C (2:36)

So, yeah, you know what, Mike?

A (2:37)

We.

C (2:37)

We learn things in a variety of ways. Is your family still in Atlanta?

A (2:42)

Yeah, the whole family's still There.

C (2:43)

Yeah, except for you.

A (2:44)

Yeah, I'm in Boston, obviously, hence the Boston skyline behind me.

C (2:49)

While I was preparing for this interview, I read that you're one of the most cited doctors on obesity medicine. And you have many qualifications, but are probably most well known for really helping us understand obesity as a chronic health issue, as a chronic disease. And so I wonder if you can just share the beginning, like, when did you decide this area of medicine really would be where you would direct your time, your energy? You're clearly very capacious and capable brain.

A (3:25)

You know, I think that the field chose me more than I chose it as a field. I want to take us back really to the late 90s, early 2000s, when I really first began to understand that this was a chronic disease issue that disproportionately impacted some communities, but really impacted the global community. And I, at this time was doing my master's of public health, was working in communities, looking at black church communities, looking at how we could modify eating and nutrition in a way that was culturally appropriate within those church communities. But we were really looking at lifestyle modification as the means by which we would achieve this. But where we go is we would take this project, put this within the community as soon as that funding was up, take that project outside of that community, and unfortunately, the health of that community would resume what it was prior to that intervention. And so if we fast forward to my time in medicine, I would work with individuals and see that these interventions were short lived and not really sustainable.

C (4:30)

And by interventions you mean like changes to diet or changes to exercise.

A (4:35)

Exactly. So, you know, I'm reminded of a patient that stood out to me in my residency. So I completed residencies in internal medicine and pediatrics. And if I think about one particular patient that stands out in my mind, that really helped me to understand that this was beyond just lifestyle, particularly diet and exercise. Exercise modifications. I'm thinking of a woman who was in her 40s at the time, who really implemented all of the changes that I had requested of her over the three years that I'd been caring for her. She had done all of the dietary modifications, all of the exercise modifications, and despite all of these modifications, she really still struggled with curing what we call excess adiposity or excess fat mass. And it was at this time that I realized that this needed to be something beyond just what she was doing and had to be more biological in nature. And so I needed to delve more into understanding how I could be more of assistance. Instead of me just saying, hey, do X, Y, and z to achieve better health outcomes. And I also realized some of the biases that I had towards individuals that were trying to make changes and weren't seeing results. And so I realized how we as physicians were complicit in the widely held biases against individuals that happen to carry excess weight or have obesity.

C (5:59)

I'm curious, when you talked about the patient who really was trying to follow all of your recommendations, probably more than trying, was following all of your recommendations, and you kind of had this aha moment of, you know, maybe I need to ask different questions. How did that change your practice either in internal medicine, as a pediatrician, as a researcher?

A (6:23)

I would say it drastically overhauled everything that I did. I would say I was like, I want to say I was nearly 100% lifestyle focused. It was all about, you do this, you do this, you do this. And if you aren't doing this well enough, then it's obvious that you're failing at achieving a healthy weight. And I feel like a lot of this mantra has become commonplace in the current maha movement that we're seeing in the federal government. The make America Health Healthy Again. We are seeing some of this. We saw some of the commercial ads during some of the programming that we've seen during some major sporting events, for example. So if you haven't achieved a healthy weight, then it must be your fault.

C (7:06)

I'm really thankful that you brought up some of the maha ads that we've seen recently. And I want to start kind of our next segment by listening to one of those ads that played during the super bowl starred boxer Mike Tyson and seems kind of painfully apt for our kind of that can't be true title of this podcast.

B (7:31)

My sister's name was Denise. She died of obesity at 25. She had a heart attack. I was so fat and nasty, I would eat anything. I was like £345, a quart of ice cream every hour. I had so much self hate when I was like that, I just wanted to kill myself. We're the most powerful country in the world and we have the most obese, fudgy people. Something has to be done by processed food in this country.

