GLP-1 Side Effects, Risks, And Who Should Actually Be Using It | Dr. Christle Guevarra

Summary

Podcast Summary: The Dr. Gabrielle Lyon Show

Episode: GLP-1 Side Effects, Risks, And Who Should Actually Be Using It
Host: Dr. Gabrielle Lyon
Guest: Dr. Christle Guevarra
Date: April 21, 2026

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Overview

This episode is a deep dive into the evolving landscape of GLP-1 medications (commonly known as Ozempic, Wegovy, etc.), their side effects, risks, proper use, and broader implications for fat loss, muscle preservation, and the health care system. Dr. Lyon and Dr. Guevarra blend their expertise in family and sports medicine with personal stories of struggle and success in both weight management and medical training. The conversation breaks down misconceptions, explores who should have access to these medications, and situates GLP-1s within the context of resistance training, body composition, and behavioral change.

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Key Discussion Points & Insights

1. GLP-1s: Revolution in Weight Management

• Origins & Development:
  • Originally FDA-approved for type 2 diabetes (since 2005 with Byetta).
  • Noticed modest weight loss, but only £5 on average, with older drugs like Saxenda requiring daily injections ([05:29]).
  • Semaglutide, Ozempic, and Wegovy have since set new standards for efficacy ([04:32]).
• Shift in Medicine:
  • "There has never been something more effective than these medications." - Dr. Lyon ([04:21]).
  • GLP-1s are moving weight loss medication beyond the ineffective or unsafe diet drugs of past decades ([03:34]).

2. Behavioral Change and Social Support are Key

• Despite medication, sustainable fat loss requires attention to behavioral and lifestyle factors, particularly resistance training and nutrition.
• The medical system’s traditional model provides little support between appointments, hindering behavioral change ([01:50]).
• Community and accountability—whether through sports, powerlifting, or online forums—play a pivotal role in long-term success ([06:55]).

3. Patient Candidacy and the ‘Deserving’ Debate

• Who qualifies?
  • “The technical FDA cutoff is BMI over 30... BMI over 27 plus some comorbidity, like high blood pressure, high cholesterol.” – Dr. Guevarra ([12:42]).
  • There’s “gray room” based on individual diet history, persistent food obsession, and failed attempts; not just a numbers game ([14:08], [15:01]).
  • Quality of life and the psychological burden are crucial considerations.
• Notable Quote:
  • "Who am I to argue with somebody who says that [GLP-1], even with pancreatitis, is still a net benefit overall?" – Dr. Guevarra, discussing risk-benefit analysis ([38:10]).

4. Society’s Stigma: ‘Cheating’ and Moral Failure

• Dr. Guevarra’s personal journey emphasizes the guilt and shame many feel when they struggle with fat loss (“I took it... as a moral failure on my part. Like, I'm just not trying hard enough.” [08:22]).
• Pushback exists both for using and not using GLP-1s—some think it’s “cheating,” while for many patients, it’s the only avenue to real progress ([11:04], [11:29]).

5. GLP-1 Side Effects, Risks, and Realities

• Side Effects:
  • Most common: nausea, vomiting, constipation, diarrhea ([38:43]).
  • Typically managed with hydration and gradual dose escalation; often subside over weeks to months ([39:12]).
• Serious Risks:
  • Pancreatitis risk is very low but must be acknowledged ([38:10]).
  • Anecdotal evidence of GLP-1 reducing alcohol consumption and even cigarette cravings ([16:40]).
• Muscle Preservation:
  • Muscle loss is not inherently caused by GLP-1s; it’s the caloric deficit that’s primarily responsible ([40:02]).
  • Emphasis on resistance training and adequate protein prevents muscle loss ([42:44]).
  • “As long as you are actually resistance training and keeping your protein intake reasonable, you can really avoid all of that.” – Dr. Guevarra ([40:02]).

6. Long-Term Use and Maintenance

• Many stay on GLP-1s for up to two years; 70% discontinue after this time, often for insurance reasons ([21:38]).
• Maintenance is possible with the right behavioral changes and support systems ([21:54], [22:48]).
• “For some people, even for myself, I probably will be on it for life and I’m okay with that. It’s not a moral failure.” – Dr. Guevarra ([21:54]).

7. Holistic Approach: Nutrition, Training, and Patient Autonomy

• Dr. Guevarra’s practice integrates careful nutrition assessment, mindset work, resistance training, and supplementation (creatine, multivitamins) for GLP-1 users ([31:44], [50:24]).
• Minimum recommended protein: 0.8–1g per pound of ideal body weight or at least 100g/day ([49:25]).
• Practical, budget-friendly dietary suggestions are vital, particularly with limited food access ([51:35]).

8. GLP-1s, Sports, and Anabolic Agents

• GLP-1s are monitored, not banned, by WADA; potential performance enhancement in weight-based sports like wrestling is a concern ([62:57]-[63:42]).
• Dr. Guevarra and Dr. Lyon highlight the medical double standard favoring fat loss drugs over muscle-building interventions ([64:12]).

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Notable Quotes and Memorable Moments

| Timestamp | Speaker | Quote/Comment | |---------------|-------------|-------------------| | [04:21] | Dr. Lyon | "There has never been something more effective than these medications." | | [08:22] | Dr. Guevarra | “I took it, for decades, as a moral failure on my part. Like, I'm just not trying hard enough.” | | [11:29] | Dr. Guevarra | “It’s an amazing tool to use... It has allowed not just for myself to thrive, (but) so many other people…” | | [14:08] | Dr. Lyon | "BMI doesn't tell us anything about the body composition... much more relevant." | | [16:40] | Dr. Guevarra | "Anecdotally... people are not really wanting to drink or if they do, it's a lot less." | | [21:54] | Dr. Guevarra | “…I probably will be on it for life and I'm okay with that. It's not a moral failure…” | | [38:10] | Dr. Guevarra | "The pancreatitis thing is a very low absolute risk... still worth it [for some patients]." | | [40:02] | Dr. Guevarra | “As long as you are actually resistance training and keeping your protein intake reasonable, you can really avoid all of that.” (re: muscle loss) | | [66:09] | Dr. Lion | "Now I know the correct term, menopause replacement therapy." | | [70:48] | Dr. Guevarra | “If you are having persistent food noise... You are not broken.” | | [81:11] | Dr. Guevarra | "Right now we don't have, you know, a medication that can just be like, here you go, take this pill and magically grow muscles." | | [82:18] | Dr. Guevarra | “Just working on a lot more content. I did mention at some point, I think writing a book... on food noise and how that has shaped my entire life and the decisions I've made.” |

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Topic Timestamps

| Topic | Timestamps | |-----------|----------------| | Personal struggles & introduction | 00:00–09:01 | | GLP-1s history and efficacy | 04:21–06:13 | | Who should use GLP-1s? Criteria and gray areas | 12:26–16:20 | | Side effects and risks | 37:44–39:12 | | Muscle loss, training, nutrition | 40:02–44:26 | | GLP-1 in athletes, sports, WADA | 62:38–64:09 | | Social support, behavioral change, maintenance | 31:44–36:40, 48:21–49:06 | | Dietary guidelines, protein, supplementation | 51:00–57:41 | | Obesity stigma, body composition, scale fixation | 72:10–76:46 | | Closing reflections and future plans | 81:54–82:45 |

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Actionable Takeaways

• GLP-1 medications are groundbreaking, but not a cure-all: They work best with behavioral change and social support.
• Resistance training is vital: Both for muscle preservation and mental health—“pick up something heavy, challenge yourself, and call it a day” ([70:49]).
• Nutrition is individualized and practical: Minimum protein target should be 0.8–1g/lb or 100g for most; cost and practicality matter ([49:32]).
• GLP-1s are not for everyone: Should be avoided for those with eating disorders or low BMI ([45:59]).
• Self-compassion is key: Struggle with food or weight is not a moral failure; seek support and know that “you are not broken” ([70:48]).
• Stigma must be challenged: Both for fat loss and muscle-building therapies; medical double standards do a disservice to patients ([64:12]).

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Conclusion

This episode encourages nuanced, compassionate, and evidence-based use of GLP-1s for weight management, emphasizing the importance of social support, realistic timelines, individual patient stories, and the bedrock roles of nutrition and resistance training. Both hosts stress that modern medicine must adapt, breaking the cycles of shame and inefficacy that have haunted weight care—and that sustainability and muscle health must remain central in every approach.

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For further learning:
Follow Dr. Christle Guevarra’s content and stay tuned for her upcoming book on food noise and her personal journey integrating medicine, fat loss, and strength.
Recommended: Familiarize yourself with the latest dietary guidelines, challenge food and fitness myths, and don’t be afraid to advocate for your own health!

Transcript

[Dr. Crystal Guevara]

Throughout various parts of my life. Since I can't figure out this whole calories fat loss thing down, I am just going to focus on lifting weights and find, you know, joy in taking ownership of the fact that I can lift something heavy. It gave me a lot of confidence that I couldn't get from hunger. Fat loss, you know, losing weight.

[Dr. Lion]

We are alive at a time that the landscape of medicine is changing. GLP1s have been around for a long time, but they haven't been used, they not been FDA approved for weight loss. There has never been something more effective than these medications.

