen that with one other group of medication,

Dr. Michelle Pearlman 36:54

hormones. That’s it, and I do both. And so it’s very interesting, although I have people who they’re much more likely to open up about hormones. So I have, you know, a lot of patients who are on both HRT or menopausal hormone replacement therapy with GLP ones, and they will tell their friends they’re on hormones, and they change their lives, and they won’t necessarily disclose if they’re on a GLP one. They don’t need to disclose it. But oftentimes, I will find that people are more likely to disclose they’re on hormones rather than the GLP ones. I think it’s still, you know, there’s this thought that it’s a failure on their part, and I see that in both men and women, it’s, you know, it can be hard for them to talk about, yeah,

Dr. Gabrielle Lyon 37:36

nowhere else in medicine, you know what? I shouldn’t say that because SSRIs, lithium, some of the other psychiatric drugs, there’s been a long time stigma with that, but no one cares about cough medicine or something like that, or even a sleep medication. These medications that seem to really affect, arguably, body composition, end up really being so polarizing.

Dr. Michelle Pearlman 38:06

And I think because people put it in, like, this esthetic category where they’re like, Oh, you just want to lose weight to look better. And I would argue, I’m sorry, what’s wrong with that? What is wrong with looking good and feeling well? Because confidence is so incredibly important, if you wake up in the morning and you hate what you see in the mirror, that will set the tone for the day, right? And so there’s absolutely nothing wrong with wanting to feel confident and liking what you see in the mirror. Now, these medications are not developed to lose, you know, five pounds, so people

Speaker 3 38:36

need to

Dr. Gabrielle Lyon 38:37

understand about the percentage of weight loss that someone should expect?

Dr. Michelle Pearlman 38:42

Yeah, so depends on the medication, right? So if it’s something like liraglutide, which is six Senda, that’s about five to 6% if we’re talking about

Dr. Gabrielle Lyon 38:50

No, people don’t use that anymore. Do they?

Dr. Michelle Pearlman 38:52

Some depending on insurance coverage, some will. If that’s the only one they can get covered, then they will still use that one.

Dr. Gabrielle Lyon 38:58

We found that. And again, everyone practices medicine different ways. When we started prescribing sex center, which we don’t really prescribe anymore, it was patients didn’t like giving themselves a shot every day, and we didn’t find it incredibly effective.

Dr. Michelle Pearlman 39:13

Yeah,

Dr. Gabrielle Lyon 39:14

again, I’m sure that this is nothing against sex center, or whatever the company is. You know, I feel like it’s almost obsolete,

Dr. Michelle Pearlman 39:23

yeah, and now that we have a lot more medication, the cash pay rates are going down. I think it’s definitely less common. It just it really depends on the person, though, I would say one niche population would be if someone is really worried about side effects, and they’re worried if they do something like semaglutide, and the side effects are going to last a little bit longer because the half life is longer, then that may arguably be a reason to kind of do a test dose with something like liraglutide, because it’s, you know, quicker out of the body type of thing.

Dr. Gabrielle Lyon 39:52

And what is the mechanism of action of six Senda

Dr. Michelle Pearlman 39:56

the same thing. Yeah, that’s also a GLP one, yep.

Dr. Gabrielle Lyon 39:59

Okay. Yep, 5% with six end up, yes.

Dr. Michelle Pearlman 40:02

So sematide, you’re going to get around 12 to 14% and these are looking at max doses, typically at the 72 week mark. So 12 to 14% and then trepitide is roughly 16 to 22% and then retrotruetide, we’re looking at 22% so as these medications become more and more effective for weight management. What does that mean? Well, that means the risk of malnutrition can definitely go up, because now we’re looking at percentages that are equating to bariatric surgery. What’s interesting about bariatric surgery is there, there is a barrier to entry, right? You have to call someone, you to schedule an appointment, you see the bariatric surgeon, and then, often, for you to actually go through the process, a couple of things have to happen. Typically, you have to be cleared by a psychologist. You have to see a dietitian, typically, like, on a monthly basis for six month period. And then you get the surgery. And then you have post op care. You may not see the bariatric surgeon post op, but you’re going to have some sort of care where they’re making sure you’re getting your supplements, post bariatric, you know you’re still making progress. There is a barrier to entry because you have to call someone, pick up the phone, make the appointment and have the follow up. Versus now weight management has become weight loss commerce. You have on weight loss, weight loss commerce. Maybe I’ll maybe I’ll trademark that. So when it comes to weight loss commerce, everyone’s selling weight loss. So you have all these virtual platforms that are popping up, which are basically script mills. I’ll tell you, the easiest part of my job is writing a script. What is the hard part? It’s counseling people on what matters, on how to not only get them to lose weight in the short term. I don’t care about six months from now. I care about six decades from now, and that’s where you can never replace the foundation these drugs are becoming extremely powerful. The hard part is not losing the weight, it’s keeping the weight off long term. Because as you and I know, neither of us are getting any younger. We have metabolic adaptation, we have anabolic resistance, we have hormonal changes, we have higher risk of frailty and fractures. We get older, we have to take all these things into consideration. And so these virtual platforms, they don’t care. They’re just writing the script and saying, I’ll follow up with you in six months, and so that’s what we need to be careful about.

Dr. Gabrielle Lyon 42:23

Basically, what you’re saying is people are they used to be overfed and undernourished, and now they are underfed, arguably, if they’re on these medications and undernourished,

Dr. Michelle Pearlman 42:36

yeah, and they’re not getting guidance. So that’s where kind of the press and the media is really pushing this out is people are sharing their stories when they’ve had bad experiences. And there, there are bad experiences out there. I mean, the poison control hotlines have gone up like 1,000,000% because people aren’t being guided. They’re getting either compounded formulations or they’re using, let’s say, ozempic pens, and they’re titrating the dose based on the number of clicks. But if they’re not being guided on how to do the dosing, and with compounded formulations, it’s kind of all over the map with some of these drugs, and each batch could be vastly different, which

Dr. Gabrielle Lyon 43:11

is why someone uses a compound pharmacy. They should go to a compound pharmacy with a really good

Dr. Michelle Pearlman 43:17

reputation, exactly. So there’s just so many unknowns. Even though these drugs aren’t new, there are a lot of unknowns, and there’s not enough supervision.

Dr. Gabrielle Lyon 43:24

There’s two things that I definitely want to touch on. Number one is the effect on muscle. And then number two, we were talking about delaying gastric emptying and symptoms if someone is on these medications, are there ways to mitigate things like reflux, nausea, vomiting. You also hear about pancreatitis. I haven’t seen that clinically. Also, I would love for you to touch on I don’t know if it still carries a black box warning for thyroid cancer.

Dr. Michelle Pearlman 43:54

So yes, so the black box warning that’s easiest to tackle first, it was actually only seen in rat models, so that it’s not all thyroid cancer, it’s medullary thyroid cancer, which is actually a rare type of cancer. So I have a patient who had a history of papillary thyroid cancer, and his thyroid oncologist said, no worries. He can still go on the medication, because it’s not medullary so medullary thyroid cancer is a contraindication, and then the only other contraindication is a family or personal history of multiple endocrine neoplasia type two? Most of my patients have never heard that term before, so those are the two reasons why we shouldn’t prescribe the medication, mainly because it’s on the black box. But again, it was only seen in rat studies, but those you know otherwise, it’s fair game. Okay. Now one would also say, Well, what if I already have a lot of gastrointestinal symptoms, right? I’m a gastro so a lot of people with gastro issues come and see me. A lot of

Dr. Gabrielle Lyon 44:47

people are worried. Came to see you for knee pain. Oh, I

Dr. Michelle Pearlman 44:49

have plenty of patients that see me for knee pain. A lot of times it’s weight related, so I help them target that. But you know, a lot of people like we mentioned GI issues like acid or. Reflux and dyspepsia are related to obesity, so they’re concerned that if over 60% of people on a GLP one will have a GI side effect. Am I only making their problems worse? Potentially, yes, in the beginning, right as people are trying to understand how their body is going to react to the medication, acid reflux oftentimes gets worse before it will get better. But if we’re getting rid of the Ultimate Trigger, which is the visceral fat, then as they lose weight and they lose interest around their midsection, their reflex will often get

Speaker 1 45:30

better.

Dr. Gabrielle Lyon 45:30

Do you have tips or tricks to deal with reflux? If someone is on the medication? Is it baking soda? Do you say for a short period of time taking an antacid, take mastic gum, or any number of natural type supplements,

Dr. Michelle Pearlman 45:46

yeah, so if they’re already on, let’s say an antacid, let’s

Dr. Gabrielle Lyon 45:48

say I don’t they’re not go on, yeah, one of these medications, yeah, and their first symptom is reflux, or they’re burping something up, or you name it. But it’s kind of that reflexy symptom, yeah,

Dr. Michelle Pearlman 46:01

so very common. And I tell people this is not out of the norm, where it’s when we start a medication, typically, if we increase the dose, they’re going to feel it or within the first one to two days post injection, those would be the three most common your body will often adjust to the medication. And as you lose weight and you lose visceral fat, those symptoms will get better, okay, but some people will still have reflux. So we got to say, Okay. One thing we want to treat it, okay, what we know from the data is, if you have, let’s say, a lot of reflux or nausea, and you’re not eating as much, that doesn’t mean you’re going to be more successful with weight loss. So we want to treat you. My goal

Dr. Gabrielle Lyon 46:38

is, what do you mean? What do

Dr. Michelle Pearlman 46:39

you mean? Oh, so like, I would, let’s say, start you on an antacid. I wouldn’t say, okay, suffer through it. You’re not going to eat as much, and then I think you’re going to lose more weight. So we don’t want people to suffer through it. We know those people, if they’re having more symptoms, are not necessarily more successful with losing weight, so I always want to

Dr. Gabrielle Lyon 46:54

treat them to I see, so the symptom severity doesn’t correlate

Dr. Michelle Pearlman 46:59

with more weight loss. So if someone has significant nausea, that doesn’t necessarily mean they’re going to lose more weight, right? So we don’t want people to be miserable. But again, My other goal is not to give one someone one medication and have to give them five others to treat all the side effects I’m causing. So we always want to go back to the drawing board and say, Okay, are there triggers that have caused this? We have to go back to normal physiology, right? If someone is eating too late, and we know that this medication delays the rate at which the stomach empties. If they’re eating at eight o’clock at night, and it’s a fatty meal, and we know out of all the macronutrients, fat has the biggest influence on delayed gastric emptying. So if they’re eating, you know, a 16 ounce steak at eight o’clock at night, then they’re lying down at 10 to watch Netflix. On or off the medication, they’re probably going to have reflux. So if they have reflux with that off the medication, I tell them, it’s only going to get worse on the medication, right? So we got to figure out. How can we change that? I tend to tell people to front load their calories earlier in the day, right when you’re more active, you’re upright, you’re moving around, your stomach is going to empty faster than eating a heavier meal at night.

