The Cancer Doctors Keep Missing in Young Adults - Dr. Michelle Pearlman

Summary

Podcast Summary:

The Dr. Gabrielle Lyon Show
Episode: The Cancer Doctors Keep Missing in Young Adults - Dr. Michelle Pearlman
Date: May 19, 2026
Guest: Dr. Michelle Pearlman, Gastroenterologist and Nutrition Specialist

Overview

This episode delivers a candid, deeply educational conversation between Dr. Gabrielle Lyon and Dr. Michelle Pearlman focusing on the alarming rise of colorectal cancer in young adults, the interconnectedness of weight, gut health, and metabolic disease, and the evolving landscape of weight management medications (notably GLP-1 agonists). The discussion spotlights clinical and societal gaps in early detection, dietary advice, and the implementation of innovative therapies, while also empowering listeners to champion their own health.

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Key Discussion Points & Insights

1. Increasing Rates of Colorectal Cancer in Young Adults (00:00–00:45, 13:40–17:15)

• Colorectal cancer is becoming the leading cause of cancer under age 50, with more cases of metastatic disease in relatively healthy young individuals.
• Dr. Pearlman highlights that environmental exposures—including microplastics, pesticides, and dietary chemicals—are implicated, as genetics haven't shifted substantially in recent decades.
• Quote:

  “Colorectal cancer is very common, and it's now becoming the leading cause of cancer under the age of 50... Our genetics haven't changed... Our environmental exposures have.”
  —Dr. Michelle Pearlman (00:00, 14:00)

• Physician Blind Spots:
  Many doctors dismiss symptoms like rectal bleeding in young people as hemorrhoids. Dr. Pearlman urges that rectal bleeding, even just with wiping, always merits investigation (preferably colonoscopy).
• Alarm Signs:
  Unintentional weight loss, persistent nausea or vomiting, ongoing abdominal pain, and any blood in the stool must never be ignored.

  "Never ignore warning signs." —Dr. Michelle Pearlman (20:14)

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2. The Gap in Nutrition Education and Hospital Culture (02:59–09:15)

• Despite being a gastroenterologist, Dr. Pearlman notes,

  "In three years worth of gastroenterology and hepatology fellowship training, I learned pathology. I did not learn nutrition." (02:59)

• Patients often wake from GI procedures and are given "the very foods I told them to limit," like orange juice or processed sandwiches, undermining nutritional advice and reflecting a systemic disconnect in healthcare’s approach to prevention.
• Culture Shift Needed:
  Calls for hospitals to prioritize whole, minimally processed foods and make robust nutrition education standard.

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3. Weight, Visceral Fat, and Gut Symptoms (05:26–09:52, 36:34–37:29)

• Many GI symptoms—acid reflux, bloating, constipation—are weight-related, especially due to visceral fat’s impact on intra-abdominal pressure.
• Standard GI medications (antacids, PPIs) do not fix underlying obesity-related issues:

  “No amount of antacid is going to fix the mechanical issue.” (06:36)

• Dr. Pearlman’s practice pivoted to combine weight management with GI care, focusing on evidence-based use of medications (GLP-1 agonists), nutrition, lifestyle change, and prevention.

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4. The Complex Role of PPIs and OTC Medicines (09:51–12:19)

• Chronic use of PPIs can impair mineral and vitamin absorption, affecting bone density and overall health—even though these drugs are available OTC.
• Nonprescription equated with "safe":

  “Oftentimes people equate over-the-counter with safe. And that’s not necessarily the truth.” (11:56)

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5. Three Essential “Nevers” for Gut Health (20:03–22:08)

1. Avoid Ultra-Processed Food

   • Limit foods with excessive, artificial, or unknown ingredients.

     "The quality of our food and the ingredients really, really matter..." (12:50)

2. Never Ignore Warning Signs

   • Any persistent GI symptom (rectal bleeding, unexplained weight loss, prolonged abdominal pain) needs medical attention.

3. Don’t Skip the Foundation

   • Medications, peptides, and technology do NOT replace optimal nutrition, movement, sleep, and stress management.

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6. Colorectal Cancer Screening: Guidelines & Gaps (17:15–19:58, 53:44–55:44)

• Current guidelines: begin at age 45, but do not currently prioritize diabetics/metabolically unhealthy patients for earlier screening.
• Emerging tests: blood-based screenings show promise, but colonoscopy remains the gold standard (though not always accessible).
• Dr. Pearlman underscores pressing need for more nuanced, risk-based screening especially in those with metabolic disease and a focus on prevention rather than reaction.

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7. The Rise of GLP-1 Agonists (23:59–31:36, 33:37–38:55, 51:20–57:03)

• Context:
  Medications like Ozempic (semaglutide) and tirzepatide (Zepbound/Manjaro) have revolutionized the field, originally intended for diabetes now increasingly used for weight management, and even being studied for sleep apnea, IBD, PCOS, and Alzheimer’s.

  “We need to stop saying these are weight loss drugs and diabetes drugs. These are metabolic reprogrammers.” (28:46)

• Stigma:
  Many patients are secretive about GLP-1 use due to persistent stigma—despite the drugs’ robust metabolic and health benefits.

• New Formulations:
  Pills (Rybelsus, oral Wegovy) are available but present their own challenges (timing with food, efficacy vs. injections).

• Concerns:
  Side effects (nausea, reflux, constipation) are manageable but require active counseling. Black box warning for medullary thyroid cancer only concerns individuals/families with relevant history.

• Long-term effectiveness:
  Sustained success depends on maintaining changes to diet, movement, and understanding that medication alone won’t "cure" obesity.

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Notable Quotes on GLP-1s & Weight Loss

• “We need to stop telling people to just do it on their own... Why not use tools in the toolbox to do two things: make it a little bit easier, and a little bit less painful?”
  —Dr. Michelle Pearlman (46:00, 55:44)
• On weight regain after stopping medication:

  "The hard part is not losing the weight. It's keeping the weight off long term." (37:29)

• “No drug is going to change that. [Work is required.]” (119:35)

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8. GLP-1 Practicalities: Dosing, Side Effects, Maintenance (39:25–44:28, 46:49–50:02, 98:52–105:38)

• Addressing common GI side effects:
  • Side effects often worse at first, then improve—especially as visceral fat drops.
  • Eating habits matter immensely:
    • Avoid late/fatty meals, chew carefully, front-load calories earlier in the day (43:39).
    • Hydration and fiber crucial for constipation management.
• Maintenance after weight loss:
  • Dosing is individualized—gradually increasing interval between doses (e.g., every 10–14 days) based on hunger cues (103:44–105:38).
  • Spacing out injections is personalized and dynamic: holidays, travel, exercise, and diet all impact needs.