C (8:02)

So certainly I believe in the adage of, you know, an apple a day is probably really good for us. And clearly the death of Mike Tyson's sister is tragedy for his family and everyone who loved her. And also, this ad was paid for by the federal government. And I'm curious what your reactions were to this ad. Do you think this is an appropriate use of funds?

A (8:32)

I Have many thoughts about this.

C (8:35)

Can you share them all?

A (8:36)

I will share them all. I somehow did catch that ad live, and I specifically commented on that ad live when it came on, and I was really disappointed with the language. For example, the use of the word obese, which is a highly stigmatizing word. I can imagine if people were watching this and they happen to have the disease of obesity. How highly stigmatizing? That was the use of the word fat, which is also highly stigmatizing. And then a lot of the blaming and shaming of individuals that have this disease, and then this idea of that. It's as simple as just, oh, I can eat an apple and this will all go away. So I think that there was a lot of problems in this ad.

C (9:17)

What would your ideal ad messaging have been?

A (9:22)

So I would have said, or if I were constructing that, I would have

C (9:24)

said, you know, yeah, you have full control. This is like. You are like the director.

A (9:28)

The director. Oh, I love director. Yeah, I love being in control. This is. This is lovely. This fits me a lot. So I would have, you know, done something like, okay, you know, aiming to eat healthy, be active, like something kind of like around the Olympics. Right, right. You know, we're going into the Olympics at the same time anyway. And then I would have said something, you know, oh, but if, like, this doesn't work, kind of seek care from your healthcare professional. There are other options. If this doesn't work, you know, you may need support. We can still help you. So, hey, do these things, do these things. But if this doesn't work, hey, we have these other modalities or treatments that are available. And I think that this would have rounded out the thought process, because the way this is set up is that here I eat this apple or, I don't know, a carrot. And what's very interesting for someone like myself who's treated more than 10,000 patients with obesity is most of my patients that come to me since I exclusively treat this disease process, have already tried those treatments. They've already tried the diet, they've already tried the exercise. They've already tried all of these things. And so by the time they make it to me, if I were to say, you know what? I think you should just go and eat an apple, you know, I can't imagine what they would feel, you know, if they came through my door of my clinic, and that's the messaging I gave them, I can imagine that most of those people would leave probably within the first five minutes of meeting me or maybe the first three minutes because that's not the messaging they need to receive. They one of the first questions I ask them is, how many attempts have they made to lose weight? And the resounding question, or the answer, I'm sorry, that they give me is they've made numerous attempts. And I see people from age 2 to age 90, so even my little kids that I see will say they've made numerous attempts. So if I were to ask them that question and then say, oh, you know, you just need to eat an apple, or oh, you just need to do X, Y or Z, that would be, you know, somewhat patronizing to them.

C (11:31)

You know, last year at the super bowl, there was a GLP1 ad and that, you know, sparked a lot of conversation. I feel like even in the last year, there's much greater awareness and less stigma around kind of people Talking about their GLP1 usage or talking about family members. I wonder, in clinic, has this awareness led to kind of more people coming in and asking for something specific? Are there certain kind of myths that you kind of encounter frequently? Just how has this growing awareness shifted kind of your clinical practice and your work as a public health educator?

A (12:14)

You know, that's a really interesting question. I find that patients with this kind of like, I would say, GLP1 era that we're in, people are more interested in therapies. You know, as someone that's been in this field for a long time, people were very resistant to try medications.

C (12:33)

Dr. Stanford, when did you first prescribe a GLP1 to a patient?

A (12:38)

Oh, we were using these a long time ago. So 2012 maybe.

C (12:44)

I just asked that because I think many people think like, oh, these are still very novel.