Dr. Gabrielle Lyon 48:09

So that when you also recommend they take the injection.

Dr. Michelle Pearlman 48:12

So the time of the injection actually doesn’t matter so much, because the half life is a week, so you still have some of the medication in your body. The day of the injection should be fairly consistent. The time of the day doesn’t matter so much because it is a long acting medication, but the eating habits are very important. So we want to eat earlier in the day. If we’re going to have a fattier, heavier meal, we want to have that also earlier in the day, which is very important. We also need to chew our food. So I don’t know about you, but I am really guilty of inhaling my food, and so if we’re not chewing properly, we’re not going to digest properly, we’re not going to absorb properly, and we’re more likely to swallow a lot of air and cause more reflux and bloating symptoms. So those are really two powerful tips to mitigate a lot of those side effects that we see. But

Dr. Gabrielle Lyon 48:58

no Are there any natural supplements they use. And the reason I ask is because I swear, when I was pregnant, I had the world’s worst reflux. It was I also had high promises gravity,

Dr. Michelle Pearlman 49:07

oh,

Dr. Gabrielle Lyon 49:08

it was

Dr. Michelle Pearlman 49:08

awful. Then you also can’t take a lot of medication. Yeah,

Dr. Gabrielle Lyon 49:11

yes. But one of the things that really helped me was DGL,

Speaker 3 49:15

it’s,

Dr. Gabrielle Lyon 49:16

you know, this licorice type extract. I don’t know if there’s things, and also, I don’t know if there’s evidence behind

Speaker 3 49:22

that,

Dr. Gabrielle Lyon 49:22

yeah, are there any kind of natural type supplements, or, say, aloe, something like that.

Dr. Michelle Pearlman 49:27

Some people will take Aloe supplements. I’m a big fan of, like, decaf tea. Ginger tea is like a smooth muscle relaxer, so I’m all for ginger tea. As far as supplements, I’ll use, like peppermint capsules. There’s things like IV guard or FD guard that have like menthol and peppermint in them, but they’re delayed release. So if someone’s having intestinal spasms, that can help, kind of with the smooth muscle relaxant effect in the gut. But if you have a bunch of mint, like mint and gum that actually can worsen reflux, mint can relax the lower esophageal sphincter. So it depends on what the sim. Them is there are natural remedies, but a big part of it is, if you’re eating pizza at 10 o’clock at night,

Dr. Gabrielle Lyon 50:06

good for you

Dr. Michelle Pearlman 50:06

probably not going to feel well on this medication. So the lifestyle again, the foundation we cannot skip if you want to lose weight, maintain your weight loss, and, more importantly, feel well doing so, the nutritional changes are absolutely essential.

Dr. Gabrielle Lyon 50:22

What about constipation?

Dr. Michelle Pearlman 50:24

Very common, more so with semaglutide, I see it less with Trejo zapitide. So if you were to ask me, How do I pick one medication from another? Obviously, it depends on the person. It also depends on what their budget is. Some of the medications are more expensive than others. Nowadays, at least the cash pay rates are going down. Insurance I honestly have lost a lot of faith in insurance coverage. A lot of my patients meet all the FDA criteria available and still get denied because it’s not under their benefit plan. So it’s a problem when it comes to coverage. That’s very frustrating for people, because they say, Doc, like I have diabetes or I’ve been struggling with weight my whole life. Why is my insurance company covering bariatric surgery and won’t cover wegovy? I mean, it’s so backwards. Why we’d go to a more aggressive method when we can try medication first? But that’s, you know, the healthcare system for you. Hopefully

Dr. Gabrielle Lyon 51:19

it’s changing. Hopefully, hopefully it’s changing soon. Are you concerned about so for constipation? For example, in our clinic, we might give people a regiment of Seneca and MiraLAX if we start them on a GLP one. Yeah. Do you have protocols like that to help with constipation?

Dr. Michelle Pearlman 51:38

Yes, absolutely. So part of the way these medications work is they also have a diuretic effect, so sometimes dehydration can contribute to the constipation. If I’m lowering your appetite and I’m telling people to focus on protein, oftentimes they’re not getting enough fiber. So that’s really important is targeting 25 to 35 grams of dietary fiber a day, and that also just helps with the gut microbiome and the health of the of the colonic cells. And then, obviously, using things like supplements or medications. Big fan of MiraLAX, all that does is an osmotic laxative. It just helps pull water into the colon. Then you can also use like stimulant laxatives, like Senna or dolco lax, and those will stimulate the bowel to move. Some people just they have bulky stool, and it gets trapped in the rectum, and so that’s where suppositories or enemas can be helpful. So not all bowel regimens are created equal. It really just depends on what the person’s going through. What I also see so much of is pelvic floor dysfunction in both men and women. So you could be on the latest and greatest bowel regimen in the world if you have pelvic floor dysfunction, where you’re trying to push and you’re not able to generate enough pressure to get it out of your rectum. No amount of colonic stimulation is going to help you with that. So I send a lot of patients to pelvic floor physical therapy

Dr. Gabrielle Lyon 52:51

for specifically for constipation. Yes,

Dr. Michelle Pearlman 52:53

absolutely.

Dr. Gabrielle Lyon 52:54

We had Dr Sue McDonald on

Speaker 3 52:57

the

Dr. Gabrielle Lyon 52:57

podcast, which she was on, Dr Amy Pearlman, you might know her, Larry lip Schultz, they did an episode. I believe both Larry and Dr Amy did an episode. Dr C McDonald. If you guys did not hear that episode yet, please listen. She covers pelvic floor dysfunction,

Speaker 3 53:19

yeah.

Dr. Gabrielle Lyon 53:19

In women, of course, but in men, yeah,

Dr. Michelle Pearlman 53:22

yeah, which we often, like I was told in gastro that it’s typically women who have had four step vaginal deliveries that get pelvic floor dysfunction. Those are not the only people that struggle with that a lot of people do. So anyone with constipation or this feeling of incomplete evacuation that can definitely be a problem and and starting a GLP one medication can oftentimes just exacerbate the problem. So we want to make sure we are tackling it from all different points of view. But yes, so magnetite is definitely more likely to cause constipation than newer medications like turzepatide The Oh,

Dr. Gabrielle Lyon 53:55

is it time for it’s time for show and tell, because I want to talk about fiber too.

Speaker 2 54:02

This is going to be for the yoga ones.

Dr. Michelle Pearlman 54:04

Yeah, so I’m going to go over some of the options.

Dr. Gabrielle Lyon 54:06

And also, I think that we can also break this out for a short for her, the team would just let them know. Okay, time for show and tell.

Dr. Michelle Pearlman 54:20

Okay, so there are many medications on the market. There are many different pen delivery systems, and there are injections and there are pills. So I want to kind of simplify it for the viewers, because even in someone who practices in this space, it can be quite confusing. And I’ll tell you this, it’s only getting more confusing, because

Dr. Gabrielle Lyon 54:38

we’re going to have different generations,

Dr. Michelle Pearlman 54:40

yeah, because there’s more medications coming out on the market, so patients need to understand, what are the different options out there, and why is their provider choosing one or the other? That’s really important. So the first medication I have here is ozempic. Ozempic comes in a multi dose delivery pen. So this is FDA approved for diabetes. But, you know, I will actually use it off label in non diabetics, because they can kind of multi dose it, and it kind of saves them money. And

Dr. Gabrielle Lyon 55:07

when you say multi dose,

Speaker 3 55:08

so

Dr. Michelle Pearlman 55:09

what I mean by that? So you can use the clicks here and kind of adjust the dose. Okay, now this is not necessarily what the manufacturer is telling you to do, but a lot of providers are doing it because it will save cost. So you’ll still deliver a standard dose, but it’s just a highly concentrated pen, if that makes sense. This is different

Dr. Gabrielle Lyon 55:29

dose,

Dr. Michelle Pearlman 55:30

so the starting dose is always 0.25 milligrams per week of Somato type. Now this is the same medication as wegovy. Why would I choose this one instead of this one.

Dr. Gabrielle Lyon 55:41

And if you guys are just listening, in one hand, she has the ozempic pen, yep. And in the other hand she has the wegovy pen, yes.

Dr. Michelle Pearlman 55:51

So these are the exact same medication. They are both by Novo they’re both semaglutide. This one is just a different pen delivery system. This one, you can adjust the dose. This one is a single dose auto injector

Dr. Gabrielle Lyon 56:05

is the first one is the asemic pen on auto injector.