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9. The Critical Role of Protein, Fiber, and the Microbiome (63:26–81:58)

• Protein:
  • Aim for at least 100–120g/day for satiety, muscle and hair maintenance—especially critical with GLP-1s, as appetite often drops.
  • Gradual increase advised; meet patients where they are.
• Fiber:
  • 25–35g/day recommended; real food sources preferable for microbiome health (nuts, seeds, legumes, whole grains, vegetables).
  • Ultra-processed food, even if "high-fiber," can be misleading and cause GI distress.
• Microbiome:
  • Defined as trillions of bacteria, fungi, and more—impacts immunity, metabolism, and overall health.
  • Prebiotics (dietary fiber) fuel beneficial bacteria who then make postbiotics (short-chain fatty acids).

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10. Muscle, Bone Health, and Hormones: The Missing Conversations (84:01–115:57)

• Hormone Replacement Therapy (HRT):

  • Underutilized and often stigmatized, especially in women.
  • The best clinical results for perimenopausal and menopausal women occur when HRT (estrogen, progesterone, testosterone), nutritional optimization, and GLP-1s are combined.

  “The secret sauce is the combination of HRT and GLP-1 therapy… I can tell exactly the point that I start a patient on a GLP1 on hormone replacement therapy because their lean mass losses... start to gain muscle when I'm optimizing specifically my women on testosterone.” (88:34)

• Muscle as the Longevity Organ:

  • Emphasized as under-discussed in medicine—handgrip strength, performance, and frailty are better health predictors than BMI alone.
  • Routine clinical visits focus on outdated metrics (BP, weight) rather than strength, protein intake, or muscle functionality.

• Dr. Pearlman's Personal Journey:
  Diagnosed with osteoporosis at 39 despite optimal diet and training, illustrating gaps in both patient and physician understanding of bone health and the need for earlier, more proactive intervention for musculoskeletal health, ideally starting in one’s teens and 20s. (108:53–115:57)

• Quote:

  “We are overtraining and under-fueling… Our body tells us at some point that’s not going to work. And that was my wake up call.”
  —Dr. Michelle Pearlman (110:53)

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11. The Role of Technology and Patient Advocacy (120:11–122:11)

• Most clinical settings do not allow nuanced, proactive care (due to time and insurance constraints).

• Dr. Pearlman is developing a tech platform (Bite MD) to help patients analyze diet, symptoms, and medication responses in real time—helping fill the gap where healthcare delivery falls short.

• Emphasize: patients must educate and advocate for themselves, as many clinicians are not up-to-date on metabolic or musculoskeletal medicine.

• Quote:

  “The people who need to be watching your podcast are not only the patients, they are the providers.” (116:08)

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Timestamps for Key Topics

• 00:00–01:46 — Colorectal cancer's rise in young adults
• 03:59–09:15 — The lack of nutrition training in GI medicine, hospital nutrition issues
• 13:40–17:15 — Food processing, carcinogens, environmental factors
• 20:03–22:08 — The “Three Nevers” of gut health
• 23:59–38:55 — GLP-1 history, stigma, delivery forms, new uses
• 39:25–50:02 — Managing GI side effects and complications (constipation, reflux)
• 63:26–81:58 — Protein, fiber, microbiome, dietary basics, myths
• 84:01–88:34 — Hormones, body composition, clinical anecdotes
• 88:34–96:49 — HRT/GLP-1 synergy, muscle, strength as longevity markers
• 108:53–115:57 — Dr. Pearlman’s personal osteoporosis experience and lessons
• 120:11–122:11 — Tech, clinical innovation, systemic challenges

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Memorable Quotes

• On dismissing symptoms:

  “Even if it's just rectal bleeding with wiping, I recommend a colonoscopy. What are some of those alarm signs? It would be unintentional weight loss." (00:24)

• On GLP-1s' broader potential:

  “These medications are going to infiltrate every single field in medicine.” (55:44)

• On weight loss maintenance:

  "The hard part is not losing the weight. It's keeping the weight off long term." (37:29)

• On patient care paradigm:

  “No amount of medication will replace [nutrition, sleep, movement].” (22:08)

• On medical training and culture:

  "I learned about disease. I did not learn about prevention." (02:59)

• On the importance of muscle:

  "Muscle and bone, they are longevity organs… It literally affects our health span and lifespan." (113:50)

• On evolving practice:

  “We are at the precipice of an entirely new landscape of medicine.” (56:24)

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Conclusion

This episode highlights the urgency of updating both physician knowledge and public awareness regarding the early signs of colorectal cancer, the role of diet and body composition, and the necessity of integrating advanced metabolic, nutritional, and hormonal approaches for optimal health—and doing so long before midlife. Dr. Pearlman delivers both practical advice and a vision for a future where technology, patient empowerment, and true preventive care coincide.

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For listeners seeking guidance:

• Take GI symptoms seriously and advocate for thorough workup if alarm signs are present, regardless of age.
• Question and improve dietary quality—prioritize whole, minimally processed foods, and adequate protein/fiber intake.
• Understand that new weight loss therapies require lifestyle foundations for best (and safest) outcomes.
• Push for clinical conversations about muscle, bone, and metabolic health—long before old age or problems set in.
• Seek out providers committed to preventive, evidence-based medicine and be prepared to champion your own health.

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Transcript

[Dr. Michelle Pearlman]

Colorectal cancer is very common, and it's now becoming the leading cause of cancer under the age of 50. And we're seeing it at earlier ages. So in most other cancers, we are making progress when it comes to prevention and lowering prevalence. But we're seeing more metastatic disease in younger individuals.

[Podcast Host]

Most people don't go to a gastroenterologist thinking, I'm going to do nutritional work. They're thinking, I'm bloated, I'm having reflux.

[Dr. Michelle Pearlman]

Most gastroenterologists would say, you're too young for colorectal cancer. It's probably just hemorrhoids. And then we realized it's not just hemorrhoids in a lot of people. Even if it's just rectal bleeding with wiping, I recommend a colonoscopy. What are some of those alarm signs? It would be unintentional weight loss.

[Podcast Host]

Medicine isn't about disease prevention. It's about fixing a problem.

[Dr. Michelle Pearlman]

We need to stop telling people to just do it on their own. They're going to be doing it on their own. But why not use tools in the toolbox to do two things? Make it a little bit easier and a little bit less painful? Why not?

[Podcast Host]

You realize that we are at the precipice of an entirely new landscape of medicine.

[Dr. Michelle Pearlman]

I would say this has completely revolutionized healthcare. These medications are going to infiltrate every single field in medicine. So the first medication I have here is.

[Podcast Host]

Doctor Michelle Pearlman. Welcome to the show.

[Dr. Michelle Pearlman]

Thank you so much for having me.

[Podcast Host]

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

[Dr. Michelle Pearlman]

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

[Podcast Host]

Not surprising. It's kind of this evolving field. When we were talking before the camera started rolling, you had said that you were doing a ton of endoscopies, the little cameras that you swallow. And that's a routine pro done by gastroenterologists. Also, you do colonoscopy, so you do both ends, not at the same time. That would be impressive and very convenient because it would really minimize the amount of time that one was in the operating suite or whatever it is. You had said something that I thought was really interesting from a medical perspective. Number one, typically, medicine isn't about disease prevention. It's about fixing a problem. And when you were scoping these people, they would finish their scope and say, I'm still not feeling well.