A (12:48)

Yeah, GLP1s came around in the early 2000s. Right. The very first set of GLP1s. Right. So they were first prescribed for patients with diabetes in the early 2000s. We were using them off label for patients with obesity. Even then. The first ones that were approved for obesity were, you know, when we're getting into the 2000 and tens. So that was liraglutide or saxinda. These were patients that were willing to give themselves a daily injection. But these didn't really become popular until we saw that kind of ozempic wegovy era, which was kind of circa 2021. Right. Kind of in that pandemic era, we start to really kind of see these really take off because at once a weak shot, particularly with the potency of response. When we started to see about 15% total body weight loss, people started to see that These were pot, just a once a week type of situation. And people started to really then ask for these as a potential treatment modality, which was a major shift. People went from being scared of needles to being like, wait a minute, it's only once a week. I think I can handle this. We start to see these medications even begin to get approved for people as young as 12 years of age. Right. So we start to see this even shift into the pediatric population. So I would say the difference now is that. So patients come in, they're interested in these therapies. They sometimes think that this will be the. What I will call the Holy grail, this will just solve obesity, regardless of how severe their disease is. This is, I think, a major problem that I see. I'm a major believer in using the right tool for the size of the problem. So what do I mean by that? I usually equate this to a snowstorm. I live in Boston now, and I've been here for a long time, so I'm used to snowstorms now. And I often will ask, ask people that if there is a big snowstorm, what would be the proper tool for a city to use if there's a big snowstorm? And people will often say that if I were to get two feet of snow or a foot of snow, that it would probably make sense for the city to pull out the snow plows because that would be the proper tool to remove the snow. And it wouldn't make sense for all of us in the city of Boston to go and get teaspoons out of our. Our. Out of our kitchens. Right. That wouldn't make sense, but that would be the equivalent of me using lifestyle for someone with severe obesity. Okay, well, what about if, you know, I, you know, the city of Boston put a mandate. Mayor Wu says, hey, why don't we all go get our shovels out of our respective homes and let's all go and shovel. Well, that would be the equivalent of using medication for someone with severe obesity. And so why am I bringing this up? Because right now, we're in the era of patients with severe obesity expecting a medication to treat the severity of their disease, and it won't by itself. You still need to utilize something like a surgical intervention for the severity of that type of problem. And so I think that there's often a mismatch or a misuse of the problem. But in the same vein, let's go to the other end of the spectrum. There's a misuse of the medication where patients that don't need the medications. This idea of microdosing or using the medications because they want to look cute for the Met Gala or something like that.

C (16:10)

Expand on that a little bit, because people may not know kind of what you mean by microdosing.

A (16:15)

So I don't see this in my clinic, because to get into my clinic, you have to have disease, right? But in the airwaves on the TikTok and the IG and all of these things, because I know you all are there, trust me, I see you. I know what's happening. I know that patients that don't have disease, meaning they don't have metabolic disease, characterized by obesity or type 2 diabetes or liver disease, or, you know, something that is characteristic of something that these medications would respond to. But you're like, you know, I need to look cute because I'm going to the Oscars or I'm going to the Met Gala or whatever it is. I want to look cute because I have my, you know, upcoming reunion, you know, just need to lose, you know, about 10 pounds, you know, like about 12 pounds, you know, and so I'm one of these medications for that reason. That was not the intended use of these medications. All of the trials that have been run, which me and my colleagues have helped run, these medications were not supposed to be used for these reasons. They were used to treat patients with either overweight or obesity or type 2 diabetes or obstructive sleep apnea or kidney disease, et cetera. These were used to treat actual disease. They were not to look cute on Miami Beach. So this idea of microdosing, because I want to maintain a certain image, there are no studies to support that. There. There are zero studies published here in the United States or anywhere around the world for this idea of giving a small dose to maintain a certain image. That's not the intended purpose of these medications.

C (17:49)

And so do you worry that, you know, in the absence of evidence, we just don't know what kind of effects, short or long term, there may be at a population level.