[Dr. Crystal Guevara]

I feel like there's still a lot of a disconnect, especially with the way medicine traditionally is set up. Sometimes it can get a little hard to help with the behavioral change aspect of the GLP1 use. And so I find that there are still a lot of people who are struggling with how do I eat, how do I exercise? It seems like we could do a little bit better in providing that social support when it comes to the behavioral change part.

[Dr. Lion]

What are some of the biggest challenges that they come in and say they've

[Dr. Crystal Guevara]

struggled with when somebody's eating to get in as much fiber to feel satiated and they still don't. I have to wonder is that.

[Dr. Lion]

Doctor Crystal, welcome the show.

[Dr. Crystal Guevara]

Thank you so much for having me.

[Dr. Lion]

Now you're a family physician and you also trained in sports medicine. You are educating a lot on the use of GLP1s, which we are going to talk all about that. We're going to talk all about fat loss. And you're very interested in muscle preservation as well as performance, correct?

[Dr. Crystal Guevara]

That is correct.

[Dr. Lion]

Take me through what you are seeing

[Dr. Crystal Guevara]

right now in the landscape GLP1 use. It seems like there's a lot of good things happening and, and there's a lot of things that I'm like, who we could do a little bit better. Um, there's a lot more emphasis on resistance training across the board, which is, you know, obviously I. That's always awesome. And so women. I'm seeing a lot more women in the gym physically. So that is also amazing. And a lot more patients are just receptive to the fact of like, oh, I don't want, you know, this ozempic butt. So I'm going to get into the gym and lift something and challenge myself. I feel like there's still a lot of a disconnect where, you know, especially, especially with the way medicine traditionally is set up with clinic with checkups once every four weeks, three months. I think sometimes it can get a Little hard to help with the behavior change aspect of the GLP1 use. And so I find that there are still a lot of people who are struggling with how do I eat, how do I exercise? I just this shot and I kind of, you know, I have these side effects and I'm going to wait, you know, X amount of weeks till my next follow up appointment to bring them up. And so the medical system in which, you know, we're kind of in the traditional practice model just doesn't seem like, it seems like we could do a little bit better in providing that support when it comes to the behavioral change part.

[Dr. Lion]

And you've actually been really public on your Instagram, social media, talking about your own Journey with JP1 News.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

Do you think that obesity five years from now, not even 10, do you think we're still going to be struggling with obesity?

[Dr. Crystal Guevara]

I think we're going to be struggling with it a lot less. So I think there are still going to be people who are hesitant to take these medications just because of whatever, you know, this, it still feels like too good to be true because we have a long standing history of diet medications that have not been so healthy for us and have been recalled by the FDA back in the day, the rainbow pills in the 1960s, 50s and 60s. So people still have that hesitation towards drugs that are FDA approved and people will still hesitate. But I think overall, population wise, I think that obesity is going to decrease.

[Dr. Lion]

And again, you train in sports medicine, family medicine, you are on the front lines. There has never been something more effective than these medications.

[Dr. Crystal Guevara]

Correct. This is a new, this is, you know, a new breakthrough and it's only going to get better, especially with the drugs that are still in clinical trials and they're coming down the pipeline. But you know, after semaglutide, Ozempic, wegovy came, you know, became FDA approved for chronic weight management. It's just been, you know, it's just only gonna go up from here.

[Dr. Lion]

And I think that brings us. How many generations are we in now? So that we're. Is this now we're entering the third generation?

[Dr. Crystal Guevara]

I think so. Read a true Tide.

[Dr. Lion]

Read a true tide. Yeah. And that's in phase three trials, correct? What I understand, correct. The GLP1s have been around for a long time, but they haven't been used. They have not been FDA approved for weight loss, but they were used for diabetes. What was the, what was it FDA approved for? For diabetes. Right.

[Dr. Crystal Guevara]

Originally it was for type 2 diabetes and that was in 2005 with Vietta and that was a twice a day injection. The. And if you take a look back, they were noticing some changes in weight loss, but it was somewhere along the order of £5. And the error, if you look at, actually look at the graph in the, in the paper, the error bars are just all over the place. And it was not nothing spect and I think it was Saxenda that was in 2014.

[Dr. Lion]

That's right.

[Dr. Crystal Guevara]

But again, the weight loss aspect was also still not that impressive and you had to inject every day.

[Dr. Lion]

So we use six on the, in our practice. When that came out, it was again, it was the best that was available, but it was not, it was nothing like the GLP ones.

[Dr. Crystal Guevara]

Every single time I tried to get that approved, insurance just denied it. So I just stopped eventually trying at least.

[Dr. Lion]

And you've been someone who's been fit and training, have you been fit in

[Dr. Crystal Guevara]

training your whole life? I've had some periods where I was not so, not so mindful of my diet and exercise and. But overall over the course of what, the last 40 something years? Yeah, I've always loved sports. I was always very competitive. So, you know, whether it's in the classroom or in sports, so I've always been active for the most part.

[Dr. Lion]

You were doing competitive powerlifting. Competitive powerlifting. How was that? It was, it was good.

[Dr. Crystal Guevara]

It was a, it gave me a chance to start lifting weights and throughout various parts of my life, adult life, I felt like, okay, since I can't figure out this whole calories, fat loss thing down, I am just going to focus on lifting weights and I get my confidence or find joy in taking ownership of the fact that I can lift something heavy. I'm competitive, I'm okay at this and I'm having a really good time with meeting all these people at these different meets and posting my training online on these forums and meeting people. So it gave me a lot of community and it gave me a lot of confidence that I couldn't get from hunger, fat loss, losing weight because I couldn't get that part of the equation down. So I'm just going to focus on this for a really long time.

[Dr. Lion]

As a fellowship trained physician, it was hard for you to get your macros and your nutrition under Ross.

[Dr. Crystal Guevara]

It was the calories, it was the meanings. Yes.

[Dr. Lion]

Compared to you who are so highly trained and you're doing a fellowship for you, it was difficult. I can only imagine what someone who didn't have your education, the resources, how difficult it's been for people.

[Dr. Crystal Guevara]

Yeah. I almost felt even More guilty about it because. Yes, you are. I am. You know, I'm in medical school, I'm doing all these things, I'm taking care of patients. This seems really easy. Why can't I do it? Like, what is wrong with me? So I took it, I literally, for decades, took it as like this moral failure on my part. Like, I'm just not trying hard enough. I must be doing something wrong. And maybe if I do this X, Y, Z thing, you know, maybe this will help. But I dieted myself to, to the point where I failed medical school anatomy the first time. And I had to retake it in back in the early.

[Dr. Lion]

Okay, wait, tell me more, tell me more.

[Dr. Crystal Guevara]

Oh, gosh. I was working with a coach who, you know, gave me my, my meal plan instead of macros, and it kind of was around 1100 calories. Five 45 minute sessions of cardio a day.

[Dr. Lion]

We had how many? Five, five a day or.

[Dr. Crystal Guevara]

No, five, five a week.

[Dr. Lion]

Okay. So I was like, there's no way.

[Dr. Crystal Guevara]

No, no, no, no. Excuse me. That.

[Dr. Lion]

That would be impossible for anyone.

[Dr. Crystal Guevara]

Lifting four times. Four, four times a week. And then, yeah, eating this X amount of calories. And some days there were no carbs, so it was just protein and fat and I felt like garbage. I had entered medical school summer anatomy. And of course, it was summer anatomy for all of the overachievers who wanted to take it first. And then in the fall when the rest of the med students come in, you can be a TA and you can put it on your resume and get paid. Of course I was going to do it. I couldn't sleep because the hunger pangs were so intense. I could hear my stomach growling. And then I would come into anatomy lab just a zombie, trying to figure out what muscle is what. And I'm just like, I don't know because I'm exhausted and, you know, my neurons are just arguing over the last calorie. And so, yeah, I failed by a couple percentage points. And I just remember feeling like, wow, I can't die. I'm nowhere even close to being lean. My lifts are all in the tank. And I just felt like I had to willpower my way through it. And I failed anatomy. Like, this is the worst way to start off my medical training. And so, yeah, I learned a whole lot of things from that experience. But for somebody to say that, oh, you just didn't try hard enough. I just want to be like, let me tell you, we tried. We really tried.

[Dr. Lion]

It's interesting though, because we are seeing two sides of the story. And what do I mean by that? People will say. The people that don't use GLP1s are saying, okay, well, if you use it, you're cheating. And as someone who was struggling with it and who tried, I mean, is that your perspective?

[Dr. Crystal Guevara]

Oh, gosh, no. I think it's. It's an amazing tool to use. We have in the toolbox. And it has allowed not just for myself to thrive, so many other people couldn't find. They just were struggling to even get out of bed and get to the gym and found that, you know, some days, like, after starting this medication, yeah, their. Their weight started to go down, but they also found the motivation to make it to the gym and start doing the things that everybody's telling them to do, like, you need to eat less, you need to move more. Well, some people are still so stuck in a loop of, you know, dysregulated hunger, feeling depressed. Depressed and guilty, because why can't I just do this thing? And here is this medication that shuts off that food noise, that persistent, like, drive to think about food, that they can actually focus on the tasks that they need to do. Their quality of life just goes up, and it only goes up from there.

[Dr. Lion]

And it's amazing. And the other part that I think that we're seeing online is who gets it, who deserves, for lack of a better term, to be able to utilize it.