[Dr. Michelle Pearlman]

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

[Podcast Host]

Okay. And now you in your own clinical practice, so you have a private practice. You combine both nutritional sciences with gastroenterology.

[Dr. Michelle Pearlman]

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

[Podcast Host]

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

[Dr. Michelle Pearlman]

My practice has definitely evolved. Initially I was seeing people mostly for weight management. So people who wanted to be able to lose a good amount of weight for overall health, not to see a six pack and walk around on south beach, although I do have a couple of those. But most of my patients wanted to lose, let's say 10 to 15% of their body weight and be able to keep it off. And so that's the initial practice was weight management. How things evolved is a lot of my patients were middle aged women and a big part of my Practice is using GLP1 medications to improve cardiometabolic health and help with the weight loss process. Because most of the patients come to see me, it's not their first rodeo. So they've struggled for decades. The last thing they want is to go to a doctor and be told by just another person to eat less and move more because they're really struggling. So I use all the tools in the toolbox to help optimize someone's health when they come to see me.

[Podcast Host]

Which is counterintuitive because most people don't go to a gastroenterologist thinking I'm going to do nutritional work. They're thinking I'm bloated, I'm having reflux, maybe I need my scope, which is now 45 is when they.

[Dr. Michelle Pearlman]

For colonoscopy.

[Podcast Host]

For colonoscopy.

[Dr. Michelle Pearlman]

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

[Podcast Host]

Oh yeah.

[Dr. Michelle Pearlman]

I would have patients wake up from their endoscopy, they would literally still be half asleep, lying almost flat and the nurse would give them orange juice or they'd give them a very high sodium turkey sandwich or a cookie or a muffin. And I would tell them I literally just spent an hour with this patient talking about optimal nutrition. It really sends them a very confusing message to give them everything I told them to limit. And I was told by the staff that I was too aggressive for asking for hummus and carrots and healthier snacks when my patients woke up from their procedure.

[Podcast Host]

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

[Dr. Michelle Pearlman]

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

[Podcast Host]

Do you use PPIs?

[Dr. Michelle Pearlman]

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

[Podcast Host]

Probably. I mean, I think there's some pretty good data. And this is because that affects vitamin

[Dr. Michelle Pearlman]

D and calcium and all these things.

[Podcast Host]

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

[Dr. Michelle Pearlman]

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

[Podcast Host]

If you were to tell them. People listening. What's up, guys? Three things never to do. What would you tell them? Please don't say. Please don't say carbonation. And I know your sister is here, Dr. Amy Pearlman. We're not talking about sex toys just yet, but would it be, for example, I love carbonation, please don't tell me to stop drinking carbonated things. Are there just a handful of things that you're like, you know, when it

[Dr. Michelle Pearlman]

comes to acid reflux and acid reflux?

[Podcast Host]

Or how about gut health, just in general?

[Dr. Michelle Pearlman]

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

[Podcast Host]

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

[Dr. Michelle Pearlman]

So for instance, like deli meat is considered a Class 1 carcinogen, increased risk of things like colorectal cancer and gastric cancer. So you had mentioned kind of the new screening guidelines for colorectal cancer. So really since the beginning of time, it was age 50, but we are seeing metastatic colorectal cancer in 20 year olds.

[Podcast Host]

Why do you think that is?

[Dr. Michelle Pearlman]

It's our environmental exposures. These are people without genetic predisposition. And the interesting thing is our genetics haven't changed within the past couple of decades. Our environmental exposures have. And that changes the way our genes are expressed or epigenetics.

[Podcast Host]

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

[Dr. Michelle Pearlman]

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

[Podcast Host]

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

[Dr. Michelle Pearlman]

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

[Podcast Host]

Yeah, I just, I think, do we have, you know, the carcinogen classification has been a real challenge for me because, you know, there was that Annals of internal medicine Bradley Johnston came out with, you know, basically he looked at red meat and he looked at the risk factors and he used the grade analysis for you guys listening and we'll link these papers, I think they're available to everybody. But basically the great analysis of how the quality of the evidence and basically if his whole red me he didn't find a relationship between cancer or heart disease, which makes me think, is it a weight problem? Is it, for example, if we've got 20 year olds that are coming in with metastatic cancer, I mean, it's gotta be pretty complex. And it's probably also, from what I understand, one of the risk factors for colorectal cancer, if I'm not mistaken, is obesity.

[Dr. Michelle Pearlman]

Oh yeah, no, absolutely. But what's interesting about that is that hasn't made it into the screening guidelines. So if, let's say I have a patient who has metabolic disease and obesity, I'm not screening them any earlier based on guidelines. I'm still waiting until I'm 45. I think that's where the guidelines probably need significant improvement. If we know that, you know, diabetes or insulin resistance or fatty liver, if these things may play a role in development of polyps, then that should make it into the screening guidelines. To the point where, let's say you have someone who's very healthy and they have a colonoscopy at 45. Do they need a repeat colonoscopy in 10 years? Maybe, maybe not. Versus someone who, let's say, is diabetic and has other metabolic issues? Maybe we shouldn't wait 10 years even with a normal colonoscopy at 45. I think that's where there's a lot of unknowns.

[Podcast Host]

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

[Dr. Michelle Pearlman]

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

[Podcast Host]

I just want to pause for. This is really important and I believe in early cancer detection. Are you talking about the grail test or the gallery test that looks at methylated DNA for various types of cancers or cologuard or something like that?

[Dr. Michelle Pearlman]

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

[Podcast Host]

And how specific, like how sensitive are those tests?

[Dr. Michelle Pearlman]

Yeah, you're still going to have false negatives and false positives. But if someone is willing to do a colonoscopy with a positive blood test versus they'd say, I'm never doing a colonoscopy, which I have patients like that and I'm sure you at least they're going to get screened. Now, would you offer the blood test if they said even if it's positive and not getting a colonoscopy? Not sure in that regard it's going to be helpful. But sometimes it will lead someone to get a colonoscopy if they say, okay, you know, I need to take this more seriously because it was a, you know, a positive test. But yeah, you can still have false negatives and false positives. Colonoscopy is technically the gold standard, but not everyone has access to colonoscopies and not everyone is willing to do that as their first step.

[Podcast Host]

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

[Dr. Michelle Pearlman]

Okay, I never say never, but the first one is to avoid or try to at least limit ultra processed food.

[Podcast Host]

Number two.

[Dr. Michelle Pearlman]

Number two is never. Well, I guess I do say never. Almost never. Never ignore warning signs.

[Podcast Host]

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

[Dr. Michelle Pearlman]

Yeah. And I think we're seeing it in the celebrity realm where people are coming out. James Van Der Beek, Colorectal cancer That's

[Podcast Host]

what I was thinking. Yeah.