Dr. Michelle Pearlman 56:10

So it’s not necessarily you attach a needle here. This one, the needle is built in, and you adjust the dose here, and then you would click it and then inject the medication. This auto injector, I’m literally not doing anything. I pull off the cap when I’m ready to inject. I push this little plunger in here. The needle pops out. And so it’s a one and done thing. And then they throw one exactly. It’s one pen per week on this you can adjust the dose on the pen, okay, but again, it’s the same exact medication. But technically, if you want to go kind of by the guidelines, ozempic is FDA approved for diabetics. Wegovy is FDA approved for non diabetics for weight loss? Okay, so this came out in 2018 wegovy, 2021

Dr. Gabrielle Lyon 56:56

and these medications can be also used off label, yes, for

Dr. Michelle Pearlman 57:00

so a lot of people would say, Oh, I’m only using the FDA indication. But the reality is, when they do drug studies, they’re not trying to get every indication covered, because those studies would take literally a million years. What we’re seeing nowadays is we’d

Dr. Gabrielle Lyon 57:15

be really old by that we

Dr. Michelle Pearlman 57:15

would be really old. So initially developed for diabetes, then weight management. Now next kid on the block is zepbound, which is Trejo petite, and then you have the same delivery system, monjoro, so those, there’s no delivery system changes. It’s just this single dose pen here. So this is Zep bound. So now Zep bound is actually FDA approved for moderate to severe sleep apnea, so that’s the added indication here. And wegovy is now approved for f2 f3 fatty liver, so f2 f3 means the degree of fibrosis. So more indications are expanding. They are doing active clinical trials in Alzheimer’s, alcohol, PCOS. Near and dear to my heart is inflammatory bowel disease. So as a gastroenterologist, it used to be when these medications first came out, I wouldn’t touch a patient with Crohn’s or ulcerative colitis with a 10 foot pole with these medications. Now we’re actually doing clinical trials in IBD patients because of the anti inflammatory effects. So that’s where you have this pleiotropic effect with these with these medications, way beyond weight management and insulin control. Now we’re looking at the anti inflammatory effects, and there’s clinical trials in autoimmune conditions. What

Dr. Gabrielle Lyon 58:27

is the dose?

Dr. Michelle Pearlman 58:28

Is

Dr. Gabrielle Lyon 58:28

the dosing different?

Dr. Michelle Pearlman 58:29

So the dosing for zebound and monjoro are the exact same, the

Dr. Gabrielle Lyon 58:32

dosing for anti inflammatory,

Dr. Michelle Pearlman 58:35

oh, different. Yeah, it’s different. So I’m hearing that it’s more like the micro dosing versus these other doses, which are different, yeah, so it depends on what the target is, but at least for sleep apnea and for fatty liver, those doses are the same that we would see in diabetes and weight

Dr. Gabrielle Lyon 58:53

management, because the mechanism is in part weight loss,

Dr. Michelle Pearlman 58:56

exactly. Yeah, and the insulin pathway versus the anti inflammatory pathway. It’s so

Dr. Gabrielle Lyon 59:01

fascinating. Do you think it’s too good to be true? I

Dr. Michelle Pearlman 59:04

think there’s a lot of things that are too good to be true. I would say this has completely revolutionized healthcare, where even if you as a prescriber or a doctor are not prescribing these medications, I will tell you your patients are on them, whether or not they’re telling you these medications are going to infiltrate every single field in medicine. We need to stop telling people to just do it on their own. They’re going to be doing on their own. But why not use tools in the toolbox to do two things make it a little bit easier and a little bit less painful? Why not?

Dr. Gabrielle Lyon 59:41

It’s fascinating that we are. I mean, you realize that we are at the precipice of an entirely new landscape of medicine. It’s, you know, I used to run a weight management clinic in my fellowship. We didn’t have access, and these were. Morbid people struggled with morbid obesity, and we were not using these medications because it wasn’t indicated. And it was heartbreaking to watch two years later, you know, they come to the program, they fall off so many comorbid conditions, it’s amazing.

Dr. Michelle Pearlman 1:00:20

Well, we’re also using it in post bariatric patients, because, you know, these these tools, these medications, bariatric surgery, they’re not cures for obesity, they are treatments. And what we even see in the bariatric population is weight regain, let’s say, five years later. So a lot of those patients are actually going back to their bariatric surgeons, and they may get, you know, a revision surgery. But many of them are actually going on GLP ones to help combat some of the weight regain that we see

Dr. Gabrielle Lyon 1:00:47

the you also had the pill form. Oh, yes, show me the pill form.

Dr. Michelle Pearlman 1:00:52

Oh, here we go. Okay, so Novo just came out with the pill form. So the pill form has actually been out for a couple years now. That was named rybelsis, but that was FDA approved for diabetes, and they were at lower doses. They are daily pills. The past couple of months, once a day, once a day. Yeah, the past couple of months. A couple months ago, Novo came out with wegovy, which is the pill version. Now, the pill version of rybelsis, the highest dose of that didn’t get you anywhere close when it came to the weight loss that the injections of ozempic did, and so you didn’t get the degree of weight loss that you got with the injection. So if people needed to lose more weight, we would typically put them on injections instead of the pill, but they’ve actually changed the delivery device or the vehicle so that our body doesn’t break down this medication. So now we’re seeing that the wegovy pills are equally as effective as the injections available now, you may say, or a lot of people would think that, Oh, why would someone want to, you know, Jab, Right? Do the jab? I don’t know if you’ve heard that phrase, never. People are using it all the time now for these medications, why would you do the jab if you could take a daily pill? Now, I’ll tell you from experience, and I’ve talked to a lot of my patients, I’ve asked them, Do you want to change to the pill, or do you want to stay with the injection? And oddly enough, I don’t have a single patient that said they wanted to change to a pill because they’re used to the injection. It’s once a week. Or I now have some patients who are in their maintenance phase who are injecting every two weeks, and they’re like, honestly, it’s a one and done thing. I’d rather not have to take a daily pill. People also need to realize that they’re not really that easy to take this medication. In particular, it has to be on an empty stomach. You can’t take with other pills. You can only take it with four ounces of water. Then you have to eat 30 minutes later. If you’re kind of someone who’s traveling, kind of on the go and things like that, it can realistically be a little bit of a challenge to take.

Dr. Gabrielle Lyon 1:02:41

What about drug drug interactions with these medications?

Dr. Michelle Pearlman 1:02:45

So we don’t really know. You know, it’s interesting. When I used to do a lot of endoscopies, I would see undigested pills still in the stomach, you got to wonder, like, are we telling people, oh, you’re not taking your medication, or their medications not effective? What if that person just doesn’t have the ability to even break down the capsule. They’re not absorbing the medication. I mean, it’s really crazy. We haven’t done clinical trials to say, Okay, you’re on wegovy. How is that going to affect your blood pressure medication? Because technically, that medication is going to sit in your stomach longer than it otherwise would have. But I would argue, you know, in let’s say, poorly controlled diabetics, if they have a higher propensity for gastroparesis, which is delayed gastric emptying. Are we doing drug trials in them to say, Okay, if you’re a diabetic, you need to take this blood pressure medication instead of this one, because you’re going to digest it differently. We’re not. We assume everyone digests it the same, but that’s not true. So gastric and intestinal motility do play a role in drug absorption. We don’t have the studies to actually show what happened.

Dr. Gabrielle Lyon 1:03:42

We don’t know, for example, if someone was on oral birth control, how would these medications make it less effective? Do we? Yeah,

Dr. Michelle Pearlman 1:03:51

so birth control is one that we have to be careful with, because it can definitely affect the efficacy. Where, I don’t know if you’ve heard of like, ozempic babies, right where, because, but I actually

Dr. Gabrielle Lyon 1:04:02

thought it was because of increased fertility.

Dr. Michelle Pearlman 1:04:05

Yeah, there’s a couple things, right? So if people are more likely have infertility because of, let’s say, PCOS, and they’re losing weight and we’re improving their insulin resistance, they are more likely to get fertile. And so some of them may or may not be practicing safe sex, but now that they’re more fertile, they can’t get away with that anymore. So that’s one reason. The other thing is, it can, it can affect the efficacy of birth control. So typically, what we tell people is, when you’re starting the medication, or you go up on the dose, you should be on two forms of birth control. But I don’t think we honestly know enough about it, but better safe than sorry, even

Dr. Gabrielle Lyon 1:04:39

though these medications have been around for 20

Speaker 3 1:04:43

years,

Dr. Michelle Pearlman 1:04:43

do you but, as you know, research in women were were just too complicated. I

Dr. Gabrielle Lyon 1:04:48

remember even says that. But

Dr. Michelle Pearlman 1:04:51

so it makes sense that we should do clinical trials. But I think, you know, it’s really hard to do clinical trials in, you know, well, in. Women, it’s just, it’s not that it’s hard. It’s just not done that often, but, but, yeah, we just don’t have the data. We don’t know, unfortunately,

Dr. Gabrielle Lyon 1:05:08

from a personal perspective, not evidence based, but just evidence informed. Are you seeing that perhaps it affects antibiotic use? Are there other things that an individual would want to think about as they’re on these medications.

Dr. Michelle Pearlman 1:05:23

I do see hair loss, and that is a big concern in my patients. Now, I think it’s multifactorial. One is a lot of these patients are mid age, so are they also perimenopausal? Absolutely. I think that’s contributing. The second thing is, they’re eating less and they tend to be eating less protein, and as we know, protein is really important for hair, so I want to obviously optimize protein intake.

Dr. Gabrielle Lyon 1:05:46

How do you end up recommending people do that?

Dr. Michelle Pearlman 1:05:50

So I actually aim on the higher end of protein recommendations. So I really tell people, well, my ultimate goal is like one gram of protein per pound of ideal body weight. But if I’m starting someone on a GLP one, that’s like, that’s not going to be ha, that’s not going to be happening, it’s not realistic. So I’ll tell people, in general, to try to hit at least, you know, 100 to 120 grams of protein per day to start. And I knew you you know, tell people at least 100 grams a day. So I have to be realistic. If I tell someone 200 grams, they’re going to say, you are crazy. That’s never going to happen. I have to meet the patient where they’re at, and it also depends on how much protein they’re getting at baseline. If they’re used to getting 30, and I start them on a GLP one, I cannot realistically recommend, oh, hit 150 you know, by tomorrow, that’s ridiculous. So if someone’s hitting 40, I say, Please track your protein. Let’s try to get you to get you to 80, and then next month, let’s try to get you to 100 it has to be a step rise. Approach

Dr. Gabrielle Lyon 1:06:46

for hair loss in our clinic, we typically look at ferritin stores, iron stores, we look at Copper.