A (18:02)

We really don't. We have no data. And, you know, as a scientist, as someone who spends a lot of my time conducting research, we have no idea. Now, someone may rebut if, you know, they were, like, debating on, you know, the debate floor and say, well, okay, well, Dr. Stanford, I've also heard you say, well, there's a lot of potential for these medications for other disease processes that are being investigated. Well, there's a potential for these medications for alcohol use disorder or potential for rheumatoid arthritis or you know, and the list goes on and on and potentially yes and maybe. And these are not use case scenarios where we're looking at people with excess weight. And so yes, the jury's still out on a lot of these conditions. We know that GLP1 receptors are located throughout the body. And so yes, these conditions will likely see some improvement and yes, these will likely have approval in the future for all of these use case scenarios. But until we have the data to support that in individuals that don't carry excess adiposity, it's hard for me to endorse the utilization of these medications for the intended purpose that people have been using them off label. And so I say let's wait for the data because if we're going to be using this on a population wide level and we, we see a sizable portion of the country that is using this. I mean, we've seen some reports say that up to a third of individuals have used a GLP one at at some point, not sustained use, but have used it at some point. And that's a sizable percentage of the population.

C (19:38)

And you know, Dr. Stanford, when you are referencing the kind of Instagram and TikTok videos of people, you know, talking about their microdosing, what do you think about the doctors who are prescribing them?

A (19:55)

I have to pause a little bit because I realize I'm speaking about people that are practicing medicine. I worry about what their intent is. Is it just, hey, I know that I'm going to be lucrative because prescribing these medications on a platform that's not governed very well will indeed be lucrative. I think that we have to think back as physicians to our Hippocratic oath. Our first part of that oath is to first do no harm. And that first do no harm is based upon data and research. And so I, I think that's.

C (21:06)

I know. Dr. Stanford, you said earlier that you've seen more than 10,000 patients and you have been in this work for more than two decades. And over the course of those decades and seeing your patients, obesity rates and obesity related diseases have risen substantially in the United States. I think that partly explains the visceral sense that many people have to kind of the maha rhetoric around processed foods as being kind of the core villain in the sense that yes, our diets have changed so dramatically, like that's why. And so if we undid that we would get healthier, I understand why there's such receptivity to that simplistic, but also kind of very clear, even if not evidence based, why do you think obesity rates have risen so dramatically in the last 30, 40 years? And risen disproportionately in some communities, particularly for African Americans, Native Americans, Hispanic Americans, particularly for women in those communities, and also for kids. Like, if it's not just processed food or ultra processed food, what do you think helped explain why we're even arguably having this conversation today?

A (22:30)

So I think this is a multifactorial question and or answer that I'm going to give. I think food is part of the problem, but I think that there are a lot of things that have changed in the last 50 years and I'm going to go over some of these things that when we add these things together can explain why we've seen these dramatic, this dramatic rise in obesity. Actually, obesity rates started to go down over the last few years. So I want to correct that a smidge because we've actually seen them go down. These, we think are attributed to the GLP1s. We don't know why, but we can possibly call the GLP1s into question. As for the small drop in obesity rates, still a rise in severe obesity, but a drop in obesity rates overall over the last two years. But let's look at what's happened. Yes, we've had a rise in more processed foods. Okay, that's one thing. Let's look at the rise in weight promoting medications, medications that we prescribe that alter brain chemistries that cause an increase in weight. Medications like Lithium, Depakote, Tegretol, Celexa and Cymbalta. Effects are Prozac, Ambien, Trazodone, Lunestic, Avapentin, Glyburide, Glitozyclomepporide, long term insulin, long term prednisone, just to name a few.

C (23:41)

And Dr. Stanford, sorry to interrupt, but those are prescribed for what?

A (23:46)

So these medications are medications like antidepressants. Some of these are medications to treat type 2 diabetes, these medications are antipsychotic medications, some of these are seizure medications, some of them are for sleep. And so a lot of times one of the key things I do is I'll just review the medication list for patients and I'm like, oop, that causes weight gain. That causes weight gain. That causes weight gain. And I look at them and they're on four different weight promoting medications.