[Dr. Michelle Pearlman]

And how.

[Podcast Host]

Who, by the way, didn't have a weight problem?

[Dr. Michelle Pearlman]

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

[Podcast Host]

How much weight loss? 5%, 10%.

[Dr. Michelle Pearlman]

There's no percentage. It's just, it would be unintentional. So because it depends on what your starting weight is, if someone's £200 and they lose £5, I probably wouldn't be so concerned. If I have a patient who's 120 and they lose five pounds, that could be a big deal if there is no other explanation. So unintentional weight loss, nausea, vomiting, abdominal pain, if it's getting worse or if it's not improving. So not Just a run of the mill gastroenteritis. If something is prolonged or getting worse, that would be a warning sign. And then rectal bleeding or blood in the stool.

[Podcast Host]

So never ignore warning signs.

[Dr. Michelle Pearlman]

Yeah.

[Podcast Host]

Avoid ultra processed foods.

[Dr. Michelle Pearlman]

Yeah. And the third one I would say is we can't skip the foundation with all the hype with peptides and GLP1s and GLP1s are a big part of my practice and all the technologies and innovation that are coming out within the medical and the, and the wellness industry. We cannot skip the foundation, which is optimal nutrition, getting our protein as you know, moving our bodies on a daily basis. No amount of medication will replace those things. Sleep, stress management, that social network, all of those things are incredibly important for overall health and wellness.

[Podcast Host]

Okay. The worst is going to buy sheets and they look pretty. You get home, unpack them, wash them and they are terrible and scratchy and ultimately just need to be thrown out. And that is why I chose Cozy Earth as one of the sponsors of the show. I've been using Cozy Earth products for years. They have the software softest, coziest, most comfortable home products ever. Beyond sheets, they have towels and they have comforters. And their comforters are breathable, temperature regulating, incredibly soft without feeling heavy and scratchy. And it makes winding down at night effortless and beautiful. They also have essential socks that are thoughtfully cushioned and supportive and even are better with a foot rub. So whether you are traveling, training or just at home, I love these products and they are built with intention and they are beautiful. And Cozy Earth stands behind their products with 100 night sleep trial and a 10 year warranty. Huge fan have been using them for years. Head to cozyearth.com and use code DRLION for 20% off. You can experience it at home. Foot rubs don't come with it. Talk to me about GLP1 use. And also there's various delivery systems for GLP1s.

[Dr. Michelle Pearlman]

You know, it's fascinating the GLP1s because in my years of training I had very little exposure. So these medications, oddly enough, have actually been around some of them for about two decades. A lot of people just remember the Ozempic jingle that came out a few years ago. What is that? And they. Oh yeah, oh yeah, oh yeah. There's a jingle. I have a terrible voice. I'm not going to sing it, but it was on all the commercials all over tv. But some of these medications have actually been out for about two decades. So they are not brand new. And they've been doing research on them for A long time. It's just the initial medications didn't pan out in clinical trials. But none of my training really talked about GLP1s because they didn't reach the press and the media, and they weren't more accessible until around 2018 when Ozempic or semaglutide came out for diabetics. So my first exposure actually to these medications, so I was a GI fellow at the time, and I actually got exposure to this medication outside of my own training program. So I was already very fascinated with weight management and cardiometabolic health. So I asked someone who ran the weight management program at UT Southwestern. He he's an endocrinologist. And I said, I'm a gastroenterology fellow, but I would love to rotate through your endocrine clinic.

[Podcast Host]

Who was that?

[Dr. Michelle Pearlman]

Dr. Jamie Almandez. He is phenomenal. He is the man who changed the trajectory of my career, not even within my own training specialty. So I rotated through his clinic, and that was my first exposure to watching a dietitian talk to a patient. It was my first exposure to see a doctor talk to a patient about what does their family unit look like, what does their budget look like, what are their health and wellness goals, what is their nutrition intake, what is their movement, and then give them a realistic plan on all the foundations of health and wellness, nutrition movement, but then also introduce medications when they were appropriate. And to the point that he inspired me, I kind of created my own little weight management clinic as a trainee, and I was actually teaching my attention things at the time. Unbelievable. Fascinating.

[Podcast Host]

You bring up a really good point. The misconception about GLP1s is that they are new medications, but they have been around and have been FDA approved for type 2 diabetes. Then 2018, they are then available to be used for weight management. And I think that that's probably the biggest shift. Would you agree? Because the medications were around.

[Dr. Michelle Pearlman]

Yeah. So the initial medications, Victoza, was initially FDA approved for type 2 diabetics. They started seeing that people were losing weight. They did additional clinical trials, and that's when Saxenda came out. So these are daily injections, and that's Liraglutide is kind of the generic name. Now, Liraglutide, or Saxenda for weight loss only gave you about 5 to 6% weight loss. So it's something. But for overall cardiometabolic health, we typically want to hit around 7 to 10% of weight loss. It's not 100 or 200 pounds, it's 7 to 10%. So it was helping. The good thing also about it is a lot of the other diabetic drugs on the market, like insulin, which we used to use a lot, were weight promoting. So it wouldn't be fair to the patients if we said, you know, hey Sally, you got to lose a bunch of weight. We have to start insulin for you because of your diabetes. But my goodness, we just made it a lot harder for Sally to lose weight because we're giving her insulin, which is a fat storage hormone. So at least we had medications that were targeting both the diabetes management but also help them lose weight. And then Ozempic came out in 2018. So that is a once per week injection. So the other name for that is Semaglutide. But actually Wegovy, which is the same medication but different dosing, came out in 2021. So it actually wasn't until 2021 that we had medication FDA approved for weight management in people with a BMI of 27 or above with a comorbid condition, weight related or 30 and above, and they didn't need a comorbid condition. And then more recently is Tirzepatide. So Tirzepatide, we have Zepbound for non diabetics and we have Manjoro for diabetics. So a lot of people think Ozempic is the only medication out in the world. And that's not true. There's really the two kind of main ones, which is semaglutide enters appetite. It's just there's a lot of other names because of FDA approvals and indications, but it goes way beyond weight loss and diabetes control. I actually went to a recent longevity conference locally in Miami and one of the cardio metabolic specialists, he's a lipidologist, he was speaking on GLP1s and longevity. So GLP1s are now actually entering the whole longevity space, which I think is amazing. He made a very interesting phrase. He said we need to stop saying these are weight loss drugs and diabetes drugs. These are metabolic reprogrammers.

[Podcast Host]

And I love that the Saxenda would give an individual daily injection. 5% or so, arguably could be good for liver, but not necessarily effective for cardiometabolic health. In terms of reasons why someone wouldn't try these medications, what are those reasons?