[Dr. Crystal Guevara]

Yeah. And, you know, I'm so glad we're having this conversation now and not, what, four years ago when the shortages were, you know, apparent. And so you had people with type 2 diabetes, you had people with obesity kind of fighting over, like, who really deserves it. The, you know, the technical FDA cutoff is over BMI over 30, you know, and then BMI over 27 plus, you know, some comorbidity, like high blood pressure, high cholesterol, syndrome X. Right. And sure, like, that makes sense. There is a little bit of wiggle room, because I think a very common question I get asked is, like, what about somebody with a BMI of 26 or because it's overweight, but it's not in normal BMI calorie who might be struggling? I think there is some gray room. And in medicine, there's an art to it. So you have to think about somebody's diet history and then why did they fail? Why did they struggle? And are they having persistent food, you know, thoughts about food, like, what happens, you know, 10 weeks down the line or 12 weeks during a diet? Like, do you, you know, do you just stop working out. Do you, you know, are you binge eating or whatnot? Like, you have to ask these detailed questions about why it is, you know, why did these other things not work? And so, you know, it's not just a numbers game whatsoever.

[Dr. Lion]

I mean, totally agree with you. We also know that BMI doesn't tell us anything about the body composition. For those of you listening, you all know what BMI is. Body Mass Index. It's really used or had been traditionally used for insurance to determine outcomes potentially. But it doesn't say anything about your body fat percentage and your percentage of muscle mass, both of which are much more relevant.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

When it comes to assessing health outcomes. And then the other thing is, as physicians, who is it to say for us to say if a patient wants to try something.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

And they might not meet the criteria from our perspective or from a BMI number or even a body fat percentage. And I'm not saying that their body fat percentage is 18%.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

But let's say they have struggled with the same five to ten pounds and it is causing them so much grief and it is consuming them.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

How is that for us to say, well, continue for another five years to try X, Y and Z, but this person who is 20 pounds overweight, they deserve to have it.

[Dr. Crystal Guevara]

Exactly. And that's the part that's. And I've, I've had somebody ask me that before and I, and I didn't have a really good answer. And I was like, that is actually a really good point because we don't. It's not like, oh, you're, you know, a 1C is, you know, 6.5. Therefore you definitely deserve. I think there is a gray room because there's a lot of people. A lot of the things that I have picked up from the fitness space of, you know, make sure you get tons of fiber or make sure you eat lean protein. Well, when somebody's eating, you know, like a whole bag of frozen strawberries and like a whole bag of frozen broccoli to get in as much fiber to feel satiated. And they still don't. And they're still trying to pretend like this food, like they're not persistently thinking about food, I have to wonder, is that person, would that person benefit from a GLP one versus trying to employ all these other.

[Dr. Lion]

So.

[Dr. Crystal Guevara]

And I don't know.

[Dr. Lion]

So if it were me, I would say, yes, they would. Even if it's not to the full dosing.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

Right. There's ways in which we use medications off label all the time and Then we're starting, I'm sure you're starting to see the data emerge that is helping with addiction, with alcohol usage.

[Dr. Crystal Guevara]

Yeah. Anecdotally and yes, I have started to see that anecdotally. I find that people are just not really wanting to drink or if they do, it's a lot less than what they used to consume. And it's hard to say whether or not that comes with the. Also all the other behavioral changes or not, at least in my patients, because that it's, it's all, all in one. I can't separate the two. Cigarette smoking, anecdotally, seeing a lot of people who are like, eh, I don't really want that as well.

[Dr. Lion]

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[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

When I was doing my fellowship in nutritional sciences, the big thing was bariatric surgery. They were doing bariatric surgery because these medications. So part of the Job is a fellow, I'm sure. I mean, what. You probably had to work games and.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

What was. So. So you guys listen, in fellowship, each fellow is responsible for. It's typically a clinic within that specialty. And for nutritional sciences, because I did a combined nutritional sciences geriatric fellowship for the nutrition part, I had to run. I got to. It was actually amazing. Run a weight management clinic. Oh, it was a weight management clinic. And this was 2015. GLP1s were not approved for weight management.

[Dr. Crystal Guevara]

Oh, boy.

[Dr. Lion]

These people struggled so much.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

That many of them would end up doing bariatric surgery. The outcomes for bariatric surgery, whether it was banned or roux en y, they're not good.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

I mean, the immediate weight loss is impactful, but the secondary complications with gastric emptying, with nutritional deficiencies, it seems as if a lot of people end up reverting back. These medications were not FDA approved or used. Now we're in an entirely new landscape that is taking away. I mean, if someone were to choose bariatric surgery or GLP1. I mean, this is a new landscape now.

[Dr. Crystal Guevara]

Yeah. The approval process, the surgery, like surgery itself, is a risk factor. And especially for somebody who is obese, the anesthesia, you know, having to intubate them to get surgery, all of that has complications. And so, yeah, I would, I would honestly have them recommend, you know, let's see what all these medications can do first. And then if all of that fails, which I, you know, I haven't come across a. A patient yet where medication has complete. Like we have a couple of different choices other than GLP1s where we need to start thinking about surgery. Something a little bit more extreme.

[Dr. Lion]

Do you think that. Meaning they fail GLP1s?

[Dr. Crystal Guevara]

Correct.

[Dr. Lion]

That. How often do you see that?

[Dr. Crystal Guevara]

I don't see that quite often. What I. The more typical scenario that I do see is insurance, you know, comes in and says, we're not covering this, or we're only covering this partially, or your insurance has changed. Congratulations. So. So let's figure it that out.

[Dr. Lion]

Are your patients maintaining the use of GLP1? So some of the recent data that I've been seeing is that the typical person will stay on a GLP one for two years and that 70% come off after two years.

[Dr. Crystal Guevara]

I have seen some of my patients come off of it mostly because of insurance reasons, and they are still able to maintain it's. It is definitely a lot more. A bit more of a challenge than when they were on it. But they, you know, the behavioral change part the lifestyle part is so important and having that support system is also, I think, is pretty much, you know, key to maintaining that and keeping regular follow ups. So. And I've seen other, other people who've shared their stories with me online where they've come off of it because they wanted to and are still thriving and still doing great. So it's not like you are doomed for life, but for some people, you know, even for myself, I probably will be on it for life and I'm okay with that. It's not a moral failure because it's

[Dr. Lion]

improved your quality of life so much. Yes, gosh, it's not.

[Dr. Crystal Guevara]

And it's not just the physical aspect of it. It's. It's a lot of people when they describe the, like the first time you start on the medication, it's like this light bulb went off in my head and everything just went quiet. And now I'm able to have a conversation with you. Like if we would have had a conversation five or six years ago, I wouldn't be able to pay attention to because I would be thinking, gosh, I'm so hungry right now, the lights are so bright. But like, I don't, I'm really embarrassed. I don't want to admit that, you know, I have a problem thinking about food all the time. And it would just be like this, this spiral of despair going on in my head and I would just smile and nod and be like, everything's okay and everything's not okay. And so it's really given me the space to think about how I want to show up in this world, how I want to live my life. Who am I talking to? How am I talking to you? And just really gave me a chance to do a lot of self reflection.

[Dr. Lion]

Is that why you were able to be more public about it as opposed to not necessarily share your story?

[Dr. Crystal Guevara]

I think it was a combination of that and just being in, in my 40s and, you know, perimenopausal. I think there's also that shift too where it's like, I just don't like you just stop caring what other people think. And I think about all the struggles that I've gone through trying to lose weight over the course of decades. And if I can help one person, you know, not feel so alone in, you know, in all of this, like, I feel like it was worth it. It was worth whatever it is the, you know, Internet has to throw at me.

[Dr. Lion]

Hopefully good things. And also at this point it's if it's good, if it's bad. It's. This is the new world that we live in. But one of the things that I really respect about you is that you are a trained physician now. It's also what we're seeing in research that there's a lot of filler information. People don't know where to go for good information anymore. Someone could have a doctor in front of their name and it might be deeply misleading. Maybe they're, I don't know, a doctor of botany or something. And there is something to be said for a trained medical provider that has studied general health, family medicine, sports medicine to be able to make informed decisions.

[Dr. Crystal Guevara]

There is something to be said about having that base time in the clinical hours. Because if there's one thing that I took from family medicine and sports medicine training is there is just this deep intuitive sense that you don't get until you get face to FaceTime. And the Times where I have nailed a zebra diagnosis or you know, some like life or death situation is not because I had the answer, like I memorized the book or I read some, you know, study on PubMed. It's because I looked at that person, I was listening to them and it was like, something just seems really off and I'm not sure why. So let's get this ultrasound, let's get this MRI and let's go from there. And you know, sure enough, you know, semi athlete with a leg clot, a blood clot or something like that. And it's just something just is telling me that like this, you know, this isn't normal.

[Dr. Lion]

Unconscious competence. Yeah, the unconscious competence you mentioned, perimenopause.

[Dr. Crystal Guevara]

Yes.

[Dr. Lion]

How has that changed your perspective on hormones for yourself, for your patients?

[Dr. Crystal Guevara]

Oh my gosh. So that was definitely an experience that has really got me thinking about, you know, all the other physicians in the forefront of hormone merit per menopausal hormone therapy. Just because I had no idea, it sort of blindsided me and I was like, what is going on? All of these symptoms were.

[Dr. Lion]

What were some of them? What were some of your symptoms? She's like, what?