Dr. Michelle Pearlman 1:06:54

Are there certain markers that you look at in the blood when just as it relates to hair loss? So I do a whole gamut of labs to get their nutritional status. And what a lot of people don’t realize is, just because someone is overweight, a lot of overweight or obese individuals are malnourished. So we should be checking baseline labs, baseline labs, I would check now, not having to do with hair, but it’s, you know, an advanced lipid panel. It’s their insulin level, their complete metabolic plan, all their blood count, but I also check their B 12, their vitamin D, and then, depending, you know, their iron labs. I have a lot of people who have normal hemoglobins but are very iron deficient, and a lot of people are missing that. So I want to check, yes, their baseline nutritional status.

Dr. Gabrielle Lyon 1:07:37

Do you find? Obviously, you say for hair loss, one of the recommendations that you have is protein. Another thing that we use in the clinic are essential amino acids, which, especially if someone is starting on a GLP, one that can be so helpful because it just is providing amino acids with none of the bulk, yeah, we’ve just found that that’s really easy to tolerate. Do you see any labs get worse? Meaning? Do you see, obviously, hscrp improves, but do you see things like ferritin getting worse? Or do you see various markers? I haven’t, but, you know, I’m just curious.

Dr. Michelle Pearlman 1:08:18

Yeah, I haven’t either, and I do trend these things. You know, I wouldn’t do it every month. It really depends on the person. I’m all for supplements. I’m all for food is first. But supplements can be very helpful, especially when it comes to B, 12 iron, vitamin D, those key players. I’m a big proponent of creatine. People are plus or minus on collagen. I’ve had a lot of patients that report better skin, hair and nails on collagen, so I’m all for it. There’s little, very little harm. But I think we also have to be careful with a lot of the other supplements out there. I’ve had liver enzyme abnormalities with things like neutrophil so it does depend on the quality of the supplement. I’m not one for giving someone a supplement that has everything in the kitchen sink, right? I’m all for Okay, your b 12 is low. Let’s optimize your b 12. Your iron is low. Let’s optimize your b 12. Because a lot of these all in one type supplements, they are containing so many things in there that actually interfere with the absorption of another, like multivitamins. If we know that calcium interferes with iron, why would I give you a supplement that has calcium and iron

Dr. Gabrielle Lyon 1:09:22

because you want to cause constipation. Obviously, the Metformin craze, there was a whole Metformin craze. We actually had Dr Eisenberg on the show. He’s a urologist, and he was talking about how Metformin can potentially affect birth defects. The reason I bring this up is because Metformin, again, used ubiquitously affected B vitamin metabolism. 12 makes sense. Do you think that there is something like that with GLP ones?

Dr. Michelle Pearlman 1:09:59

Well, a lot. Lot of my patients are already starting with low B 12, and so I obviously want to optimize that. So I can’t obviously blame the GLP one on that a lot of my patients because we’re delaying gastric emptying and affecting digestion. Red meat is just less appetizing, or it tends to really just stain their stomach like a brick. So they tend to be getting less B 12 through their nutrition on the GLP one medications. So oftentimes I will supplement those folks as well if they’re having trouble taking in dietary vitamin B, 12 sources. That

Dr. Gabrielle Lyon 1:10:30

makes sense. And basically what I’m trying to get to the underbelly is, is there something potentially we’re missing? Because, again, these medications, are they too good to be true? I I mean, I don’t know. Look at hormones. One could also argue that hormones, estrogen, progesterone, testosterone, are too good to be true, but our body makes them, and our body does make GLP one, yeah, the overdose situation with the new medications, the half life is long. Do we have a solution? If someone, by accident, takes the wrong dose, they take a much higher dose, are they going to be stuck with nausea, vomiting? I mean, I can only imagine that would be terrible.

Dr. Michelle Pearlman 1:11:14

Yeah, there’s no antidote for these medications. So if someone takes too much of a dose, or they’re just having a side effect, if we up, titrate it, or they’re initiating the medication. There’s no medication I can give you, something like a benzo or morphine, where I can reverse the effect. So a big part of it, you know, it’s all about supportive care. It’s maybe

Speaker 3 1:11:33

you

Dr. Gabrielle Lyon 1:11:33

should do that.

Dr. Michelle Pearlman 1:11:34

I have me too. Yeah, they got mixed up. They were doing it in the car. They weren’t paying attention. They called me a day after, and they said, I am just so miserable. And I said, walk me through what happened. And I’m like, okay, all right. Now, luckily, they did not go to the hospital. They were fine. They were just pretty miserable for about

Dr. Gabrielle Lyon 1:11:51

a week, right? Because,

Dr. Michelle Pearlman 1:11:52

Oh, absolutely, yeah. So it’s all about supportive care. Hydration is key, right? So, like, they don’t. People can survive without food for a week. We can’t survive without fluid. So my go to is it’s actually not slamming down a bunch of water. It’s making sure we have oral rehydration solutions. So simple things like PD lite or I have, you know, recipes of homemade solutions. If people don’t like Gatorade, Gatorade is fine, but it’s not technically a hydration solution. There’s not enough salt in there, so you have to actually add salt to maintain hydration. So it’s maintaining hydration is the key, and then using medications as supportive care to help prevent the vomiting, the diarrhea, so it can happen, I would say, Are we missing something? Are these too good to be true as access improves, which is great, you still are going to have these weight loss companies that are just writing scripts for people. So we want to make sure we have an appropriate candidate. We want to make sure, how do we define appropriate candidate? Well, someone who is ready to invest in their health and make the other foundational changes along with the medication. I want people to have realistic expectations that the goal is not just to lose 50 pounds, stop the medication, because what do we see in the data? We see the weight regain, and people may gain with the weight gain, gain a little bit of muscle, but the majority is regaining a lot of that fat, and then ends up causing this vicious cycle. So we have to really look at how do we optimize long term health outcomes, improve cardio metabolic health. So yes, improving access is important, but making sure the patient understands how do these medications work and how can I be successful long term is really important. Now, the typical indications, though, were all weight related. I have plenty of people that come to me who have a normal BMI, who I think are candidates for GLP, one medications. Maybe they’re struggling with alcohol. I live in Miami, that’s a big problem. Maybe they’re perimenopausal and they have a normal BMI, but they’ve gained a bunch of fat around their midsection, and they’re struggling, and now they’re, you know, insulin resistant. I use those medications off label in those individuals, so that’s where there’s really the art to the medicine piece,

Dr. Gabrielle Lyon 1:14:01

compounding pharmacies. We didn’t mention that as you’re showing the pills and the injectables. We do use compounding pharmacies. I think that they’re great as long as they’re reputable. Yeah, the other thing that I wanted to ask you about was you talked about the foundational plan, fiber. I know that you have some show more, show and tell which I appreciate them being updated, fiber, the microbiome.

Dr. Michelle Pearlman 1:14:27

Yes, fiber is so important. But what’s interesting about kind of social media is you have people, yeah, that. Or, you know, you have people who are pro and who are against, like people who are all about keto and plans are trying to kill us, type of thing. There is overwhelming evidence to support the optimal effects of fiber on the gut microbiome. So we use a lot of different terms, like prebiotic and probiotic, and it can get a little bit complicated for people. So let me break it down. Prebiotic is dietary fiber, so nuts, seeds. Whole grains, all of those things. When we eat dietary fiber, those molecules are broken down by the bacteria in our gut and then produce other molecules that have more downstream effects, things like short chain fatty acids that then hit our colon and help optimize the health of our colonic cells. So that’s one of the reasons why dietary fiber is really important, but also our bacteria in our gut really like the dietary fiber, so it helps promote a healthy gut microbiome. When we eat whole food, when we eat dietary fiber, our bacteria like it, and then we grow the good bacteria. When we have good bacteria, those bacteria take care of us, because our gut is our large immune organ when we eat Ultra

Speaker 7 1:15:44

muscle,

Dr. Michelle Pearlman 1:15:45

yes, well, I mean muscle, I guess is it an immune organ? It probably is. But our gut, with the square footage, it’s a lot. Our intestine is very, very long, so when we eat Ultra processed food, and you and I may define that a little bit differently, but I would define Ultra processed. I mean, technically, let me grab my little show and tell here. Technically, all these things are processed, right? They’re in a bag. This did not

Speaker 3 1:16:11

so she

Dr. Gabrielle Lyon 1:16:11

has for you that are not watching this, which you should, because her outfit is fabulous. We’ve got what are we I

Dr. Michelle Pearlman 1:16:20

have my plain Greek yogurt. I have my good culture cottage cheese, roasted chickpeas, peanut butter powder, roasted lentils, a chia seed bar and almonds. Wait,

Dr. Gabrielle Lyon 1:16:30

peanut butter powder, yes, let me see that.

Speaker 3 1:16:32

So

Dr. Michelle Pearlman 1:16:33

it’s literally just pulverized peanuts that is super easy, that you can kind of mix in with, like a Greek yogurt or cottage cheese, and it adds, typically, about eight grams of protein, or you could add it to a shake,

Dr. Gabrielle Lyon 1:16:44

but that’s fake news. Fake protein, eight grams. It’s probably closer to four. So

Dr. Michelle Pearlman 1:16:55

that’s my little peanut butter powder here. So yeah, so fiber is very important, proteins very important. These are all things that are travel friendly, except for at the airport. These are a little bit too big, unfortunately, to get through. So yes, these are technically all processed, because they’re not coming from that naturally, but they are healthier alternatives to most of the stuff you’re going to find at the nearest 711 gas station or at the airport. And many of these also contain fiber. Now, these are not high protein sources. You’re not going to get your protein, you know, requirement for the day, but they will give you at least some protein towards your

Dr. Gabrielle Lyon 1:17:41

daily goal the first fiber component, insoluble versus soluble. Fiber. You said 25 to 30 grams? Do you believe is that enough? Should it be higher depends

Speaker 3 1:17:53

on

Dr. Michelle Pearlman 1:17:53

someone, where someone is starting from. I think we should. We could probably benefit from more. But to put things into perspective, like one cup of broccoli gets you about four grams of fiber. So that’s a lot of broccoli to eat in a day. A lot of people are eating like 10 grams of fiber. And fiber is one of those things where, as a gastroenterologist, I see people either too little or too much. If you overdo fiber, like anything else, too much of a good thing can be a bad thing. There’s a lot of diet food products like these keto tortillas or breads that in one serving will get you like 25 grams of soy.