[Dr. Michelle Pearlman]

I think there's a lot of fear mongering out there. So with social media and the digital age, obviously it's an incredible resource for information. But when it comes to GLP1 medications, it is very stigmatizing. You have people who are pro and you have people who are anti. And there's not many people in the middle ground with, which is kind of fascinating to me. It's also a big stigma for patients themselves. I have many patients who will not tell anyone, even their husbands or their wives, that they're on the medication because oftentimes they think it's a failure on their part because they couldn't lose the weight, quote, unquote, on their own, which I think is really awful. You know, these medications act in probably 50 different mechanisms, most of which we don't quite, quite yet understand. I think a lot of people have this thought that they just shut down your appetite, which is not the only mechanism. Yes. They delay gastric emptying, so they slow down the rate at which your stomach empties. Takes a normal stomach about four hours to empty a standard meal, like an egg sandwich. These medications slow down that process so that maybe the meal stays in your stomach for five hours or six hours. So it helps in particular for people who eat a meal and they don't feel satisfied or they feel satisfied and then they have hunger one or two hours later. That's where it can be very helpful. It also, you know, our body naturally makes this hormone GLP1, right? People talk, oh, I want to go on a peptide. I go, listen, you're already on one glugoo gun, like one peptide, right? So this hormone, when food goes down into our intestine, our body releases this GLP1 hormone. It sends signals back to our brain, and it says, brain, I'm full. But our body also has an enzyme that breaks that down pretty quickly. So for people who say, oh, just take berberine or take all these other supplements that enhance your natural GLP1, well, they may, but they're not preventing the quick breakdown of it. So these medications like semaglutide or tirzepatide, they are synthetic versions of that hormone. So they stay in the body longer. They help get you fuller sooner. They keep you fuller longer. We also have GLP1 receptors in the brain, so it works on the cravings and the plan pleasure pathway. Now, what I tell people all the time, my goal is not to shut down your. Your hunger. It's not to create food aversions. I want you to feel hungry, because when you work out, if I were to shut down your hunger and you don't eat after your workout, is that a good thing for muscle growth?

[Podcast Host]

I mean, I feel like I'm gonna throw up,

[Dr. Michelle Pearlman]

but I imagine you probably eat something to fuel within a certain Period.

[Podcast Host]

Yeah, within the day. Not necessarily post training, but definitely within the day.

[Dr. Michelle Pearlman]

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

[Podcast Host]

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

[Dr. Michelle Pearlman]

Yeah.

[Podcast Host]

We've only, I would argue we've only seen that with one other group of medications. Hormones. That's it.

[Dr. Michelle Pearlman]

And I do both. And so it's very interesting, although I have people who, they're much more likely to open up about hormones. So I have, you know, a lot of patients who are on both HRT or menopausal hormone replacement therapy with GLP1s and they will tell their friends they're on hormones and they change their lives. And they won't necessarily disclose if they're on a GLP1. They don't need to disclose it. But oftentimes I will find that people are more likely to disclose their. On hormones rather than the GLP1s. I think it's still, you know, there's this thought that it's a failure on their part. And I see that in both men and women. It's, you know, it can be hard for them to talk about. Yeah.

[Podcast Host]

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

[Dr. Michelle Pearlman]

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

[Podcast Host]

So people need to understand the percentage of weight Loss that someone should expect.

[Dr. Michelle Pearlman]

Yeah. So depends on the medication. Right. So if it's something like liraglutide, which is Saxenda, that's about 5 to 6%. If we're talking about no one's eat,

[Podcast Host]

people don't use that anymore, do they?

[Dr. Michelle Pearlman]

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

[Podcast Host]

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

[Dr. Michelle Pearlman]

Yeah.

[Podcast Host]

Again, I'm sure that this is nothing against six Sena or whatever the company is. You know, I feel like it's almost obsolete.

[Dr. Michelle Pearlman]

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

[Podcast Host]

And what is the mechanism of action of Saxenda?

[Dr. Michelle Pearlman]

The same thing. Yeah. That's also a GLP one. Yep.

[Podcast Host]

Okay.

[Dr. Michelle Pearlman]

Yep.

[Podcast Host]

5% with Saxenda.

[Dr. Michelle Pearlman]

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

[Podcast Host]

I am.

[Dr. Michelle Pearlman]

We have metabolic adaptation, we have anabolic resistance, we have hormonal changes, we have higher risk of frailty and fractures. We get older. We have to take all these things into consideration. And so these virtual platforms, they don't care. They're just writing the script and saying, I'll follow up with you in six months. And so that's what we need to be careful about.

[Podcast Host]

Basically what you're saying is people are, they used to be overfed and undernourished, and now they are underfed. Arguably, if they're on these medications and undernourished. Yeah.

[Dr. Michelle Pearlman]

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

[Podcast Host]

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

[Dr. Michelle Pearlman]

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

[Podcast Host]

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

[Dr. Michelle Pearlman]

So. Yes. So the black box warning that's easiest to tackle first. It was actually only seen in rat models, so that it's not all thyroid cancer. It's medullary thyroid cancer, which is actually a rare type of cancer. So I have a patient who had a history of papillary thyroid cancer. And, and his thyroid oncologist said, no worries, he can still go on the medication because it's not medullary. So medullary thyroid cancer is a contraindication. And then the only other contraindication is a family or personal history of multiple endocrine neoplasia type 2. Most of my patients have never heard that term before. So those are the two reasons why we shouldn't prescribe the medication. Mainly because it's on the black box. But again, it was only seen in rat studies. But, but those, you know, otherwise it's fair game. Okay. Now one would also say, well, what if I already have a lot of gastrointestinal symptoms? Right. I'm a gastro. So a lot of people with gastro issues come and see me. A lot of people are worried.

[Podcast Host]

That'd be weird. They came to see you for knee pain? Yes.

[Dr. Michelle Pearlman]

Oh, I have plenty of patients that see me for knee pain. A lot of times it's weight related, so I help them target that. But, you know, a lot of people, like we mentioned, GI issues like acid reflux and dyspepsia are related to obesity. So they're concerned that if over 60% of people on a GLP1 will have a GI side effect, am I only making their problems worse? Potentially, yes. In the beginning. Right. As people are trying to understand how their body is going to react to the medication, acid reflux oftentimes gets worse before it will get better. But if we're getting rid of the ultimate trigger, which is the visceral fat Then as they lose weight and they lose interest around their midsection, the, their reflux will often get better.

[Podcast Host]

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

[Dr. Michelle Pearlman]

Yeah. So if they're already on, let's say an antacid, let's say they don't.

[Podcast Host]

They're not on one of these medications and their first symptom is reflux. Reflux. Or they're burping something up or you name it. But it's kind of that refluxy symptom.

[Dr. Michelle Pearlman]

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

[Podcast Host]

What do you mean?