C (24:14)

And how often is that a surprise to your patients?

A (24:17)

They're always surprised. They're like, oh wow, I'm on like four different ones. I'm like, yep, yep. All of these are weight promoting medications and some most of the time, their doctors are unaware. So we have weight promoting meds. Let's look at sleep. So sleep has changed, right? So if we look at kids and we look at adults, There's a wonderful study that came out in the Journal of Pediatrics in 2008. That track tracked individuals from the age of three to the age of 30. And they looked at those that had small amount of sleep, kind of middle amount of sleep, and high amount of sleep. And they showed that those individuals that had kind of not adequate amount of sleep to kind of adequate amount of sleep and showed what was their weight over time. And of course those that didn't have had inadequate versus kind of moderate level of weight had worse weight gain over time. So this study, they don't fund studies like this anymore. The NIH doesn't do this anymore. But for studies like this that were funded like that, they showed that those individuals had significant weight gain. The ones that were inadequate sleepers. So sleep has changed. Why has sleep changed over the last 30 to 40 years? So, Chelsea, you and I can remember that when we were little girls. Do you remember how the programming used to stop and they used to have those kind of lines that used to come.

C (25:29)

Those lines. I totally remember those lines. Yeah. In the 80s we don't have the

A (25:33)

lines anymore because we have programming that goes throughout the middle of the night. We can turn on whatever on demand, we can do whatever. Why has sleep change? Because the world has changed. We are able to do anything on demand. When there is sleep dysregulation, there is problems. So let's go from not just sleep in terms of when we go to sleep, when we do things. So circadian rhythms have changed. We are up in the middle of the night. We're supposed to go to sleep when it's dark and we're supposed to wake up when it's bright. This is the normal pattern, unless you're a rodent. Rodents are supposed to be awake when it's dark and they're supposed to be asleep when it's light, which is why you don't see like rodents running around, around during the daytime. It's just not normal.

C (26:14)

Just when I go for my early morning runs. Right.

A (26:17)

So you may, you may see some at that time, but, but usually we are supposed to be asleep when it's dark. So we have shifted that now. Night shift workers, this is why you also see them gain weight. People assume night shift workers gain weight because, oh, those night shift workers, they don't eat well, they don't exercise well. No. The pattern of our brains recognize that there's a sleep dysregulation in terms of weight when we are awake during the nighttime and asleep during the daytime. Sometimes all I have to do is shift night shift workers back to being daytime workers and that can cause their weight to come back into normal weight regulation. Wow. So that pattern has changed. What about allostatic load? That's a fancy way of me just talking about stress or stressors. One of the questions you asked me, why is this disproportionately impacting some communities, those communities that carry higher rates of stress? Stress is seen as an issue for the body. When the body sees stress and stress being chronic, it likes to hold on to weight. It sees that as a protection. If that stress is chronic over time, you can imagine how that builds over time as a protective force. So you can see how all of these things added together have led to weight increase over time. Let's talk about the COVID 19 pandemic. During the COVID 19 pandemic, we saw an increase in weight during the pandemic. But what's really curious about this is that during the pandemic, people were housing in place, we were eating healthier, people were cooking at home, People like peloton. Peloton stock went through the roof. Right. People were exercising at home. Why did our weight go up? Because stress went up during this time. Regardless of how high your socioeconomic status was, there was a lot of uncertainty. When was this going to end? When we were going to get back to normal. Stress went up, storage of adipose dose goes up. So this kind of chronic nature of things has happened over time and this has led to this increase in weight and weight status over that time frame.

C (28:17)

And you think the same set of factors explain why weight gain is also increased for kids?