Dr. Gabrielle Lyon 1:18:26

No, I thought I was doing so great. I used to eat. Do you remember they still have them. They’re just these. They’re fiber wafers. I was in college. I just thought this is such a great idea. I can eat this. Have some peanut butter.

Dr. Michelle Pearlman 1:18:41

Yeah.

Dr. Gabrielle Lyon 1:18:41

But it really, I just felt terrible.

Dr. Michelle Pearlman 1:18:45

Oh, yeah, people, yeah, the bloating is a real thing because fiber, a lot of it, is indigestible by the human body. So

Dr. Gabrielle Lyon 1:18:51

care the percentage of soluble versus it

Dr. Michelle Pearlman 1:18:55

depends on the person. If you know soluble fiber is going to help kind of bulk up the stool. So if someone overdoes that, you can bulk up the stool so much that it can actually worsen the constipation. In general, any high fiber food is going to have a good mixture of both.

Speaker 3 1:19:11

Yeah,

Dr. Gabrielle Lyon 1:19:11

whole food.

Dr. Michelle Pearlman 1:19:13

Yes,

Dr. Gabrielle Lyon 1:19:14

whole food. Again, now we’re talking about the food matrix.

Speaker 3 1:19:17

Yeah, would

Dr. Gabrielle Lyon 1:19:17

have an appropriate proportion of soluble versus insoluble?

Speaker 3 1:19:22

Yes,

Dr. Gabrielle Lyon 1:19:24

broccoli is insoluble fiber, mostly lentils, nuts. Is there should someone say, if they have small intestinal bacteria overgrowth, are there certain fibers that people with gut dysbiosis should use versus other fibers?

Dr. Michelle Pearlman 1:19:40

Honestly? In my perspective, it depends on what the person likes, right? So if someone tells me they have a food aversion to lentils, I’m not going to tell them to eat lentils. A big part of it is, what are they currently eating? What are they willing to eat? Just to really reintroduce fiber into their diet. And I start there. I mean, we can either make it simple or overly. Complicated. In general, people just need to eat more whole food and more fiber. We start there and kind of go over the nuances as we go.

Dr. Gabrielle Lyon 1:20:08

Would you consider short chain fatty acids to be a postbiotic? Then

Dr. Michelle Pearlman 1:20:13

we don’t have much data taking short chain fatty acid supplements. As far as having like, better outcomes, we want to make the short chain fatty acids by the food that we’re eating. So taking things like butyric acid, people used to use it for certain conditions, like butyric acid kind of enemas that may be helpful in things like proctitis for some individuals, but taking a short chain fatty acid supplement, you’re not going to see the same results that you do from actually getting dietary fiber through

Dr. Gabrielle Lyon 1:20:43

food, and the way someone would get short chain fatty acids would be through just the consumption of exactly

Dr. Michelle Pearlman 1:20:50

dietary fiber. And our microbiome takes care of it for us. That’s a beautiful thing about the human body.

Dr. Gabrielle Lyon 1:20:56

How do we define microbiome?

Dr. Michelle Pearlman 1:21:00

It’s trillions of bacteria and fungi that live in our gut, and really the microbiome. It’s in our vaginal canal, it’s on our skin, it’s in every organ. When we talk about the microbiome, most of us are really talking specifically for the gut microbiome. I know

Dr. Gabrielle Lyon 1:21:18

you’re big into muscle.

Speaker 3 1:21:19

We were

Dr. Gabrielle Lyon 1:21:20

going to do push ups already trained, the gut muscle access,

Dr. Michelle Pearlman 1:21:24

yeah,

Dr. Gabrielle Lyon 1:21:25

we talked about the GLP ones, which some of the weight that is lost is also muscle. The other part of the gut microbiome is what it produces. And like you said, short chain fatty acids. Do you think that there are specific foods that are helpful for the mitochondria, for the myocytes, beyond protein? And I am truly curious, because I haven’t really other than urolithin,

Dr. Gabrielle Lyon 1:21:56

a I

Dr. Gabrielle Lyon 1:21:56

haven’t thought so much about the interplay between the postbiotic After we eat, and what we make and its effect on muscle. And as someone who’s very clearly, by the way, if you guys are not seeing this, she is jacked. Are there foods that you think, Okay, this is my muscle plan for muscle sparing on a GLP one.

Dr. Michelle Pearlman 1:22:19

I don’t think we know. You know, it’s interesting. When we look at the clinical trials, the dietary guidelines are very general in the GLP one study, so they’re telling people to eat protein, you know, to eat anti inflammatory foods. But beyond that, they’re not given specific dietary plans. So I couldn’t tell you whether someone’s eating more plant based versus animal based on a GLP one. That’s not how they created. The clinical trials, a lot of nutrition studies, also, they’re just really hard to interpret, because they’re relying on dietary recall. Lot

Dr. Gabrielle Lyon 1:22:53

of epidemiology,

Dr. Michelle Pearlman 1:22:54

exactly. So we don’t know when it comes to nutrition. They may get general guidance, but we don’t quite know what they’re eating on a day to day basis.

Dr. Gabrielle Lyon 1:23:04

So no supplements that you think, okay, aside from creatine, yeah,

Dr. Michelle Pearlman 1:23:09

creatine for sure, yeah,

Dr. Gabrielle Lyon 1:23:10

nothing that is kind of you’re interested in right now or on the top of your mind when it comes to mitochondrial

Dr. Michelle Pearlman 1:23:16

health. I don’t think anything is going to replace the foundation, which is whole food. I

Dr. Gabrielle Lyon 1:23:20

agree with that

Dr. Michelle Pearlman 1:23:20

fiber, protein, we got to just keep it simple and focus on those things,

Dr. Gabrielle Lyon 1:23:25

hormones. How do you think about the interplay, and I suppose, not the direct interplay between the GLP ones, but ultimately, people and patients, they want outcomes. Yeah, they want to physically transform. You have been utilizing studying and prescribing hormones for a long time. Fair to say,

Dr. Michelle Pearlman 1:23:49

actually not that long. So you had initially asked me, What is my kind of day to day look like, or what sort of patients are seeing me? And the initial practice was set up for weight management. It actually wasn’t until about a year and a half in where so my sister and I are in practice together. And what were we noticing? We were noticing that our most successful, happiest patient was our middle aged man who I was working on, his nutrition, his exercise programming. He was on a GLP one medication. My sister was managing his testosterone. This guy was hitting PRs and marathons. He had five pounds more muscle, now 40 pounds lighter. And we sat down and we said, if we can do this for women, I’m sorry for men, why can’t we do this for women? So we actually tried to find gynecologists and specialists in the Miami area to send our women patients to to optimize their hormones. And a couple things we found, one is the really good ones were already so busy, they weren’t accepting new patients, or if they were accepting patients, my patients were going to have to wait three to six months to see them. The third. Heard was some of these providers were still not on the bandwagon of hormone replacement therapy, to the point that they were telling my patients, my 45 year old patient, that I see you have osteopenia, but hormones have nothing to do with bone health. And I said, Okay, it’s one thing for a provider not to prescribe HRT. It’s one thing to gaslight my patient and give them misinformation. So my sister and I said, Okay, if we can’t find the providers in the area to see our patients soon and optimize their hormones, we’re going to take care of it ourselves. So we took a course with Dr Rachel Rubin. She taught us everything we needed to know about hormones. She’s absolutely amazing. Whenever I have a question about anything, I just choose one text away, and then now those are my happiest and healthiest patients, because we’re not only helping them improve their cardio metabolic health, getting them and maintaining a healthier weight, we’re treating their sleep disturbances. We’re treating their hot flashes, their night sweats. All of these things are incredibly important for optimal quality of life, but we found it serendipitously with our middle aged male patient who was killing it

Dr. Gabrielle Lyon 1:26:07

those guys, from a body composition perspective, there isn’t a ton of data with hormones actually changing body composition. What have you seen in your clinic?

Dr. Michelle Pearlman 1:26:18

It’s interesting because you know, as women reach middle age, and that’s, you know, mid to late 30s, right? And early 40s, we start to see body composition changes as, you know, where maybe the BMI or the weight is pretty similar, or five pounds up. But people often, you know, my women come in and they say, I have a belly I’ve never had before, right? My body has changed. My skin has changed. This is just very different for me, but my lifestyle hasn’t changed. Why is this happening to me now, if I’m doing everything I did when I was 20 and 30, right, and I say, the problem is, your physiology is vastly different. Even though you didn’t change, your body has changed underneath the hood. So that, you know, is a big thing. What do we see with horn replacement therapy? Well, a lot of people would argue, well, if I gained weight during perimenopause, if you just give me back some of the hormones, won’t I lose the weight? We just don’t see it. HRT is not a weight loss strategy. Now, if someone’s gaining weight because they can’t sleep, and you fix their sleep, then maybe it will help in that regard. But in many of my patients, I may actually see a little bit of weight gain. Why? Because we’re helping with bone and muscle, especially if they’re on testosterone, they may actually gain a little bit of weight, even though their body composition is changing. Their BMI, or that number on the scale may not be going down. But what we’re seeing actually, more and more in retrospective studies currently, is the secret sauce is the combination of HRT and GLP one therapy. And you had asked me earlier, what are we seeing with lean tissue or muscle changes? And I’ll tell you, I can tell exactly the point that I start a patient on a GLP one on hormone replacement therapy, because their lean mass losses start to kind of go straight, and then they start to gain muscle when I’m optimizing, specifically my women on testosterone. So that’s really cool to see when you’re actually tracking the data that matters.