[Dr. Crystal Guevara]

What were they? At first it started off really just sort of. I didn't. I wasn't feeling like myself. It just the word forgetfulness and it was very similar to the word forgetfulness I had when I took, when I was prescribed medication off label for weight management. Topamax.

[Dr. Lion]

Oh yeah. Is that. That's lamictal, right? No, topiramate.

[Dr. Crystal Guevara]

Topiramate, yeah. Very similar to that. And I was like, I'm not on that medication. Anxiety that worsening anxiety. I would wake up and just feel like the world is coming to an end.

[Dr. Lion]

That's called parenthood. That's called 5:45 in the morning parenthood. Let me just tell you.

[Dr. Crystal Guevara]

Insomnia, the hot flashes. And then I would get this awful, like, neck rash on top of it, eczema in my eye that just never appeared. And then finally the genital urinary symptoms was like, the last straw. That was when the workup for the thyroid, the heart, all of it came back normal. And at the time, my provider said, you know, everything's normal and there's nothing I can do for you. Those were the last words. And I just remember thinking, oh, gosh. Well, I still have all of these symptoms and all of this other stuff is normal, so we're not going to do anything like. And I think as a provider, especially as somebody who is a primary care provider, the, you know, if some. Everything came back normal, sort of, my response would be like, let's figure something else.

[Dr. Lion]

Absolutely.

[Dr. Crystal Guevara]

Let's. Let me send you to a specialist.

[Dr. Lion]

Absolutely.

[Dr. Crystal Guevara]

You know, if. I don't know if it's this, let's, you know, send you to a specialist. And so I really, I thought about that and then I remember, gosh, I can't remember if it was Rachel Rubin's big podcast. Talking about this and thinking about it in terms of, you know, sending grandma to the hospital with Urosepsis. And I just thought of all the admissions that I had to do as a resident, you know, grandma with, you know, altered mental status from a uti and thinking about, how many times could I have prevented that? That's. I think that for me, was the kicker. And I was like, I need to get. I need to get my CME up. I need to start really, like, hey, we need to just be vigilant and thinking about these things early, like late 30s and just asking those questions, how are you feeling? And, you know, if it's not this, then we need to find other answers.

[Dr. Lion]

But again, this is the changing landscape, because before the Women's Health Initiative, from what I hear from the older providers, they were all prescribing hormones. There wasn't any reason why people weren't. For the most part, it was very ubiquitous. And then, of course, the Women's Health Initiative came out, and it seemed as if overnight people stopped prescribing hormones.

[Dr. Crystal Guevara]

Yeah, I didn't. I was not really a thing when I was being trained as a family medicine physician. And so now I'm like, I gotta catch up, which is Great. Because I think they put it in such a way that, like, we are physicians, we have prescribed medication before. These are not, these are not scary medications.

[Dr. Lion]

In terms of fat loss and weight loss, what is the rate for your, your patients that come in and you're like, okay, we're going to go and we're going to try to lose X number of pounds in totality, or do you do it that way? Do they have a goal for if they're going to lose £20 and how they're going to do it?

[Dr. Crystal Guevara]

So it does depend on what they're starting, what we're starting with. But I do tell them that if the goal is 20 pounds, and that seems like a reasonable goal, we may not do it all in one shot. Because I also want to make sure that we are thinking about what happens after the diet. I also want to make sure that I'm not missing any diet fatigue markers like poor sleep, poor performance in the gym, because that can come crashing down depending on what their life situation is like. And so I don't want them to feel like I have to burn, I have to get this off, you know, now I want them to start thinking about this in terms of this is going to be a lifetime thing. So it didn't take you, it took you a long time to get to this point. Point, like, there is no rush. I want.

[Dr. Lion]

That's a really good point. People feel as if they have to rush, get it done, do it right now. When the reality is many people struggle for years, taking a step back, going a little bit slower, reorienting ourselves to wherever the goal is. Makes a ton of sense.

[Dr. Crystal Guevara]

Yeah. And I find that it's a lot, a lot more sustainable. You know, getting to the gym, lifting weights, me, you know, cooking, meal prepping, cooking whatever it is, and figuring out how is that going to look for you, how is that going to look for your family? How are they going to be involved in the process?

[Dr. Lion]

Are you prescribing JLP ones?

[Dr. Crystal Guevara]

Okay, yeah.

[Dr. Lion]

Take me through your decision making process. Again, we understand that you're not the listener and maybe your patients are listening, but again, we're not giving medical advice and here she is. But there's got to be some decision making protocol that you go through in your mind as opposed to, okay, a patient comes to you and is like, hey, I want to go on GOP one.

[Dr. Crystal Guevara]

Yeah, tell me what, tell me why, and tell me through. Take me through your, you know, like, diet history. Have you tried losing weight without a medication before? How has that Been for you and what are you currently doing right now? Take me through your day. Because I find that that is a much better way of trying to get some information because I find that patients are very well intentioned. They really want us to, you know, to not judge them because it's a very sensitive topic, for sure. And so I get a lot of, you know, I just don't understand. I'm eating chicken breast, you know, and I'm eating mean fish. And then, you know, for dinner, like, I don't snack and I'm like, okay, that's really awesome. What was your last meal like before you, you know, before we had this conversation? Take me through that and then take me. What happened? What'd you do when you woke up? And so the conversation then becomes, you know, I'll start thinking about, like, what are the major themes of, you know, why things didn't work? Is it because, you know, oh, I had, you know, this life event that happened? Or am I having persistent thoughts about food, you know, at a certain point? Or do you think, how often do you think about food? Is it like something that's, you know, ongoing in your head? Like, how do you feel like, you know, it's impacted your quality of life, your job, your relationships? From there, just thinking about, like, you know, if that is the case, maybe we can start thinking. I think a medication would be very helpful.

[Dr. Lion]

What are some of the biggest challenges that they come in and say that they've struggled with?

[Dr. Crystal Guevara]

I would say this doesn't come up as soon as they walk in. I think after a while I start to see themes of I take care of everybody else and I put myself on the back burner. And it's not just with the kind of physical aspect part, but emotional. They have seemed to be providing for everybody else, whether it's financially, whether it's relationships, whether it's emotionally and trying to find the words to kind of stand up for themselves and say, like, I'm not okay with this, or I'm not really comfortable with this conversation, or I don't appreciate being spoken to like that. Those come out later. But you have to stack up these little wins for them to get the confidence to branch out and think about how is this relationship kind of affecting me and is this now net positive now that I start, I'm starting to take care of myself and I really like myself and I really like this new me, this new life, this new identity.

[Dr. Lion]

So cool, right? It's so transformative for people. And again, if you're listening to this, we're not saying that you have to use a GLP1 or you don't have to use a GLP1, but just as a very broad overview, it allows people to choose as opposed to before oftentimes. And again, I ran a weight management clinic. They didn't have a choice. And when I say they didn't have a choice, it appeared that food was running their life. No matter what they did, they couldn't get ahead. And so these medications now allow people to step into a new version of themselves, and then their lives change. So there's two things that I seem to experience with the patients is that on one hand, they are uncomfortable with their weight loss or uncomfortable with just this new version and they might sabotage themselves. That's. That's one. One group. And again, it's not black or white. And then the other group is they really transform their lives and their relationships change.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

Their friend groups change everything. It's almost as if they're on this rocket ship where now they get to make these choices.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

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[Dr. Crystal Guevara]

What the science versus hype in terms

[Dr. Lion]

of GLP1, you'll hear, oh, GOP1 medications at any moment in time, you will hear about all the. The negatives. Yeah, right. Oh, yeah, they're gonna get pancreatitis, thyroid cancer. It's gonna stop your gastric emptying. Oh, gosh. Okay, so tell me about some of the. The actual risks versus the perceived risk.

[Dr. Crystal Guevara]

The pancreatitis thing is a very low absolute risk. And you know, anecdotally, I will say I have a colleague who, whose patient did end up going to the hospital for pancreatitis and still managed to text going to the hospital for pancreatitis. GLP1 still worth it. So. Which also, you know, but honestly though, it. When we talk about quality of life, the person is still clearly having a very serious event and is still making that choice of like, this is still a net benefit overall.

[Dr. Lion]

So.

[Dr. Crystal Guevara]

And who am I to argue with somebody who says that? But again, the risk is low. It's serious. But when it happens, but it is very low. Most commonly, nausea, vomiting, constipation, diarrhea are the most common symptoms. And those can be managed with expectations, with making sure to not crash diet, making sure to stay hydrated, and they tend to go away over time.

[Dr. Lion]

How long does it take for some of the symptoms to reside?

[Dr. Crystal Guevara]

For some people it can take, you know, weeks. For some people, it can take a few months. And I think it's, you know, I, I don't have enough of a kind of, you know, general enough of a kind of n to generalize, like how often, but it can vary.