A (28:23)

Oh, absolutely. These things have affected kids. I mean, we saw this, for example, during the pandemic. We saw this disproportionately happen for children. During the pandemic. We've seen weight promoting medications increase during like I see both children and adults. Genetics plays a large role. People hate it when I bring up genetics. But genetics account for a large degree of weight and weight changes during this 40 to 50 year shift. People are like, well, our genetics haven't really changed. But if you mate two individuals that carry excess weight, there's a high likelihood that you're going to produce a child that carries excess weight. That's why I take care of so many families that have this disease. So I think we have to take that into account.

C (29:05)

We've talked about GLP1s, and we talked about diet and exercise. And I know that you've talked about obesity as a brain disease. Why do you think it's important to frame that in that way? And why do you think it's important that psychology and psychiatry are part of this conversation?

A (29:25)

I really want to frame this in terms of a patient that I saw recently who was actually very fearful to see me, which was unsettling for me because I've never had a patient should, at least to my knowledge, be fearful to actually see me in her brain when this is. And I'm going to try to quote hers directly. And so I hope she actually gets to hear this. She said, when I talk about obesity as a disease to her, and this is why the psychology piece is very important, she thinks of it as kind of like her body is molded inside. It's all black and molded inside. And when I talk about obesity as a disease, I'm talking about it as there's a brain gut connection, there's pathology that we can treat. I've never thought of it is that she's a molded inside. And so when she said that to me, it was very interesting because she was able to connect with one of our five psychologists that we have on staff, and she explained this to our psychologist, who then reframed what my messaging is when I talk about it as a disease. But you can imagine how that would have really created some problems with her going through with her treatment plan.

C (30:40)

Yeah, I could not imagine if I felt like there was mold in my body. Like, what a terrifying state to live in and try to navigate every day.

A (30:53)

It was bewildering, but I can't take away that that was how she was framing it. And I was so thankful to my psychology colleague that was able to come in, intervene and help her reframe that thinking and help her explain. No, no, this is not what she was saying. Let me help you understand, and let's unpack why you're thinking of it that way.

C (31:16)

You mentioned earlier the microdosing and concerns about doctors prescribing without evidence. I wonder what other concerns you may have that we haven't talked about around GLP1 medications. And I'm partly asking because in a previous episode in which we focused on disordered eating, my guest noted that these medicines, without appropriate understanding of a patient's history, may not be the best or even an appropriate prescription for someone with a history of any type of disordered eating.

A (31:57)

Yeah, no, I. I think that Disordered eating is, is definitely one. But let's look at the nutritional support that's necessary for someone that's on these medications. Caloric intake can go down dramatically with these, these medications. And so we need to be monitoring that. You know, if you're in the middle of a clinical trial, we're gonna be monitoring it like every single calorie you take in. But most people aren't in a clinical trial. So what's happening in the free world? Are they being monitored? Are they monitoring themselves? So, so if you've always struggled to lose weight and now you're losing weight rapidly, maybe you're intentionally not monitoring how much you're getting in. Now you're kind of obsessed and you're getting too low and you're like, okay, well, this is the lowest I've ever been. I haven't been this low since I was 12 years old. Well, if you're 72, maybe you don't need to be the weight you were when you were 12. Okay, we don't need you to be the weight you were when you were in middle school. Okay. So we need to be real. And this comes back to the piece you asked me about. Where does the psychology and the psychiatry piece play a role? We need to be connected with those individuals so they can recognize this isn't healthy, this isn't safe. So these are really important for me to be thinking about the side of the really, you know, kind of common side effects, the nausea, you know, digestive issues that, you know, where we have, that slowing of gastric emptying, all of those things are easy for us to mitigate, but these are the things that become more concerning, particularly if people are really high responders to these medications and we can get into kind of dangerously low weight status. And if they're not being monitored well, particularly if they're on online platforms and not seeing someone like me that's monitoring them very, very closely, I get very concerned about these issues.

C (33:38)

Do you have any concerns about your patients being on these medications possibly for the rest of their lives?