Dr. Gabrielle Lyon 1:28:10

Do you have a number in mind if someone is coming in? Because again, there is still, surprisingly no aside from hypo sexual desire disorder, no other FDA approval. Dr Amy Pearlman is sitting in here for testosterone. Do you think about okay, so the patient comes in, they’re on a GLP one. We know that they don’t do anything magic for muscle loss, and I’ve just been reviewing some of the data, so I’m excited to hear kind of what you were seeing when it comes to muscle health. From my perspective, it helps with improve muscle health, not decrease muscle health, because people will say individuals are losing more muscle mass. It’s perhaps the rate of weight loss is accelerated with the GLP ones, but the quality of muscle seems to improve.

Dr. Michelle Pearlman 1:29:10

Yeah, absolutely. I mean, people will blame everything and anything on GLP one therapy, but what do we actually see in the data? So when you compare diet and exercise, GLP one therapy and bariatric surgery, the absolute percentage of lean tissue loss is the same across all 25 to 40% of losses you’re going to see across all three modalities, but people are losing more weight now on GLP ones than they’ve ever been able to lose before with diet and exercise. So of course, the absolute number is going to be more than just diet and exercise, but like you mentioned, is muscle mass. Is that the Holy Grail? I would argue it’s not, because I’m tracking that right. But if I have a patient that says, Okay, I’ve lost 30 pounds, yes, I’ve lost five pounds of muscle, but I feel stronger now than I did when I started. How am I. Clinics. Do you think are testing hand grip strength, six minute walk tests, a get up and go test? Because ultimately, that’s what matters. Is performance. Is strength, not how much muscle mass you have, but the actual contractile forces you’re able to to to, you know, have right frailty and fracture. What matters? That’s my issue. Actually. With DEXA scans, we’re looking at bone mineralization. We’re not looking at how strong are your bones in actuality. So I think that’s where we’re missing the boat when it comes to, you know, talking about frailty, fracture, muscle mass, metabolic health is not just what are you made of, but you know, how strong is your muscle and how productive can you be to reduce your risk of frailty and fracture?

Dr. Gabrielle Lyon 1:30:45

You are highlighting the diagnostic gap that as healthcare providers, this should be standard. Someone goes to their provider and they get blood pressure checked,

Speaker 3 1:30:56

they

Dr. Gabrielle Lyon 1:30:57

get weight checked, but they don’t get hand grip strength, which we know is a great, one of the greatest indications of longevity,

Dr. Michelle Pearlman 1:31:08

and it literally takes 30 seconds or less,

Dr. Gabrielle Lyon 1:31:11

even it might even be, I don’t want to say that it’s more important than blood pressure, but The indications when we think about strength and survivability. Muscle is underutilized under diagnosed. It’s not part of the normal conversation,

Dr. Michelle Pearlman 1:31:28

yeah, and

Dr. Gabrielle Lyon 1:31:29

I’m really glad to say that

Dr. Michelle Pearlman 1:31:31

we don’t even have, well, okay, I will say we have a blood pressure cuff at our clinic only because my sister does procedures, so we need it. If someone feels faint, or if someone says, I have a headache, I will check their blood pressure. Other than that, I never check blood pressure in patients. Why? Because I live in Miami, and people are driving in Miami traffic, so I would much rather a patient check their blood pressure at home, send me their wearable information, which is more realistic to how they live on their daily basis. Not a one data point from when they’re here in clinic, but yet, in the typical healthcare scenario, the number of profound medical decisions we make on one data point in clinic is absolutely insane to me.

Dr. Gabrielle Lyon 1:32:14

Amen to that. When how are we for time?

Speaker 2 1:32:20

Got an hour 32

Speaker 3 1:32:21

okay,

Speaker 2 1:32:22

we had a middle part, so it’s probably like an

Dr. Gabrielle Lyon 1:32:24

hour point. Well, I have more questions. When is Are you okay? On time? Yeah, okay,

Dr. Gabrielle Lyon 1:32:30

Michelle, real quick, it’s 138 was time to leave for the airport. Oh, I’m good, yeah.

Dr. Gabrielle Lyon 1:32:37

When you think and start to see a decline in lean tissue. From the perspective of patient care, how do you decide, is it going to be estrogen? Is it going to be progesterone? Is it going to be testosterone? Let’s say they are perimenopause, so not totally in menopause. Maybe their estrogen numbers are lower. Maybe all their hormones are low. How, from a clinical decision making standpoint, do you approach that?

Dr. Michelle Pearlman 1:33:04

Yeah. So one thing is, we can’t, you know, we have to track in order to see someone’s progression. So for instance, people who see me in clinic, I see them on a monthly basis, and I use a medical grade bioimpedance scale called the Seca, and I’m tracking every month now, I will have patients who see me, let’s say out of state. They’ll send me their data from, let’s say, a withing scale or the Hume scale. So I have, you know, the body fat and the muscle, the trends are important. The absolute numbers, not so much, but the trends are really important. So if someone’s, let’s say on a GLP one medication, even though I previously mentioned like that, mass is not the end all be all. It gives me data to say, Okay, you lost two pounds of muscle this month. How much protein are you taking in? And I know you’re telling me you’re having chicken breast for lunch, but can you please weigh it out I need to know if it’s two ounces or six, because there’s a big difference there. So it gives me a platform to better inform myself and the patient to say, Okay, are you getting enough protein before I even delve into the hormone piece, the exercise piece, as you know, like exercise is so incredibly important for longevity. If we could package that up in a pill, you and I would never have to work another day in our life, right? Exercise is so important. But I have so many patients that, let’s say, See trainers, or they’re on this orange theory bandwagon, or Barry’s boot camp, and they’re doing endless kind of circuit training moderate intensity, and they’re not making gains. And so I will actually talk to a lot of trainers. I’ll have a phone call. I’ll have a zoom,

Dr. Gabrielle Lyon 1:34:29

yeah.

Dr. Michelle Pearlman 1:34:30

I’m like, No, but I need to understand, because not all trainers are created equal, like not all doctors are created equal. What is your exercise programming look like? Because if I’m not seeing the results that I anticipate in my patient by what they’re telling me, I need to truly understand what does their exercise program look like. And I have so many patients that will get a trainer for 45 minutes. They’re rushing from exercise to exercise. They’re doing like, 15 exercises. And I’m like, how much are you how much time are you resting in between exercise? And they’re like, two minutes. And I’m like, No, that math doesn’t math. That’s. Yeah, you’re doing 15 exercises, four sets of each, like, in 45 minutes. You know, we’re

Speaker 3 1:35:05

doing

Dr. Gabrielle Lyon 1:35:05

cardio

Dr. Michelle Pearlman 1:35:06

exactly like, where do we where do we build muscle? Not in the gym. We build muscle outside of the gym. But, you know, with recovery and fuel, but you need to actually make sure you’re resting in between sets. You’re doing progressive overload. And my patients kind of just follow whatever the program is if they don’t have the knowledge to start talking to their trainer about it. So I kind of fill that gap and have that conversation. And I’ve had patients that switch trainers, and all of a sudden they start gaining muscle. So that’s really key. When it comes to the hormones. It depends on what their symptoms are, right? If they’re having hot flashes and night sweats, we’re going to start with the estradiol and then progesterone if they still have a uterus. If, you know, a lot of my patients don’t necessarily realize the importance of testosterone as you know, we as women have more testosterone than we do estrogen in all phases of our life. So they’ll say, oh, I don’t want to look like a bodybuilder. And I say, do you understand how hard to look like a bodybuilder, right? My goal is not to give you male doses of testosterone, but if someone is worried about bone health, if they’re worried about muscle health, if they want to improve their cognition, they’re libido, right? Testosterone can be very, very beneficial in that regard, but we have to start terming just like GLP. Ones are not just weight loss drugs. We have to stop calling hormone replacement therapy as or testosterone as just libido enhancers. They are brain hormones, they are heart hormones, they are muscle and bone hormones. So it depends on what the person’s ultimate goals are, but I look under the hood, and if they’re eating the protein, they’re doing the resistance training, but they’re struggling with bone and muscle health. I will say I really think we should give testosterone a try.

Dr. Gabrielle Lyon 1:36:47

How do you think about dosing for testosterone?

Dr. Michelle Pearlman 1:36:50

So I do use a compounding pharmacy for testosterone. I aim on the lower side instead of the higher side because I’ve had patients come in with significant hair loss, with acne, with mood changes, with, you know, clitoral enlargement, which can sometimes need surgery to correct. So I usually start them low, because a lot of my female patients are already worried about hair loss. The last thing I want to do is convert more of that into DHT. So I will typically do a daily cream that’s compounded, or I will use oral testosterone like Kaiser tracks, which is a little bit higher doses.

Dr. Gabrielle Lyon 1:37:23

You are the first physician, I think that we’ve had on that is maybe a year ago. I think Kais attracts is a great,

Dr. Michelle Pearlman 1:37:31

yeah,

Dr. Gabrielle Lyon 1:37:31

great.

Dr. Michelle Pearlman 1:37:31

I’m on it myself.

Dr. Gabrielle Lyon 1:37:32

Okay, yeah, talk to me about Kaiser trucks, the oral testosterone.

Dr. Michelle Pearlman 1:37:37

So, you know, a lot of people are worried about taking oral hormones, and I get it because same thing like oral estrogen that can increase, even though it’s a small, increase risk of clotting and the old oral testosterone formulations cause liver issues. Now, the nice thing about Kaiser

Dr. Gabrielle Lyon 1:37:53

tracks first passage,

Dr. Michelle Pearlman 1:37:54

exactly. Yeah. So the nice thing about Kaiser tracks is we absorb it through our small intestine. Right now, we do have to take it with with fat in order to optimize absorption, but it’s a very easy pill to take. Now, we don’t have the, you know, the dose is approved for women, so I will start at the lowest dose possible, and it is a little bit higher than what we’re going to get with the cream. But it, yeah, it depends on the person and what sort of formulation they want or they’re willing to take.