[Dr. Lion]

Yeah, we see that in our. Our clinics. We have a telemedicine clinic. It's called strong Medical, which, because obviously muscle is the most important organ. Although we've had urologists on the podcast, they think that it's something else. Muscle and fat regulation and the use of these GLP1s. This is again, more of a conversation. Do you want to touch on the rate of muscle loss or muscle loss with GLP1 medications and counterbalancing, you know,

[Dr. Crystal Guevara]

the rate of muscle loss with these GLP1s? I'm not too entirely familiar with the. The exact numbers on it. Honestly, with the. As long as you are actually resistance training and keeping your protein intake reasonable, you can really avoid all of that. And you can actually, for somebody who's relatively new to resistance training, can actually get some pretty decent recomposite body recomposition in ways that I'm just like, actually sort of like even more surprised to myself because for somebody who's never gone to the gym, I will give them something very easy to do. Like three sets of 10 to start off with, and only because 10 is an easy number to count to. And watching them sort of progress from there and as long as they are consistent, you can get a whole lot out of it for a while before you have, you know, start thinking about like, let's move on to like a more, you know, advanced protocol or start thinking about all these other things. Like, no, you can just, we can just stay here for quite some time and milk these sort of newbie gains out before we need to start thinking about anything else.

[Dr. Lion]

Meaning in terms of adding more complexity.

[Dr. Crystal Guevara]

I would rather have somebody go to the gym consistently than really start thinking about like, oh, do I need to be on this program or do I need to be on that program? Yeah, we could talk about that. Let's build up some, you know, consistency first and then let's think about, you know, something a bit more advanced.

[Dr. Lion]

What was the biggest, or what has been some of the biggest surprising features in the use of GLP1N training?

[Dr. Crystal Guevara]

The way in which it calms down sort of this persistent thoughts about food in a way that's completely different from a stimulant like fen phen or using caffeine.

[Dr. Lion]

Ephedra.

[Dr. Crystal Guevara]

Yeah, ephedra. Uh, it's a. It just, it's so different. It really is. Just like you, you know, there are times you have to be a lot more intentional about your nutrition because you people can. And I've done this a couple of times where it'll be 3pm I'm like, oh, oh, why am I, why am I lightheaded? Oh, I haven't eaten. I should really think, you know, and I next day I'm like, I really. Breakfast, breakfast. And make sure I eat that and make sure it's, you know, I fuel myself so I don't end up in this situation. But so many people have ended up in that sort of similar situation where you have to think about your food consciously versus, you know, before the medication when you've got, you know, food is just taking up all that space in

[Dr. Lion]

your brain in terms of the protection of muscle mass.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

The data doesn't show that there's something inherent to the GLP1 that negatively affecting skeletal muscle mass.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

Honestly, if you look at some of the other bigger data sets, I think it improves muscle quality by decreasing this intermuscular adipose tissue, this intramuscular fat. Again, you get that from training.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

But there's something, I think we're going to begin to see more positive effects on muscle versus any kind of negative effects. Do you always talk about training with your patients and. No. And or provide them with some kind of protocol?

[Dr. Crystal Guevara]

Yeah, I do. I. It's one of the very first things that is like part of the kind of things that I tumming to Dr.

[Dr. Lion]

Crystal, you're going to get jacked.

[Dr. Crystal Guevara]

We're going to at least, we're going to at least do our best to be always talking about how important resistance training is. And I think it's also because a lot of people just have busy lives so, you know, versus cardio. There's nothing wrong with cardio. I love cardio.

[Dr. Lion]

How much cardio are you doing?

[Dr. Crystal Guevara]

Am I doing?

[Dr. Lion]

Personally she's like none.

[Dr. Crystal Guevara]

I. Well, I do train jiu jitsu. I do a lot of no gi so it's a little bit more faster paced, a lot of like wrestling takedowns. And so you do need to be in some, a lot more of a cardio shape to handle that kind of sport. So I do that twice a week, but one of the days is a two a day and so I'd say 1, 2, 3, 4, about five hours of that a week.

[Dr. Lion]

Amazing. And that's what you use for cardio?

[Dr. Crystal Guevara]

I do.

[Dr. Lion]

When you are using a GLP1 and obviously your macro intake is probably much lower, your total caloric intake is lower. Do you find and you also work with athletes as well?

[Dr. Crystal Guevara]

I do.

[Dr. Lion]

Do you find that their performance decreases with GLP1 use?

[Dr. Crystal Guevara]

I think it really depends on what their diet is looking what their diet is all about. Because not everybody who's on a GLP1 is necessarily like trying to lose fat. There are times where people are on a GLP1 and trying to maintain whatever their body weight is and I find that, you know, if they're in maintenance, they do just fine. There are some very mild, mild trade offs when you are in a calorie deficit and trying to do a sport or you know, or whatnot. But overall it really depends on the calories and not necessarily like the drug itself.

[Dr. Lion]

That's an excellent point. There is somewhat of a discussion that people seem to be either for or against such is the way of the world nowadays. But it's either they're just really on board with Jeffy ones or they're not and it's the decrease in potential performance is not necessarily related to the drug the mechanism of action as to what this drug is doing to tendons or flexibility or any of these other

[Dr. Crystal Guevara]

you

[Dr. Lion]

know markers of fitness or the requirements of fitness but the decrease in total calories who would you not recommend having these medications?

[Dr. Crystal Guevara]

I mean somebody who I'm concerned with anorexia but that seems pretty that seems obvious I yes but also can never be too trivia it can never be too obvious the I'm trying to think of all of the concerns from the social media community about you know what to look out for for eating disorders. Yeah thinking about somebody who is excessively exercising somebody whose calories are already pretty that would make sense but it seems to make sense I'm just really struggling to find you know maybe that population just hasn't I haven't come across too many people in that population group who

[Dr. Lion]

we don't actually get the those patients either but then again be much less likely to prescribe some of those kind of going down that resistance training is a non negotiable correct for you when you have patients on the GLP1s what are the markers that you are seeing change the most or that you are looking to see change in terms of

[Dr. Crystal Guevara]

blood work total cholesterol LDL typically goes down I do see improvements in A1C for you know I do have some people who have you know who are I prescribe it for weight management but also they have diabetes so I am seeing improvements in their blood sugar their sugar logs overall just with the resistance training loan has been a huge help and so I think that's you know really about it I don't pay attention too much with any labs beyond that just because whether it's insure an insurance issue or whatnot because then I start

[Dr. Lion]

have to thinking I see so you're very strategic in terms of this is going to cost I see the profile we see changes in triglycerides we see decrease in fasting blood sugar. We see changes in insulin sometimes we see lower levels of insulin hemoglobin A1C what else you know what else that we're seeing anecdotally a decrease in inflammatory markers So I think we're both in favor of GLP1s I am so maybe it's a bit biased but also we've also worked I mean I've worked in weight management OBC medicine for I don't know I started studying nutrition almost 20 years ago.

[Dr. Crystal Guevara]

Yeah. And I will admit I do have a bias because of my own experiences struggling with this. I am, you know, biased in the sense that I probably would lean more towards prescribing this medication than, you know, trying to gatekeep just because of what I've experienced both there and then also in the fitness space, trying to do all the lifestyle things which are important.

[Dr. Lion]

It's a non negotiable because the, the medication can quiet the noise that affects the brain, decreases gastric emptying, can improve insulin sensitivity. However, you can't just go eat Cheetos and drink RIP its.

[Dr. Crystal Guevara]

Oh, gosh, no. I feel like people who've actually done that have ended up getting sick. And then you're like, okay, this is a learning lesson.

[Dr. Lion]

Sure.

[Dr. Crystal Guevara]

Like, we need to start being way more intentional about our nutrition. And you know, there are times where I've had to act more like I feel more like a mom, a nagging mom than I do a doctor, where it's like, hey, let's get some goddamn fiber in here. Let's get a fruit, let's get a vegetable in here. Like, how can we make.

[Dr. Lion]

This doctor is just. She's dropping the hammer. What is the minimum amount of protein that you recommend for your patients?

[Dr. Crystal Guevara]

So what is it? You know, the 0.8 to 1 gram per pound of ideal body weight?

[Dr. Lion]

We say 100 grams.

[Dr. Crystal Guevara]

Yeah. Less than 100 grams. Yeah, I guess. So that really does turn out to be such that. And, and then from there I'll try and figure out like, what meals are. How. How do you actually cook your meals? And then trying to figure out what can I swap in or give them sort of a, you know, here are some proteins to choose from. And let's start there. How does this, you know, you know, go. And sometimes they'll text me from the grocery store like, hey, how does this look? And I'm like, patience.

[Dr. Lion]

You better not be texting Dr. Crystal because you just better not be doing that. I'm kidding. My face. What about supplementation? Do you utilize supplementation, especially with the use of GLP1s and if calories are down, total food consumption is down.

[Dr. Crystal Guevara]

I think especially at first, the overall food is down because they're thinking about the nausea and whatnot. Eventually the food volume does go up, the hunger sort of returns. I keep it very simple, especially for resistance training. I'll have them, you know, try creatine.

[Dr. Lion]

How many grams?

[Dr. Crystal Guevara]

Gosh, five. Five grams.

[Dr. Lion]

My dad's really big into creatine right now. We usually recommend between 3 and 5 for muscle and then 10 to 12 for brain health.

[Dr. Crystal Guevara]

Okay, okay.

[Dr. Lion]

My dad's like, I mean, listen, my dad's major placebo and he does listen to this podcast. But anyway, what we're seeing is that for cognitive function, also perimenopause.

[Dr. Crystal Guevara]

Yeah, yeah.

[Dr. Lion]

So creatine is 1.

[Dr. Crystal Guevara]

Creatine's 1. A multivitamin, just to make sure you're covering your bases. And then from there it really becomes what, you know, what can you afford? What are you, you know, interested in? Then becomes a conversation. Because I do find that I want to be very mindful of financial costs as far as, you know, risk, benefit, pros and cons.