A (33:45)

No, I have none. You know, we've for, particularly for the GLP1s. Right. The GLP1s have been around for, you know, 20, about 20 years now. So we have, have long term Data on the GLP1s. Now you could say the dual agonist, I. E. The combination of a GLP1 with a GIP, which GIP stands for glucose insulinotropic polypeptide. You could say, well, we don't have information about that GIP Component. We don't. Right. We don't have really long term data on that piece of the puzzle. We have the triple agonist right. Being tested now, which is a combination of a GLP1, a GIP and a glucagon receptor agonist. Okay, so that hasn't hit the market, but we won't have long term data on those. But I would say we have really good safety data on the GLP1s themselves. And I have not seen any safety signals for those patients that have been on these for 20 plus years to say I'm concerned. I have patients in their 90s that are on dual agonist. I was at a 90th birthday party in November and I get there and I was at the head table right next to the, the, to the patient and I, so I asked the, the, the doctor, I was like, well, why am I at the head table? And they were like, oh, cuz, you're the one keeping her alive. And I was like, okay, fair point. But it was, but it was very interesting because I think it, it speaks volumes to what, you know, what these medications potentially can do and how they can lead people to really lead happy and sustainable lives.

C (35:35)

Before we move on to our last segment, which is called fact or fiction, when I will kind of throw out different claims and you'll kind of say whether they're fact or fiction. How do you keep yourself healthy? I imagine your patients ask you, like, what do you do? What do you eat? Like, how do you.

A (35:51)

Oh, I love this question.

C (35:52)

Move in the world. I know you're quite athletic from what you posted online.

A (35:57)

I'm one of those no days off kind of workout persons. A huge, huge, huge peloton fan. Peloton, you should add me to your board. I'm saying that publicly, so just, just putting that out there.

C (36:09)

The treadmill, the bike. All of the above.

A (36:12)

All of the, all of the above.

C (36:13)

All of the above. Oh, Peloton, you definitely should be listening.

A (36:15)

Yes, peloton, you should listen. I have the Peloton bike tread row and guide. I have.

C (36:20)

What's the Peloton guide?

A (36:22)

Oh, see I, yeah, so I have the guide which tells you how, how you should lift your weights and it gives you feedback on if you're lifting correctly, if you're going along low enough in your squat, if you're not parallel enough, you know, with your squat.

C (36:34)

Oh wow.

A (36:35)

But I alternate. So I'll do like a cardio day day, cardio strength, cardio day, cardio strength. But one those strength days, strength is going to Be predominant.

C (36:42)

Clearly an underachiever. That's what I'm getting from.

B (36:44)

Yeah.

A (36:44)

Okay.

C (36:45)

Yeah.

A (36:45)

So, yeah. But I love, you know, I love fitness, and I love to encourage it. I think my patients, for me, it's about being a model for them and making them understand that, you know, even in someone that works, you know, 80 hours a week, that, you know, you can still get this done. I have to do it first thing in the morning or it won't get done. And. And I tell them that even if I'm traveling, which is very, very frequently the first thing I do, landing in whatever country I'm in or wherever, I'm going to go look and see where's the workout facility. I remember I was in Peru recently and I forgot about the elevation issue, and I was like, why is nobody in the gym? And I was like, oh, because no one can breathe.

C (37:24)

I tend to also underestimate elevation. I'm a big runner, and a few months ago, was somewhere at a high elevation and went for a run and was feeling. And then at, like, mile eight, I was like, oh, and now I'm gonna die. I'm gonna, like, go to the edge of this trail and I'm gonna lie down and I'm just gonna die. Like, that's what's gonna happen right now.

A (37:44)

You're like, it's bad.

C (37:45)

So I have deep, deep sympathy for that. Well, just our last section, you know, as mentioned earlier.

A (37:51)

Yeah.

C (37:52)

I'm gonna start with something that we didn't talk about and maybe we should have in the main interview.