[Dr. Michelle Pearlman]

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

[Podcast Host]

to IC so the symptom severity doesn't

[Dr. Michelle Pearlman]

correlate with more weight loss. So if someone has significant nausea, that doesn't necessarily mean they're going to lose more weight. Right. So we don't want people to be miserable. But again, my other goal is not to give one someone one medication and have to give them five others to treat all the side effects I'm causing. So we always want to go back to the drawing board and say, okay, are there triggers that have caused this? We have to go back to normal physiology. Right. If someone is eating too late and we know that this medication delays the rate at which the stomach empties if they're eating at 8 o' clock at night and it's a fatty meal. And we know out of all the macronutrients, fat has the biggest influence on delayed gastric emptying. The so if they're eating a 16 ounce steak at 8 o' clock at night, then they're lying down at 10 to watch Netflix. On or off the medication, they're probably going to have reflux. So if they have reflux with that off the medication, I tell them it's only going to get worse on the medication. Right. So we got to figure out how can we change that. I tend to tell people to front load their calories earlier in the day. Right. When you're more active, you're upright, you're moving around, your stomach is gonna empty faster than eating a heavier meal at night.

[Podcast Host]

Is that when you also recommend they take the injection?

[Dr. Michelle Pearlman]

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

[Podcast Host]

But no. Are there any natural supplements that use. And the reason I ask is because I swear when I was pregnant I had the world's worst reflux. It was terrible. I also had hyperemesis gravinol.

[Dr. Michelle Pearlman]

Oh, it was awful. Then you also can't take a lot of medications. Yeah. Yes.

[Podcast Host]

But one of the things that really helped me was dgl. It's you know, this licorice type extract. I don't know if there's things and also I don't know if there's evidence behind that.

[Dr. Michelle Pearlman]

Yeah.

[Podcast Host]

Are there any kind of natural type supplements or say aloe, something like that?

[Dr. Michelle Pearlman]

Some people will take aloe supplements. I'm a big fan of like Decaf tea. Ginger tea is like a smooth muscle relaxer. So I'm all for ginger tea. As far as supplements, I'll use like peppermint capsules. There's things like IV guard or FD guard that have like menthol and peppermint in them, but they're delayed release. So if someone's having intestinal spasms, that can help kind of with a smooth muscle relaxant effect in the gut. But if you have a bunch of mint, like mint and gum, that actually can worsen reflux, mint can relax the lower esophageal sphincter. So it depends on what the symptom is. There are natural remedies, but a big part of it is if you're eating pizza at 10 o' clock at night, good for you. Probably not going to feel well on this medication. So the lifestyle, again, the foundation we cannot skip. If you want to lose weight, maintain your weight loss and more importantly, focus, feel well doing so. The nutritional changes are absolutely essential.

[Podcast Host]

What about constipation?

[Dr. Michelle Pearlman]

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

[Podcast Host]

Hopefully it's changing.

[Dr. Michelle Pearlman]

Hopefully.

[Podcast Host]

Hopefully it's changing soon. Thank you to Timeline for sponsoring this episode. Time isn't just about how long you live. It is about the quality of those years. It's having the energy you need to move through your day without fatigue, the strength to pick up your kids, your grandkids, who knows, someone else is as kids, and the clarity to show up as your best self. Now that kind of strength does go deeper than muscle. It starts with your mitochondria, the energy producing engines inside your cells. We've learned about mitochondria, I don't know, in our fifth grade science class. And here's the reality. As we age, those mitochondria decline. In fact, it's one of the key hallmarks of aging, and it directly impacts strength, recovery, and overall how we feel. One of the ways your body protects itself is through mitophagy, which helps clear out damaged mitochondria and replace them with healthier ones. And you're thinking, okay, so why is she talking about this? Well, I use Timeline, powered by Mitopure, because it contains urethin A, which is a molecule backed by over 18 years of research and multiple human trials. It works at the the cellular level to support mitochondrial renewal. It's not a quick fix or a stimulant. It does support your body from the inside out over time. And if you've been considering trying, it is a great time. Timeline has just lowered their price, and you can get an additional 20% off your first month when you go to timeline.com lion and use the code Lion. Lower price, same science, bigger biceps. Hey, living longer doesn't mean living less vital. Are you concerned about. So for constipation, for example, in our clinic, we might give people a regiment of Senokot and Miralax if we start them on a GLP1. Do you have protocols like that to help with constipation when it happens?

[Dr. Michelle Pearlman]

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

[Podcast Host]

Specifically for constipation.

[Dr. Michelle Pearlman]

Yes, absolutely.

[Podcast Host]

We had Dr. Sue McDonald on the podcast which she was on. Dr. Amy Perlman, you might know her name, sounds familiar. Larry Lipschultz. They did a. An episode, I believe. Both Larry and Dr. Amy did an episode. Dr. Sue McDonald. If you guys did not hear that episode yet, please listen. She covers pelvic floor dysfunction in women, of course, but in men.

[Dr. Michelle Pearlman]

Yeah, yeah. Which we often like. I was told in gastro that it's typically women who have had forcep vaginal deliveries that get pelvic floor dysfunction. Those are not the only people that struggle with that. A lot of people do. So anyone with constipation or this feeling of incomplete evacuation, that can definitely be a problem. And, and starting a GLP1 medication can oftentimes just exacerbate the problem. So we want to make sure we are tackling it from all different points of view. But yes, Amagatite is definitely more likely to cause constipation than newer medications like Tirzepatide. So there are many medications on the market, there are many different pen delivery systems and there are injections and there are pills. So I want to kind of simplify it for the viewers because even in someone who practices in this space, it can be quite confusing. And I'll tell you this, it's only

[Podcast Host]

getting more confusing because we're going to have different generations.

[Dr. Michelle Pearlman]

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

[Podcast Host]

And when you say multi dose, so

[Dr. Michelle Pearlman]

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

[Podcast Host]

And what is the starting dose?

[Dr. Michelle Pearlman]

So the starting dose is always 0.25 milligrams per week of somaglutide. Now, this is the same medication as Wegovy. Why would I choose this one instead of this one?

[Podcast Host]

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

[Dr. Michelle Pearlman]

Yes. So these are the exact same medication. They are both by novo. They're both semaglutide. This one is just a different pen delivery system. This one, you can adjust the dose. This one is a single dose.

[Podcast Host]

Auto injector is the first one is the omic pen on auto injector.

[Dr. Michelle Pearlman]

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

[Podcast Host]

And these medications can be also used off label.

[Dr. Michelle Pearlman]

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

[Podcast Host]

And we'd be really old by that.

[Dr. Michelle Pearlman]

We would be really old. So initially developed for diabetes, then weight management. Now, next kid on the block is Zepbound, which is tirzepatide. And then you have the same delivery system, Manjaro. So those. There's no delivery system changes. It's just this single dose pen here. So this is Zepbound. So now zepbound is actually FDA approved for moderate to severe sleep apnea. So that's the added indication here. And wegovy is now approved for F2, F3, fatty liver. So F2, F3 means the degree of fibrosis. So more indications are expanding. They are doing active clinical trials in Alzheimer's, alcohol, pcos. Near and dear to my heart is inflammatory bowel disease. So as a gastroenterologist, it used to be when these medications first came out, I wouldn't touch a patient with Crohn's or ulcerative colitis with a 10 foot pole with these medications. Now we're actually doing clinical trials in IBD patients because of the anti inflammatory effects. So that's where you have this pleiotropic effect with these, with these medications way beyond weight management and insulin control. Now we're looking at the anti inflammatory effects and there's clinical trials and autoimmune conditions.