[Dr. Lion]

Have you always been like that with the patients?

[Dr. Crystal Guevara]

I have. And I think my personally, just coming from a child, the child of immigrants, I just am always thinking. That is always something that I'm thinking about. How can I, how can I make this work on a shoestring budget? So there are times in medical training where I've tried to shop, like, see how few dollars I can spend, whether it's, you know, chicken breast versus chicken thighs, whether it's oatmeal as a source of carbs. Thinking about frozen fruit because fresh can sometimes go bad. Thinking about what is available, like through snap, you know, ebt, which, by the

[Dr. Lion]

way, what is going to be available is changing now.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

What do you think about this new food guide, Food guidelines?

[Dr. Crystal Guevara]

The. I'm still really can't get past the, the destruction of my plate. I'm still very like, it was just very easy for me. And I mean, I mean, you could still use.

[Dr. Lion]

So in.

[Dr. Crystal Guevara]

You could, you could. You saw that forever strong. I know I did. And I was like, the plate, right.

[Dr. Lion]

We kept the plate because, you know, from our perspective, the. You're laughing, but we see patients. And so first of all, I love the new guidelines and also Don Lehman and some of my colleagues wrote the guidelines. I am completely biased. However, all the science is available.

[Dr. Crystal Guevara]

Oh, good.

[Dr. Lion]

Meaning if you go to the website, you can see that where they chose the data is transparent. It's not epidemiology. They only use randomized control trials. For you guys listening or watching this at home, why that's so important is because in the past it's always been epidemiology, which is low quality data which should only be used to pose a hypothesis, not to make broad public generalizations and implications on public health.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

So I'm very excited. I, I hated to cut you off there, but.

[Dr. Crystal Guevara]

No, no, no.

[Dr. Lion]

I'm gonna tell you about how much I love these dietary guidelines.

[Dr. Crystal Guevara]

The dietary guidelines are great. I just. I just said about the plate. I am very upset. I'm. I think I'm way, way too more upset than I need to be. And it's just. I have so much emotion. It's just. I couldn't. I was like, staring at the. The screen like, where is. Where's the cutoff with the lean meat and the oil? And I just couldn't.

[Dr. Lion]

That is it. Can we touch on that? Because that is. Do you want to share what your perspective is on that? And I will definitely love to.

[Dr. Crystal Guevara]

I just. I literally just. I have really terrible eyesight in general, and so I'm in the club, girl.

[Dr. Lion]

We need more lutein and zeaxanthin and vitamin A. We're all in trouble.

[Dr. Crystal Guevara]

So, yeah, I don't know if you have any insight on who designed the. The graphic.

[Dr. Lion]

So that part I don't. But what I can say is that the 10 saturated fat is. We need more data. We need more research. Should it be 10% saturated? There's no evidence that it should be 10. That should be 15. We just don't have a lot of data. And I think that it is a challenge because the 10% has been there for so long. So basically, the food. The new food pyramid, the UPS. The upside down pyramid, keeps saturated fat at 10%. What that does, however, is. Well, number one, we don't have data to change that higher or lower. We had Dr. Tom Branagh on the show. He wrote the. He's been on the last three guidelines. He wrote the fat part. We'll have Kevin Mackey. He's been on the show. He's coming back again. And these are fat. These are fat experts. There needs to be more research. And I will say something else that blew my mind is that the saturated fat recommendation came from a hydrogenated whale blubber. During times of war, when they needed to feed people, it wasn't meant to be used. This hydrogenated oil wasn't meant to be used. But the studies in the 60s grouped this hydrogenated whale blubber and called it saturated fat.

[Dr. Crystal Guevara]

Oh, gosh.

[Dr. Lion]

That they were then subsequently saying that that's bad, but hydrogenated whale blubber isn't saturated fat. I just wanted to throw that out there. That again, this goes back to us believing, hearing something, no matter how many times we hear it, we believe it's true, even though there is an evidence for that.

[Dr. Crystal Guevara]

I don't have too much of an opinion on the new dietary guidance. I do like the increase.

[Dr. Lion]

They're great guys.

[Dr. Crystal Guevara]

I do like the increased protein recommendation. I just. For the person's, the patient sitting in front of me. How is that? Like that is when I think of like how is that going to affect the person sitting in front of me? And I can't really think of too many things that I would change when it comes to how I approach my patients with these new guidelines.

[Dr. Lion]

But the good news is you've always been interested in nutrition.

[Dr. Crystal Guevara]

Yes.

[Dr. Lion]

But most physicians are not really providing nutrition care, which it seems a bit counterintuitive, you know, especially as primary care, typically family medicine primary care. We see kids, we see all ages and we're not trained. Typically the training doesn't involve nutritional science training. But if you think about things like elevated levels of triglyceride.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

This is a carbohydrate problem, elevated levels of cholesterol. This for some people it's a fat problem. For some people it's a calorie problem. And for some people it's genetic.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

Glucose. There's all these direct relationships to nutrition and the training has to increase.

[Dr. Crystal Guevara]

And there have been times where protein like plant based, you know, meaning just eat plants and like pay no mind to the protein.

[Dr. Lion]

So.

[Dr. Crystal Guevara]

I know.

[Dr. Lion]

Said nobody ever.

[Dr. Crystal Guevara]

Some people haven't.

[Dr. Lion]

I'm kidding.

[Dr. Crystal Guevara]

Why are we doing that? Protein is an important part of this. And so I think that's why this pendulum kind of swung the other way with like we have to put protein in everything.

[Dr. Lion]

I see.

[Dr. Crystal Guevara]

We have to put protein in everything. Protein on our popcorn, protein on this and that.

[Dr. Lion]

Very misleading, isn't it?

[Dr. Crystal Guevara]

Exactly so. And I find that, I think that it's going to shift once again because I think social media is now tired of protein stacks and everything.

[Dr. Lion]

Crystal. It's so disappointing. So we've spent 20 years talking about protein. Now people are caring about it and now it's getting a bit overblown in the way that protein should be in coffee and popcorn. And that's ridiculous. And it's a protein dilution because it's not. Number one, it's not a threshold amount. Number two, you're just getting extra calories from protein. Okay, fine. So if that causes the pendulum to swing the other way, it's. We're going to be constantly doing this back and forth. That sets us up for failure.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

I still think it's the most important macronutrient.

[Dr. Crystal Guevara]

I do too. And there are times where people can't get to, you know, a quality meal. Healthcare workers, you know, we're Actually, technically not supposed to be eating while we're at our desks, but we, you know.

[Dr. Lion]

So true. I wonder why they kept kicking me out.

[Dr. Crystal Guevara]

There were times at the hospital where we had to hide our, you know, hide our food because we weren't allowed to eat at the desk and type our notes at the same time. Oh, I remember that.

[Dr. Lion]

Wait, wait, you did your residency. Where'd you do it?

[Dr. Crystal Guevara]

The Philadelphia suburbs. Okay, so right outside of Springfield, which is right outside of Philadelphia. And then one of the clinics was in Upper Darby, which is. You got to go through West Philadelphia to get there.

[Dr. Lion]

Is that unsafe?

[Dr. Crystal Guevara]

I wouldn't go walking around there at night.

[Dr. Lion]

So she's got her maid kit. I don't know if that's legal there, but I live in Texas, so there's all kinds of things that are legal here. And then your fellowship was in Vegas.

[Dr. Crystal Guevara]

Yes.

[Dr. Lion]

Tell me about that sports medicine fellowship.

[Dr. Crystal Guevara]

That was right when Covid was happening. So we had sports. They were just a little truncated. And then all the rest of the sports from fall were sort of pushed into spring, and so got to work, you know, still managed to have a really good year working with football players, working with all the collegiate athletes, you know, some pro athletes as well. And then I was thinking about, you know, I have all this free time. Free time. Let me start looking at and looking at EKGs in athletes pre and post Covid, to see if there was anything significant, because I know that when Covid first came out, we were really worried about the effects on the heart and all this other stuff, at least for very healthy athletes. I'd have to go back and look at that paper, but I don't think we saw anything too, you know, concerning, because you're already starting with very young, healthy athletes. Covid, you know, it was a very. Is a very serious disease, but in that population, it's like you're already at, you know, your healthiest, you're young. And so, as expected, you know, didn't really see any. Too many changes.

[Dr. Lion]

That really kicked everything off. Yeah. In a very interesting way that I don't think anyone has seen in decades and decades. I'm thrilled to announce one of the new sponsors of the show, and that is the Carol Bike. Now, if you've listened to the show, you know that I believe muscle is the organ of longevity. And of course, of course, you need resistance training, but you also need high intensity interval training. And I would say nothing improves cardiovascular fitness like a targeted program and tool. And that is why I'm so excited about The Carol bike. It is an AI powered stationary bike that delivers, get this, a scientifically validated reduced exertion high intensity interval protocol in just 20 seconds. Two 20 second all out sprints. All of this in under five minutes. And this isn't random hit. It's resistance that adapts in real time to your output. So you get precise and personalized stimulus to improve your VO2 max which is one of the biggest predictors of mortality. And listen, we've all cheated ourselves our efforts on the treadmill and maybe we didn't push as hard as we could on the rower. But with the Carol bike there is no cheating. For those of you prioritizing muscle, this allows you to focus on cardiovascular training that complement strength work instead of competing with it. It is efficient, it is evidence based and it respects your time. So it allows you to get after it. Visit carolbike.com and use code LION for 100 off your Carol Bike. That's C A R O L b I k e.com and use the Code lion for a hundred dollars off your bike. GLP1s and athletes should they and are they allowed to use GLP1s?