Dr. Gabrielle Lyon 1:38:18

If you guys want to learn more about Kaiser tracks, we will link it. Here it is, I really think revolutionizing the ability to take hormones, because a lot of guys, whether they are traveling or they don’t like injections, really struggle. Also women, from a perspective, with testosterone and just any kind of hormone people have kids, you know, it’s, it might be too much of a risk for transference.

Dr. Michelle Pearlman 1:38:50

Yeah, yeah.

Dr. Gabrielle Lyon 1:38:51

The oral Kaiser tracks, what is the starting dose that you guys think about for women?

Dr. Michelle Pearlman 1:38:56

So the lowest dose is 100 milligrams,

Dr. Gabrielle Lyon 1:39:00

and that’s once a day with food,

Dr. Michelle Pearlman 1:39:02

yeah, yeah. Versus for men, it’s typically they’ll do like four four pills, like 400 milligrams, twice per day, so they don’t yet have a lower version. It will be nice. I think once they have maybe lower versions. Most of my patients are on the compounded cream, mainly because I don’t want to drive up their levels too much. So it depends, because the Kaiser tracks is going to be a higher dose than what you’re going to get on typical top.

Dr. Gabrielle Lyon 1:39:25

And the women do a lot better on that.

Dr. Michelle Pearlman 1:39:28

I only have actually probably two patients on the Kaiser tracks. Actually, most of my patients are on the lotion more so because, yeah, I think they’re. Some of them are just worried about higher doses. And so I typically will start most patients on the cream. Yeah,

Dr. Gabrielle Lyon 1:39:42

do you find that the blood levels look different? For example, if someone is on the cream, do they have a higher conversion to DHT versus if someone is using an oral agent?

Dr. Michelle Pearlman 1:39:55

I think it’s hard to say, because I don’t have most of my patient. Patients are on the topical so I’m not sure if I can answer that question, but I’m mostly looking at, you know, side effects, and I will see that more so in my patients who were on pellets or injections. So I get those patients that come in and they weren’t given any other option. They were literally said, you know, you should be started on hormones. Here are pellets. They didn’t realize there were other modes of administration. So I see more virulizing effects in those patients. And so I will definitely start them on the topicals, just because it’s it’s quick, it’s lower doses, and they’re already worried about side effects. I aim more on the lower end. Yeah.

Dr. Gabrielle Lyon 1:40:39

Do you find that so for example, SHBG, shpg, you guys who are listening to this, hopefully this is not your first show, but let’s say it is. Then sex hormone binding globulin hormones are like children. They can’t go anywhere alone. Sex hormone binding globulin binds to these hormones. One of the things that we’ve seen with oral agents, just in general, is it lowers SHBG, so there’s more of the hormone available. Does Kaiser tracks? Do you find that Kaiser tracks lowers SHBG, better or more? Or do you find that it just makes hormones more available?

Dr. Michelle Pearlman 1:41:19

That I won’t be able to comment. Do you know the answer? Okay, yeah.

Dr. Gabrielle Lyon 1:41:22

We also cut that out.

Dr. Michelle Pearlman 1:41:24

Yeah, I would cut it out. She knows a lot more about the oral crime stuff. Yeah, some could have, like, a normal testosterone, but yeah, put them on oral tea, lower their SHBG. They get more protein, yeah,

Dr. Gabrielle Lyon 1:41:36

because I haven’t seen it with topical higher conversion to DHT, I’ve also see that SHBG, I mean, it’s, I suppose, the same mechanism action, but it’s hit or miss. So I didn’t know if I’m these questions are truly me, yeah, just curious. Yes. Do you find that okay? But, well,

Dr. Michelle Pearlman 1:41:53

it’s hard to say, because they only had like two people on the oral

Dr. Gabrielle Lyon 1:41:56

I love that. Yeah, I

Dr. Gabrielle Lyon 1:41:57

think that’s a could be a huge advantage of the use of, I agree,

Dr. Michelle Pearlman 1:42:01

yeah,

Dr. Gabrielle Lyon 1:42:01

so can we touch on that? I mean, I’m just so interested, because we don’t have patients, I know, well, oxy and alone, but that’s off the market. Obviously, no one is taking it for that. But you know, many years ago, do not, do not put this in here, but many years ago, we would use micro doses of oxandrolope, which is anavar and it lowered SHBG. It didn’t have a ton of the side effects. We weren’t seeing a bump in liver enzymes. And the primary hormone that we’re using is testosterone. I mean, obviously they have estrogen, progesterone, but it was just it was so fast. Was just, it was so fascinating that this was able to make the testosterone more usable without increasing the risk of viralization.

Speaker 3 1:42:51

Anyways.

Dr. Gabrielle Lyon 1:42:53

Well, that’s

Dr. Michelle Pearlman 1:42:53

in the bodybuilding world. I mean, they use and Novar a lot.

Dr. Gabrielle Lyon 1:42:56

Well, in the lips world also is

Speaker 3 1:42:59

yes, so this

Dr. Gabrielle Lyon 1:42:59

is where I learned about it. But we won’t put that in there. But I just think that that’s so fascinating. And Matt, he just does steroids all the time. I’m just totally kidding. Don’t put that in there. I know

Speaker 2 1:43:09

he doesn’t.

Dr. Gabrielle Lyon 1:43:13

Okay. Do you have an expectation of how much muscle you want them to gain? We’re talking about just the perimenopausal woman, where you’re like, Okay, we’re on a GLP one. You’ve changed your body composition. You’re going through recomp, you’ve lost 10 pounds of fat I want to see you put on. Or do you have an expectation of the amount of muscle mass that you want them to gain?

Dr. Michelle Pearlman 1:43:39

I would say my goal for each and every one of my patients is when they hit their weight loss goal and they’re in maintenance mode. That’s when the actually, that’s when the hard part begins is gaining muscle, because the easier part is losing the weight, the hard part is regaining some of the lean tissue that was lost. I want each and every one of my patients to have more muscle than when they started. And that’s doable, but it requires, obviously, that daily, consistent effort, protein, protein, not just exercising, but progressive overload, consistent resistance training. When we go on vacation, our muscles don’t care our mother,

Speaker 3 1:44:21

that’s

Dr. Michelle Pearlman 1:44:24

a really hard thing for people to realize. Is I have people business, men and women, who travel for three months out of the year during the summer. I hear only poor people stay in Miami over the summer. My sister and I are always here over the summer in Miami. But people travel for a couple of months, and they may go on cruises, or they’re walking around in Europe, and they literally stop resistance training for three months, and they assume they’re going to be able to maintain all of their muscle mass, and that’s just not the way the body works. So I want people to be feel strong. You know, a lot of my patients, they have the financial means. They have a great family support. They retire. They want to travel the world and do whatever they want. I know you asked, you know, a lot of your guests on here, what does forever strong mean to them? And to me, it means being able to do whatever, whenever you want, you know, and to have nothing hold you back, whether that’s mentally, physically, it doesn’t matter. It is freedom. It is independence. And people work their butts off their whole life for what they retire at 65 and then they can’t travel because they’re too frail. That is awful to me. One out of two post menopausal women develop osteoporosis. That doesn’t have to happen once they fall and fracture and they break a hip at the age of 70, their one year mortality is outrageously high. These things are preventable. If we talk to people in their 20s and 30s, when they’re still able to build bone and when building muscle is easier, these are the times the conversation should start, not when we get their first Texas gain at the age of 65 we have missed the boat in another realm when it comes to that. And I’m sure you saw that, you know when you were doing geriatrics as well. We are missing so many things that can be prevented.

Dr. Gabrielle Lyon 1:46:14

You feel very passionately about this.

Speaker 3 1:46:16

Did

Dr. Gabrielle Lyon 1:46:17

something happen? Did you witness someone get sick?

Dr. Michelle Pearlman 1:46:20

So I kind of went through it myself, actually. Now I’ve been a bodybuilder on and off since I was 18 in undergrad, and I did it the unhealthy way and the healthy way. So my first show, I lost 30 pounds in three months. I was doing two hours of cardio every single day. They had to kick my butt out of the gym when they were closing, because I was very OCD about it. I had female athlete triad. I would miss periods. I kind of took that as you know, like a medal like, Oh, I’m so lean I’m missing my period, right? That’s a good thing. So I kind of went through that on and off for a couple of years. I did bodybuilding shows in medical school. It was kind of like my badge of honor. I am 39 years old. I went to my gynecologist a year ago, and I said, I want to get a bone density scan. My mom has osteoporosis. I kind of had to convince her to order one for me. So I went in to get my bone density scan, and the technologist said, your bones look great. I walk out, I text my mom. I said, Mom, my bones are strong as hell. I pull up the report in my portal. Michelle Pearlman, osteoporosis of lumbar spine. I was devastated. I said, This can’t happen. I’m a bodybuilder. I’ve been lifting heavy shit since I was 13 years old. I eat 160 grams of protein a day. I’m super active. I counsel my patients on reducing risk of frailty and fracture. That this has to be wrong, right? So my gynecologist said, Oh, they make mistakes all the time. Let’s get another DEXA scan. So I ordered another bone density scan. I went to the hospital this time, went to the hospital, got my bone density scan. Same damn thing, osteoporosis of the lumbar spine, osteopenia of the hip. So not only is this something I see in my patients every single day. This is personal, because I thought I could do I did everything to minimize my risk. Now, I went to see an endocrinologist, and I said I thought I was doing everything I could to help prevent this. What should I be doing differently? Clearly, I’m missing something. Should I be doing X, Y and Z for exercise? And he looked at me, and he said, I don’t know what to tell you. And I said, Well, how I didn’t say this verbally, but in my brain, I’m thinking, if you as the bone specialist, don’t know what to tell me, as far as nutrition guidelines, as far as exercise, then what are people who aren’t doing what I’m doing, who are struggling? Where are they going for help? I think we need more research when it comes to how to optimize our bones and muscle health and everything, really, it starts in our teens and 20s. And I think that’s, you know, a big population we need to target, because those are our born, our bone forming years. And if you know what I see, and you had mentioned the term earlier, we are over training and under fueling, and again, we take that as a badge of honor, that we’re not eating that much, that we’re training really hard, we’re getting away. We’re getting away with five hours of sleep a night, and our body tells us at some point that’s not going to work for you. And that was my wake up call, and

Dr. Gabrielle Lyon 1:49:19

what are you doing about it.