[Podcast Host]

What is the dose? Is the dosing different?

[Dr. Michelle Pearlman]

So the dosing for Zeppelin and Manjoro are the exact same.

[Podcast Host]

The dosing for anti inflammatory effects.

[Dr. Michelle Pearlman]

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

[Podcast Host]

and weight management because the mechanism is in part weight loss.

[Dr. Michelle Pearlman]

Exactly, yeah. And the insulin pathway versus the anti inflammatory pathway.

[Podcast Host]

It's so fascinating. Do you think it's too good to be true?

[Dr. Michelle Pearlman]

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

[Podcast Host]

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

[Dr. Michelle Pearlman]

Well, we're also using it in Post bariatric patients, because these tools, these medications, bariatric surgery, they're not cures for obesity. They are treatments. And what we even see in the bariatric population is weight regain, let's say five years later. So a lot of those patients are actually going back to their bariatric surgeons and they may get a revision surgery, but many of them are actually going on GLP1s to help combat some of the weight regain that we see.

[Podcast Host]

You also had the pill form. Oh, yes. Show me the pill form.

[Dr. Michelle Pearlman]

Oh, here we go. Okay, so Novo just came out with the pill form. So the pill form has actually been out for a couple years now. That was named Rybelsis, but that was FDA approved for diabetes, and they were at lower doses. They are daily pills. The past couple of months.

[Podcast Host]

Once a day.

[Dr. Michelle Pearlman]

Once a day? Yeah, the past couple of months. A couple months ago, Novo came out with Wegovy, which is the pill version. Now, the pill version of Rybelsis, the highest dose of that didn't get you anywhere close when it came to the weight loss that the injections of Ozempic did. And so you, you didn't get the degree of weight loss that you got with the injection. So if people needed to lose more weight, we would typically put them on injections instead of the pill, but they've actually changed the delivery device or the vehicle so that our body doesn't break down this medication. So now we're seeing that the Wegovy pills are equally as effective as the injections available now, you may say, or a lot of people would think that, oh, why would someone want to, you know, jab, Right, do the jab. I don't know if you've heard that phrase never. People are using it all the time now for these medications. Why would you do the jab if you could take a daily pill? Now, I'll tell you from experience, and I've talked to a lot of my patients. I've asked them, do you want to change to the pill or do you want to stay with the injection? And oddly enough, I don't have a single patient that said they wanted to change to a pill because they're used to the injection. It's once a week. Or I now have some patients who are in their maintenance phase who are injecting every time two weeks, and they're like, honestly, it's a one and done thing. I'd rather not have to take a daily pill. People also need to realize that they're not really that easy to take this medication. In particular, it has to be on an empty stomach. You can't take it with other pills. You can only take it with 4 ounces of water. Then you have to eat 30 minutes later. If you're kind of someone who's traveling kind of on the go and things like that, it can realistically be a little bit of a challenge to take.

[Podcast Host]

What about drug. Drug interactions with these medications?

[Dr. Michelle Pearlman]

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

[Podcast Host]

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

[Dr. Michelle Pearlman]

Yeah. So birth control is one that we have to be careful with because it can definitely affect the efficacy. Where. I don't know if you've heard of, like, Ozempic babies, right, Where.

[Podcast Host]

Because I have, but I actually thought it was beautiful because of increased fertility due to.

[Dr. Michelle Pearlman]

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

[Podcast Host]

Even though these medications have been around for 20 years.

[Dr. Michelle Pearlman]

Yeah, but as, you know, research in women, we're just too complicated.

[Podcast Host]

I mean, my husband says that, but I don't know.

[Dr. Michelle Pearlman]

So it makes sense that we should do clinical trials. But I think, you know, it's really hard to do clinical trials and in, you know, well, in women it's just. It's not that it's hard, it's just not done that often. But yeah, we just don't have the data. We don't know.

[Podcast Host]

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

[Dr. Michelle Pearlman]

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

[Podcast Host]

How do you end up recommending people do that?

[Dr. Michelle Pearlman]

I actually aim on the higher end of protein recommendations. So I really tell people, people, well, my ultimate goal is like 1 gram of protein per pound of ideal body weight. But if I'm starting someone on a GLP1, that's like, that's not going to be hap. That's not going to be happening. It's not realistic. So I'll tell people in general to try to hit at least, you know, 100 to 120 grams of protein per day to start. And I knew you, you know, tell people at least 100 grams a day. So I have to be realistic. If I tell someone 200 grams, they're going to say, you are crazy. That's never going to happen. I have to meet the patient where they're at. And it also depends on how much protein they're getting at baseline. If they're used to getting 30 and I start them on a GLP1, I cannot realistically recommend, oh, hit 150, you know, by tomorrow. That's ridiculous. So if someone's hitting 40, I say, please track your protein. Let's try to get you to 80 and then next month let's try to get you to 100. It has to be a step rise approach.

[Podcast Host]

Thank you to one of the new sponsors of the show. If you are someone who is intentional about what you put in your body and how you use it. This is something I've been experimenting with in a very specific and particular way. It's called Lucy and I use the 2 milligram nicotine gum. For me it's not something I use passively like I'm chewing bubble gum. I use it as a tool at specific times when I want to stay focused and locked in. The science here is actually quite compelling. Nicotine mimics acetylcholine and that's a primary neurotransmitter involved in learning and focus. There's data that can support that. It improves visual attention, working memory, motor processing speed, all of these things that I need. When I have long writing sessions, travel days, high stakes projects, I need sustained attention. What I love is that Lucy is a tobacco free product. It's clear in its dosing, you're isolating the compounds to leverage its potentially neuroprotective effects and neurotropic potential without all the junk. I recognize that this may have caught some of you by surprise. Why is she using nicotine? Was she a smoker?

[Dr. Michelle Pearlman]

No.

[Podcast Host]

But I will say that for me, I, I wanted to look for something other than caffeine to help my memory, to help my focus. There is really good data about nicotine and brain function. They also have a nicotine pouch called breakers which have a small tiny capsule that you pop for an extra release of flavor. But for me, I keep coming back to the gum. You might see me chewing gum all the time. It's simple, predictable, I love it. And if you are going to use using nicotine, the key to using it is with intention. If you want to try for yourself, go to Lucy Co and use the promo code DRLION for 20% off your first order. Also, Lucy has a 30 day return policy. That's LUCY CO. And the code for 20% off is Dr. Wyan. Lucy products are only for adults of legal age and every order is age verified. Now the warning is this product contains nicotine and nicotine is an addictive chemical for hair loss. In our clinic we typically look at ferritin stores, iron stores, we look at copper. Are there certain markers that you look at in the blood when just as it relates to hair loss.