[Dr. Crystal Guevara]

So as of now I believe GLP1s are on the WADA monitoring list. So it's not a banned substance but they are monitoring athletes who are on these medications to see whether or not there is a performance benefit, whether it can help them, whether it can hurt them.

[Dr. Lion]

What about for something like wrestling you're

[Dr. Crystal Guevara]

thinking about a weight based.

[Dr. Lion]

Yeah. My immediate reaction would be like okay so my dad was a collegiate wrestler. He went to Penn, he wrestled, he was captain of the wrestling team. Patty was up for all American total overachiever. Now he's a mountain man, like, like sleeps outside. He's hilarious but also very smart. He would talk about cutting weight. And so I think maybe the question and if you guys are out there who are involved in wrestling or any weight based sport, I'd love to hear everyone's opinion because is part of a weight based sport. The ability, the discipline, the mental challenge to do, I mean I don't know to in my mind it would be part of it.

[Dr. Crystal Guevara]

And I also have concerns about the weight cut even of itself. I already have. Like should we even be cutting weight for you know, sports like wrestling and MMA as a performance enhancing drug in a weight based sport? I would say that it is, it can be very much a performance enhancer and I wouldn't be surprised if at a certain point it ends up becoming a performance enhancing drug for certain Sports like wrestling. Yeah, so. But I don't make the rules, so.

[Dr. Lion]

But you should.

[Dr. Crystal Guevara]

I'm not on that committee.

[Dr. Lion]

I don't have any athletes in our practice that are on NGLP1. But hormones is a whole different story. Yeah, anabolic agents are very helpful for muscle, for sarcopenia, for burn, for cachexia, for wasting syndromes. I, I don't know what the landscape holds. I know what I hope would happen. You know, as a, another physician who prescribes medications, do you find it odd that someone could go to their doctor and say I need a medication that count me lose weight. The physician will say sure, okay, totally can appreciate that. But if someone goes to their doctor who's like, hey, I need a medication that's going to help me build muscle. The stigma is.

[Dr. Crystal Guevara]

No.

[Dr. Lion]

Oh my God, that's cheating. Cheating for what? We're talking about maintaining muscle mass. It's just a very interesting dance because from my perspective, optimal health would be at least 50% of your body weight is muscle body fat percentage. Again, some people are leaner than others. Naturally there, there shouldn't be necessarily restriction. Again, we're not talking about abuse. We're not talking about quote steroid abuse. We're talking about if you're under muscled it is very difficult. You know, people will say, listen, I mean how long have you been trying to get bulky? Oh me personally, last four years. Yeah, 30 years just trying to put on muscle. It's not, you know, from a natural training perspective, it's very difficult, especially as they age.

[Dr. Crystal Guevara]

I mean. Yeah.

[Dr. Lion]

Your parents are what, in their 60s or 70s?

[Dr. Crystal Guevara]

Yeah, yeah. And there are, you know, especially with hormone replace, you know, hormone replacement, menopausal hormone therapy kind of.

[Dr. Lion]

Now I like how you corrected yourself. Yeah, I know my friends were old physicians. Like they didn't even, they didn't even call. We called it hormone replacement therapy. I know the correct term.

[Dr. Crystal Guevara]

Yes.

[Dr. Lion]

So menopause replacement therapy. But okay, just from my perspective, I haven't seen patients for a long time giving them hormones, progesterone, testosterone, testosterone. They are not, you're not going to really change. I'm curious your perspective. I don't see a changing body composition. You have to do the nutrition and you have to do the resistance training. Do, does hormone replacement do a whole bunch of other things? Yes, but does it inherently change someone's body composition? I haven't seen it. There may be some mechanisms that don't necessarily translate to human clinical trials. So the idea that we're going to be able to really build Maintain address sarcopenia. We have medications that can help lose body fat. Why would we have a stigma against medications that could then be anabolic agents?

[Dr. Crystal Guevara]

I'm not sure. I also think the landscape is actually changing in terms of how people view. I think when you say anabolic agents, people do think in the 90s, they think steroids are bad and legal. But the things that I'm starting to see now, even amongst physicians is the peptides, the overall peptide space. And so we went from steroids are bad to what kind of peptide? Like what kind of peptides are you on? And GLPS unfortunately gets lumped into that kind of category. But they start listing off all these other agents that some of them are on the WADA list for performance enhancing. You know, they're listed as a performance enhancing drug. And so I feel like this, like anti anabolic, you know, agents are. I think it's slowly starting to chip away because people are starting to be more mindful or starting to think about like, what do I want my quality of life to look like? What do I want, you know, 10, 15 years down the line? Like, I don't want to be sarcopenic. Like, I want to be strong. I want to do all these things. I'm doing the training, I'm doing the nutrition and. But I'm also, you know, in my 50s and my 60s and I still have a decades left to go. It's not like it's 60, you know, like life's over. What do I want the next couple of decades to look like? And I, you know, they're starting to ask these questions and I think the landscape is changing. It's not very, as much, much like taboo as it once was.

[Dr. Lion]

Are you concerned about the lack of randomized control trials for. Have you thought much about the usage of peptides, the efficacy, the evidence of where they are?

[Dr. Crystal Guevara]

I have and I am not an expert on the. All of those other kind of peptides that most people are talking about, particularly for tendon healing, for all these BPC 7500. That is a whole nother ballpark that I just, I haven't really kind of kept my ear, you know, here and there, see what people are doing. But I'm not.

[Dr. Lion]

So you're not using them?

[Dr. Crystal Guevara]

No, no. I'm like, please go somewhere else. Like, I, I'm just not an expert, like, please.

[Dr. Lion]

Honorable of you.

[Dr. Crystal Guevara]

But yeah, no, it would be nice to see randomized control trials to see what, what is the case. Because it sounds like from what I had heard that it's all just rodent data, nothing.

[Dr. Lion]

I have heard that there is collective human data, but we still have to put it to the tests and the rigors that we would anticipate, which I think are going to start to come out. And then on the other hand, there is data for anabolic agents that work with various populations. And I do think that We've accepted this GLP1 use as we are not, or that we're going to address body fat, but we also, conversely, have to address skeletal muscle. I personally think that it's from a health standpoint, even more important, but from a cognitive standpoint, GLP1, if I were to think about. Okay, so what's the list of priorities? GLP1 use is an absolute priority for the psychological reasons that you're talking about. And I think that that is absolutely where the landscape is going. What do you want patients or people to walk away with knowing after hearing our interview?

[Dr. Crystal Guevara]

Couple of things. One, if you are having persistent food noise, persistent thoughts about food, especially when you're dieting, it's. You are not broken.

[Dr. Lion]

You.

[Dr. Crystal Guevara]

There are, there are things available at your disposal, tools in your toolbox that are able to, you know, help with all of that. And asking for help or even considering having that conversation is not. Does not mean you're broken. You are. You do not fail at life. You know, we have all sorts of modern technologies that are available to us. YouTube, you know, cars, air conditioning. Why can't deodorant. Deodorant. Exactly. Why? You know this. It really just depends on your situation and how you decide to, you know, if you decide to proceed with it. Resistance training is always going to be, you know, the most important thing in my book. Just because everybody has so many other things that they got to take care of, families, jobs, et cetera. If I had to pick one thing to do, please pick up something heavy, challenge yourself and call it a day. Live the rest of your life three days a week. Three days a week? Yeah.

[Dr. Lion]

Three sets of ten.

[Dr. Crystal Guevara]

Yeah. Full body, you know, get some. Get after it, get after it. And you'll be surprised at, you know, how much you can get out of that. If this is your first, you know, kind of endeavor in the weight room and it's not a scary place. I promise you a lot of bodybuilders, many bodybuilders are really kind and awesome newbie gains. Yes.

[Dr. Lion]

Right. The earlier you are to training, the more impactful the. The outcome in that condensed window is. So, for example, if you've been training for, I don't know, 20 years. You change up your program. Good luck. Yeah, I'm gonna make incremental changes. But if you're new to training and especially the women listening.

[Dr. Crystal Guevara]

Yes.

[Dr. Lion]

The number one obstacle that I hear from women, and I'm curious as to what your patients say is I don't get bulky.

[Dr. Crystal Guevara]

Yes, that is correct. And I tell them, I start showing them pictures, you know, and saying, like, you need to really try hard. And other anabolic agents likely are coming into play.

[Dr. Lion]

When you think.

[Dr. Crystal Guevara]

Thinking about that.

[Dr. Lion]

And how tall are you? You're my size, right?

[Dr. Crystal Guevara]

We're 11.

[Dr. Lion]

Oh, my gosh. I've never been on a podcast. I'm taller than you. I am taller than you. This is amazing. I don't think I've ever been totally. This is a first. Well, actually, my sister, I'm taller than her. Okay. So I'm five one.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

And you and I trying to put on muscle. It's going to take us. Listen, I've been trying to get bulky for, I don't know, 30 years. Math. Not that long, but at least 20.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

So, ladies, it's.

[Dr. Crystal Guevara]

It's not.