A (37:57)

Okay.

C (37:57)

BMI is outdated, and we should get rid of it. Fact or fiction?

A (38:01)

Fact.

C (38:02)

What should we use instead?

A (38:05)

So I was one of the Lancet commissioners that published a full thought process at the beginning of January of 2025 that basically eliminates BMI for everyone that's under a BMI of 40. And it looks at waist to height ratio, and it. It gets rid of this idea of just height and weight being a simplification of our weight status. So that's outdated. It should have never been used.

C (38:33)

People can live in bigger bodies and be perfectly healthy. Fact or fiction?

A (38:39)

I think that there's more nuance to that. I think we have to look beneath the hood. And when I say beneath the hood, like, look at what's going on in the insides. So, like, you can't just say, you know, you're healthy. Just, you know, if you're either living in a leaner body or one that has, you know, carries more excess weight, you have to do an internal investigation, like what's going on inside of that leaner body. Maybe that leaner body isn't healthy and maybe the larger body is healthier. But what's really going on inside of that body, which is why I do a full workup of that individual before I can make that assessment. So I think there's more nuance to that.

C (39:15)

GLP1s can affect your risk for cancer.

A (39:20)

There are definitive studies that are showing that GLP1s can likely reduce the risk of multiple types of cancers. I've published some of the research. I'm working with individuals that it and helping to advise their research on this area. I think there's more to come in this area. So I think that we'll see some very promising data that is going to continue to come forward as the years move on in this domain.

C (39:42)

In multiple areas of cancer, there's this phrase, ozempic babies. Babies who are born to parents who are on GLP1s. Can GLP1s help you get pregnant? Fact or fiction?

A (39:57)

Fact. GLP1s do seem to increase fertility. They seem to reduce inflammation within the body, which can impede individuals that are having issues conceiving, particularly individuals that have a history of things like PCOS or what we call polycystic ovarian syndrome, or even individuals that may not have that carry that diagnoses but may have excess adiposity or other issues. We are seeing this actually happen. We do prefer for patients to be off of GLP1s for two months prior to conception. That is the label for all GLP1s. But we have seen this happen frequently.

C (40:41)

Consistent use of apple cider vinegar or any supplement can help you lose weight.

A (40:50)

There's no data to support that, so I would say fiction. Apple cider vinegar is a bactericidal, so meaning something that kills bacteria. I think that it can make you feel good because it's just killing some type of bacteria in the system, but there's no consistent data to support that.

C (41:11)

So. Last question. You're never too old or sick or at a certain weight to make changes to help you be healthier.

A (41:24)

Fact?

C (41:24)

Fact.

A (41:25)

Absolutely fact.

C (41:27)

Dr. Stanford, thank you so much for being here.

A (41:29)

Well, thanks so much for having me.

C (41:33)

You can follow Dr. Stanford at Ask Dr. Fatima on Instagram. Thanks for listening. Talk to you next week. That Can't Be True is a production of Limonada Media and the Clinton Foundation. The show is produced by Katherine Barnes Mix in Sound design by Ivan Koraev. Kristin Lepore is senior director of New Content and Jackie Danziger is VP of Narrative and Production. Maggie Kralshore is our Managing Director of Partnerships. Executive producers are Jessica Cordova Kramer, Stephanie Whittles, Wax, and me, Chelsea Clinton. Special thanks to Erica Goodmanson, Sarah Horowitz, Francesca Ernst Kahn, Caroline Lewis, Sage Falter, Barry Lurie Westerberg, Emily Young, and the entire team at the Clinton Foundation. You can help others find our show by leaving us a rating and writing a review. And if you can think of someone who might benefit from today's episode, please go ahead and share it with them. There's more of that can't be true with Lemonada. Premium subscribers get exclusive have access to bonus content when you subscribe on Apple Podcasts. You can also listen ad free on Amazon Music with your prime membership.