Dr. Michelle Pearlman 1:49:20

So I had to actually beg my gynecologist to start me on hormones. I said, Listen, I’ve had the IUD for years. I have no clue what my ovulatory status is, but I want to start on estradiol. I need to throw everything in the kitchen sink at my bones, because I’m 39 years old, and she’s like, Okay, well, yeah, I guess we can do that. Okay? So we started, you know, on estradiol, and I said, and I would also like to be started on testosterone, because there is data to support that. That will also help with bone density. And obviously it’s a musculoskeletal unit, the stronger our muscles, the stronger our bones. And she said, Well, that’s just not part of the guidelines. I. It f the guidelines, so I got the testosterone elsewhere, you know, but it’s crazy that myself in healthcare, as what I would consider myself, an expert in hormone replacement therapy and in bone and muscle health, that not even I could advocate for myself to get what I thought I needed, because the guidelines didn’t say it. And you and I know the guidelines are often 1020, 30 years behind what we’re actually seeing in clinical practice.

Dr. Gabrielle Lyon 1:50:30

What do you want people to know? What do you want to see, for example, to protect your bones? We need. And I know that we don’t have this number estrogen to, you know, to be 75 in the blood, you know. And there’s various, this is just an example. There’s various ways that someone could measure it, in terms of the metric units. But what as a physician, who is an expert, and obviously your sister is an expert. You didn’t have answers. And this one thing can change the trajectory of of your life.

Dr. Michelle Pearlman 1:51:13

Yeah,

Dr. Gabrielle Lyon 1:51:13

your survivability. Where do you where do we go? What do you want?

Dr. Michelle Pearlman 1:51:19

I think one of the biggest things is education, right? We have to educate ourselves, and this is where podcasts and platforms like yours are extremely helpful, right? Because you are educating the larger population on the metrics that matter, on muscle centric medicine, you always say muscle is the longevity organ, and I was never taught that in medical training or in fellowship or in the first four years of my career. I learned it because in my clinical practice, I was looking at the data and I was saying something doesn’t make sense and things are not lining up, right, and what are we missing? Why are all these women at the age of 40 coming in with osteopenia, right? It’s because no one had that foundational conversation when they were in their teens, right? These conversations weren’t coming up in pediatrics and they weren’t coming up in their 20s or 30s. So we’re picking it up and we’re being more reactive than proactive. The nice thing is, these things don’t have to be super complicated or expensive, but it requires education. You know, through platforms like yours, it’s talking about, what are the metrics that matter, muscle and bone? They are longevity, organs, right? We know that patients with osteoporosis have worsening brain function and cognitive abilities. So it’s not just about having that six pack or being able to, you know, do a heavy bicep curl or 20 push ups, it literally affects our health span and lifespan. So it’s, I think it’s reforming or rephrasing the conversation on what matters, not just getting people on an old school scale right? I don’t care when people say, What is my ideal body weight? I tell them I don’t really know what that is, right? But if you lose 10 pounds and it’s eight pounds of muscle, you nor I are going to be happy 10 pounds less, right? So it really goes back to what are you made of, and how are we going to improve your quality of life? 610, 2040, years from now, and a big part of that is the musculoskeletal system.

Dr. Gabrielle Lyon 1:53:25

Do you think we are going to get to a place where it’s equal opportunity for muscle as an organ system? From the healthcare provider standpoint,

Dr. Michelle Pearlman 1:53:37

I’m not sure it’s going to enter the typical healthcare scenario. I think where we’re going to see it is in providers who are kind of going outside of the typical box and thinking more outside of the box practices like my sister and I and yours, where we’re able to practice medicine the way we think it should be done. We are evidence based, but we’re not bounded by guidelines, right? And we’re having these conversations, both in our clinic and our sterile white walls, but also out on these social media platforms where people are hearing about it. Now the fascinating yet scary part is what we’re seeing, especially in the hormone and the GLP one space, is now that the population, the public, is getting more educated. They are now advocating for themselves, and they’re more aggressive at advocating for themselves. The people who need to be watching your podcast are not only the patients, they are the providers. And the problem is the providers who are against these things are never going to watch your podcast because they’ve been in practice for decades, and they are not willing to change their practice, because whatever they’re doing is kind of still working for them. That’s the problem. So now we have this big mismatch where we have patients advocating for themselves. They go to their provider, their provider is not up to date, and now they’re being gas lit. And then patients are like, Well, why am I going to go to a doctor? Because no one’s listening to me. Anyways, that’s where we I think can also improve

Dr. Gabrielle Lyon 1:54:58

the evolution has to. Home, because what’s going to happen is we’re going to go from an epidemic of obesity to one of sarcopenia, and we’re going to accelerate the age sarcopenia, osteoporosis. We’re going to accelerate that earlier, because these medications are available. And then it begs the question, beyond hormones, and I’ll say it this way, beyond estrogen, progesterone and testosterone, are there other anabolic agents that we can use to treat muscle?

Dr. Michelle Pearlman 1:55:37

And I think there are, because they are doing clinical trials looking at myostatin antagonist and things like that, where I think those medications can be very powerful. My argument, though, would be, if you’re not doing the resistance training, stimulate those contractile forces, I imagine you can have very large, beefy muscles, whether or not those muscles actually can have the contractile forces you need to help prevent a fall. Is a whole nother story.

Dr. Gabrielle Lyon 1:56:06

You make a really you bring up a really good point with obesity, you don’t necessarily have to work for that. Meaning, in order to build strong muscles, there’s only one way to get it, anabolic agents, various other hormones, various other selective androgen receptor modulators, are not going to take away the fact that work has to be done, and within that process of doing the work, the body systemically becomes healthier.

Dr. Michelle Pearlman 1:56:39

Yeah,

Dr. Gabrielle Lyon 1:56:40

that is a really good point, that it is medications. They have to be there. I mean, it would be the same as saying, well, you’re going to go lose weight, and the way that you’re going to do it is through diet and exercise,

Speaker 3 1:56:50

and

Dr. Gabrielle Lyon 1:56:50

then people struggle. And then people struggle, and it affects their confidence, affects all of these things. And then, on the same hand, if we think about building muscle, the foundation is critical.

Speaker 3 1:57:02

They

Dr. Gabrielle Lyon 1:57:02

have you’re not going to get away from doing the hard work.

Dr. Michelle Pearlman 1:57:05

Yeah, and no drug is going to change.

Speaker 3 1:57:07

No

Dr. Gabrielle Lyon 1:57:08

drug is going to change that.

Dr. Michelle Pearlman 1:57:09

Yeah,

Dr. Gabrielle Lyon 1:57:10

if we can get people to do meaningful practices, meaningful ways, to lean into the harder thing, and then they have access to other anabolic agents, just as they would have access to something to help them lose weight, this is what is going to have to happen otherwise. Right before our eyes, as healthcare providers, as fellowship trained healthcare providers, we are watching the World Trade, one epidemic for another,

Dr. Michelle Pearlman 1:57:42

yeah, yeah. And it’s a, it’s a multi system approach, right? We can’t just do one without the other. It’s kind of throwing everything at it. I think, you know, a big way that we can harness technology, because a lot of providers, right, who don’t have their own practice, they get 15 minutes. So how the hell am I going to have a nuanced conversation on what are you eating in a typical day? What are your portions look like? What does your budget look like? Your family unit? What are your baseline gastro symptoms? Okay, let me educate you all about nutrition. Now. Let’s start a GLP one. How am I going to educate you on minimizing all these GI symptoms in a 15 minute visit? Right? That is very overwhelming. And then you know, one of the reasons why I left my prior practice that I would have patients say I’ll see you next month, and I’d say, I’ll see I’ll see you back in six because I didn’t have the access. So where technology, I think, can be very helpful, is integrating wearable data, right? The metrics that matter, whether that’s at home, bio impedance, testing heart rate, blood pressure, all of those different sensors. Sleep I use the aura ring all the time, looking at step count. How can we integrate that data into other platforms? So I’m actually, I’m also a tech entrepreneur. I’m building out a nutrition platform called byte MD, where it’s actually going to harness all the things about gi health, nutritional intake and GLP one so you’re able to actually talk to an avatar. It’s going to pick up what you’re eating without you having to track, okay, I’m eating chicken. It’s going to see you’re eating chicken. It’s going to see how fast you’re eating the chicken. It’s going to look at your emotional state while you’re eating the chicken. Holy cow. And then you’re going to say, Okay, I just did my Z bound injection, 12.5 milligrams. I’m feeling kind of nauseous. It’s going to start to pull up these patterns, and it’s going to say, Okay, it looks like you’re nauseated because you ate, you know, barbecue chicken at eight o’clock at night, then you went to bed at 10. So how about the next time you do your injection? Why don’t we have a lighter dinner and eat it at six instead of 10? So I think it’s using technology to fill in the gap of that nutritional coach where we know we’re not going to find that in most healthcare systems.

Dr. Gabrielle Lyon 1:59:42

Dr Michelle Pearlman, not only are you an extraordinary physician, but now tech entrepreneur, it is physicians like you that really can help shift the way our culture sees medicine. Thank you so much.

Dr. Michelle Pearlman 1:59:58

Thank you so much for having me.

Speaker 3 2:00:00

Yeah,

Dr. Gabrielle Lyon 2:00:01

we have strong questions. Great job. I could have gone on for

Speaker 1 2:00:05

another holy cow. I was like,

Speaker 3 2:00:13

holy

Dr. Gabrielle Lyon 2:00:14

chicken. Okay, so we have some strong C questions. You did a fantastic job. I would think that you do professional podcasting. Thank you for having.