[Dr. Lion]

It's not going to happen.

[Dr. Crystal Guevara]

No, it isn't. And talking about the weight itself, especially when you're new to resistance training, you. The scale might not reflect. Good point.

[Dr. Lion]

Okay, talk to me about that.

[Dr. Crystal Guevara]

That is another. Definitely one of the first things, and I keep having to harp on it because I find that with a slow. Not just the slower rate of fat loss compared to, you know, whatever it is they were doing before, they get really discouraged. And so I encourage them to take a before picture. Take, you know, make note of your clothing size and a before picture.

[Dr. Lion]

With clothes on first.

[Dr. Crystal Guevara]

Yes, with clothes on. Yes, please.

[Dr. Lion]

Oh, my gosh.

[Dr. Crystal Guevara]

Clarify that, because there will be times where a lot of times they feel a lot, very discouraged. And I'm like, look at you. Send me a new picture.

[Dr. Lion]

Like, great point.

[Dr. Crystal Guevara]

And you compare the two. I'm like, did you just, like, you know, six months ago, you've only lost, like, what, five, ten pounds? And. But the body recomposition, you are down to sizes. Everybody at your work, like, doesn't believe you when you say you've lost five to ten pounds because they're like, no, it's gotta be more. You look way, like, way more leaner now. And so those are things that I definitely harp on very early on and I keep repeating because it's. It's hard because you want to see the scale drop a lot.

[Dr. Lion]

Basically, what you're saying. Is you're getting ahead of. You are seeing that the train goes down the track and you're getting. That's now, friends. This is a very smart physician. That is a very smart physician move. Is you see what is coming because you've had enough clinical experience, enough reps to hear what patients struggle with. And if they struggle with weight, for example, that they're actually putting on muscle and losing fat, but the scale is not changing, then they're going to be like, I'm done. Even if their body looks better.

[Dr. Crystal Guevara]

Yes.

[Dr. Lion]

So you are getting ahead of that. I hadn't thought about discussing that on this podcast. That is a really good point. Do you like your patients to weigh themselves?

[Dr. Crystal Guevara]

I do. And I want to do it in such a way that the scale becomes a neutral place and not a place of, like, where their emotions run and where the scale actually determines their worth. So. And that takes.

[Dr. Lion]

We've all been there. And I've been there, too.

[Dr. Crystal Guevara]

Yes. 100%.

[Dr. Lion]

I have been there, too.

[Dr. Crystal Guevara]

100%.

[Dr. Lion]

Did you gain weight in residency?

[Dr. Crystal Guevara]

Oh, my gosh.

[Dr. Lion]

Same, same.

[Dr. Crystal Guevara]

Oh, gosh. Yeah. Especially during sports med fellowship and Covid. It was. It was a time.

[Dr. Lion]

It was icu, baby. For me. It was the ICU rotation. Seriously. And it was just like, ICU er not sleeping. I was up at the nurse's station

[Dr. Crystal Guevara]

eating peanut butter and graham crackers. Oh, yeah. Oh, yes.

[Dr. Lion]

Even. Even remember the applesauce? Gross. That was me.

[Dr. Crystal Guevara]

I still eat it.

[Dr. Lion]

Peanut butter, peanut butter and jelly sandwiches. Disgusting.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

I was like, oh, disgusting. Terrible idea. Where is it? And so we've all experienced that. And I will tell you, that was a period in my life where I just felt so bad about myself. I wasn't sleeping. I was eating at the nurse's station. And just. Not that it's a bad thing, but it kind of is. A bunch of junk food. It is. Let's just call a spade a spade.

[Dr. Crystal Guevara]

It is.

[Dr. Lion]

It's a bunch of junk food. Tastes terrible. But stop reading the Krispy Kreme donuts.

[Dr. Crystal Guevara]

But when you've been up for 24 hours, anything tastes 24.

[Dr. Lion]

Exactly. 48. It changes your blood sugar regulation.

[Dr. Crystal Guevara]

Oh, yeah.

[Dr. Lion]

It's harder to lose weight. It's just. And again, the scale is a really good thing. For context, I'm 5:1. My normal weight is 110 pounds, give or take. Me, I'm a little bit lighter sometimes. In residency, when I was doing ICU, guess how heavy I was.

[Dr. Crystal Guevara]

125.

[Dr. Lion]

135.

[Dr. Crystal Guevara]

No way. Oh, wow.

[Dr. Lion]

135. Who's almost 25 pounds heavier than I am right now.

[Dr. Crystal Guevara]

Oh my gosh.

[Dr. Lion]

I was a size between size four, maybe, like. And again, you guys might be listening to this. Like, oh, whatever. Yeah, yeah. Tiny. And my natural weight is small. There is something to be said for being able to track. And my diet wasn't on point. I was exhausted. I was so stressed out. I'm like, you know, you're looking at X rays and trying to figure out what the zipper line is and what's this patient's, you know, ion gap things I don't. Right. So we call the resident. There's codes running. Remember that?

[Dr. Crystal Guevara]

Oh, yes. Oh yeah.

[Dr. Lion]

And yeah, I didn't. I just felt so terrible about my relationship to food at the time, my relationship to weight. And I can only imagine that, you know, thank God that that was a short term experience.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

But I'm sure. Did that happen to you too?

[Dr. Crystal Guevara]

Oh, yeah. When I was, when I was a resident, I, I made sure to get my protein in and I made sure to get my lifting in. That was the one thing that like, same. No matter what, no matter what. The calories were all over the place. I would eat the crusted donuts that have been sitting there for a day and a half. Like I just did not care. But I would at least make sure I hit my protein. And I went to the gym three to four days a week. And if I was on night float or like some other shift, like, I would stretch out my, like the last week of my training cycle to a week and a half to two weeks.

[Dr. Lion]

Were you competitive at that time doing powerlifting?

[Dr. Crystal Guevara]

My last competition was I was a second year resident and that. And then I hung my hat, you know, up and I was like, I'm done with powerlifting. I'm gonna switch to bodybuilding to give my joints a break. And then also because I'm, you know, obviously in a calorie surplus. Let's see how much muscle I can put on. Like, screw it. Like, I'm just gonna, you know, eat.

[Dr. Lion]

Was that on purpose or were you, was it a way of coping with the, coping the stress that you were like, if I'm gonna put on muscle, so sure. Can you do?

[Dr. Crystal Guevara]

Oh yeah, no, totally. Oh yeah. I, I just, I realized so at times where was like, I'm just going to, you know, I'm like, I think 4, 11. And around that time was somewhere between, I think I competed at 72 kilos, like 158 pounds. And so I would fluctuate somewhere between 160 and 170 at 4:11 and I was snoring, my joints hurt and I was like, I'm feeling a little beat up from powerlifting. But, but I still want to keep training. I still think that that's important.

[Dr. Lion]

Were you thinking a ton about food at that time, even if you were in. Oh yeah, 100 high calorie. During a high calorie time.

[Dr. Crystal Guevara]

Yeah.

[Dr. Lion]

So this was really, this was not food addiction. But you were, you were just consumed.

[Dr. Crystal Guevara]

Yeah, the times where I like at 165, 170 and 411, like it was manageable. But I would definitely have to keep snacks on me at like every two to three hours just so I wouldn't turn hangry, you know, in the hospital. But yeah, I decided to switch up my whole training, just give my joints a break and just increase my reps. Focus on, you know, more bodybuilding style because, yeah, I realized that I wasn't gonna get to be lean and that's okay. Like, I also realized that residency sucks and the fact that I'm doing something is better than nothing. So let's just see how much muscle I can put on or during this time. And then once training, you know, medical training is over, let's see where the chips fall and what my life looks like outside of that and kind of go from there.

[Dr. Lion]

It's tough and just like trying to get through the. Than walnuts.

[Dr. Crystal Guevara]

Right.

[Dr. Lion]

You want all women to lift weights. I do. I, I, there's no, there's no other way.

[Dr. Crystal Guevara]

There's no, there's no. Right now we don't have, you know, medic a medication that can just be like, here you go, take this pill and magically grow muscles. No.

[Dr. Lion]

Yeah.

[Dr. Crystal Guevara]

And then also I don't know if it's going to help with the tendon issue. So like how strengthen your tendons and yeah, even if you have all sorts of medical conditions, there are ways around it. Like, there's plenty of athletes who end up getting AC surgery who's like, oh, I'm just not going to go to the gym. And I'm like, you did not get, you have your other leg and you have a whole upper body. Like, we can, we can work around this. Like you can get your, you know, turn around and get back into the gym and let's figure something out.

[Dr. Lion]

Made her very unpopular. What is next for you? What are you working on now?

[Dr. Crystal Guevara]

Just working on a lot more content. I did mention at some point, I think writing a book. Awesome food noise and how that has shaped kind of my entire life and the decisions I've made and see how that goes. So I'm thinking that's kind of a little bit further down the line. But, yes, content. And then the book.

[Dr. Lion]

Well, Dr. Crystal Guevara, sooner rather than later, the book is needed. Let me know how I can help expedite that, because I think people hearing it from someone who is a highly trained physician, family medicine plus sports medicine, who also struggled, and then, you know, I really think you're normalizing it for people, and that is very valuable because this way, it. It kind of breaks that fourth wall. So thank you so much.

[Dr. Crystal Guevara]

Thank you so much for having me.