[Dr. Michelle Pearlman]

So I do a whole gamut of labs to get their nutritional status and what a lot of people don't realize is just because someone is overweight. A lot of overweight or obese individuals are malnourished. So we should be checking baseline labs. Baseline labs. I would check not having to do with hair, but it's an advanced lipid panel. It's their insulin level, their complete metabolic panel, their blood count. But I also check their B12, their vitamin D and then depending, you know, their iron labs. I have a lot of people who have normal hemoglobins but are very iron deficient and a lot of people are missing that. So I want to check. Yes, their baseline nutritional status.

[Podcast Host]

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

[Dr. Michelle Pearlman]

Yeah, I haven't either. And I, and I do trend these things, you know, I wouldn't do it every month. It really depends on the person. I'm all for supplements. I'm all for food is first. But supplements can be very helpful, especially when it comes to B12, iron, vitamin D, those key players. I'm a big proponent of creatine. People are plus or minus on collagen. I've had a lot of patients that report better skin, hair, nails on collagen. So I'm all for it. There's little, very little harm. But I think we also have to be careful with a lot of the other supplements out there. I've had liver enzyme abnormalities with things like neutral. So it does depend on the quality of the supplement. I'm not one for giving someone a supplement that has everything in the kitchen sink. Right. I'm all for, okay, your B12 is low. Let's optimize your B12. Your iron's low, let's optimize your B12. Because a lot of these all in one type supplements, they are containing so many things in there that actually interfere with the absorption of another, like multivitamins. If we know that calcium interferes with iron, why would I give you a supplement that has calcium and iron?

[Podcast Host]

Because you want to cause constipation. Obviously the metformin Craze. There was a whole metformin craze. We actually had Dr. Eisenberg on the show. He's a urologist, and he was. Was talking about how metformin can potentially affect birth defects. The reason I bring this up is because metformin, again, used ubiquitously, affected B vitamin metabolism, B12. Makes sense. Do you think that there is something like that with GLP1s?

[Dr. Michelle Pearlman]

Well, a lot of my patients are already starting with low B12, and so I obviously want to optimize that. So I can't obviously blame the GLP one on that. A lot of my patients, because we're delaying gastric emptying and affecting digestion. Red meat is just less appetizing or it tends to really just stain their stomach like a brick. So they tend to be getting less B12 through their nutrition on the GLP1 medications. So oftentimes I will supplement those folks as well if they're having trouble taking in dietary vitamin B12 sources.

[Podcast Host]

That makes sense. And basically what I'm trying to get to the underbelly is, is there something potentially we're missing? Because again, these medications, are they too good to be true? I. I mean, I don't know. Look at hormones. One could also argue that hormones, estrogen, progesterone, testosterone are too good to be true. But our body makes them, and our body does make GLP1.

[Dr. Michelle Pearlman]

Yeah.

[Podcast Host]

The overdose situation with the new medications, the half life is long. Do we have a solution? If someone by accident takes the wrong dose, they take a much higher dose. Are they going to be stuck with nausea, vomiting? I mean, I can only imagine that would be terrible.

[Dr. Michelle Pearlman]

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

[Podcast Host]

It's maybe I have actually.

[Dr. Michelle Pearlman]

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

[Podcast Host]

Because the half life is a week with Sofron.

[Dr. Michelle Pearlman]

Oh, absolutely. Yeah. So it's all about supportive care, hydration is key. Right. So like they don't. People can survive without food for a week. We can't survive without fluid. So my go to is it's actually not slamming down a bunch of water, it's making sure we have oral rehydration solutions. So simple things like Pedialyte or I have, you know, recipes of homemade solutions. If people don't like Gatorade, Gatorade is fine, but it's not technically, technically a hydra, A hydration solution. There's not enough salt in there, so you have to actually add salt to maintain hydration. So it's. Maintaining hydration is the key and then using medications as supportive care to help prevent the vomiting, the diarrhea. So it can happen. I would say. Are we missing something? Are these too good to be true? As access improves, which is great, you still are going to have these weight loss companies that are just writing scripts for people. So we want to make sure we have an appropriate candidate. We want to make sure.

[Podcast Host]

How do we define appropriate candidate?

[Dr. Michelle Pearlman]

Well, someone who is ready to invest in their health and make the other foundational changes along with the medication. I want people to have realistic expectations that the goal is not just to lose 50 pounds, stop the medication, because what do we see in the data? We see the weight regain and people may gain with the weight gain, gain a little bit of muscle, but the majority is regaining a lot of that fat and then ends up causing this vicious cycle. So we have to really look at how do we optimize long term health outcomes, improve cardiometabolic health. So yes, improving access is important, but making sure the patient understands how do these medications work and how can I be successful long term is really important. Now the typical indications though were all weight related. I have plenty of people that come to me who have a normal BMI who I think are candidates for GLP1 medications. Maybe they're struggling with alcohol. I live in Miami. That's a big problem. Maybe they're perimenopausal and they have a normal bmi, but they've gained a bunch of fat around their midsection and they're struggling and now they're, you know, insulin resistant. I use those medications off label in those individuals. So that's where there's really the art to the medicine piece.

[Podcast Host]

Compounding pharmacies. We didn't mention that. As you're showing the pills and the injectables. We do use compounding pharmacies. I think that they're great as long as they're reputable.

[Dr. Michelle Pearlman]

Yeah.

[Podcast Host]

The other Thing that I wanted to ask you about was you talked about the foundational plan, fiber. I know that you have some show, more show and tell, which I appreciate them being empty fiber in the microbiome.

[Dr. Michelle Pearlman]

Yes. Fiber is so important. But what's interesting about kind of social media is you have people. Yeah, that or, you know, you have people who are pro and who are against, like people who are all about keto and plants are trying to kill us type of thing. There is overwhelming evidence to support the optimal effects of fiber on the gut microbiome. So we use a lot of different terms like prebiotic and probiotic, and it can get a little bit complicated. Complicated for people. So let me break it down. Prebiotic is dietary fiber. So nuts, seeds, whole grains, all of those things. When we eat dietary fiber, those molecules are broken down by the bacteria in our gut and then produce other molecules that have more downstream effects. Things like short chain fatty acids that then hit our colon and help optimize the health of our colonic cells. So, so that's one of the reasons why dietary fiber is really important. But also our bacteria in our gut really like the dietary fiber. So it helps promote a healthy gut microbiome. When we eat whole food, when we eat dietary fiber, our bacteria like it. And then we grow the good bacteria. When we have good bacteria, those bacteria take care of us. So when we eat ultra processed food, and you and I may define that a little bit differently, but I would define ultra processed. I mean, technically. Let me grab my little show and tell here. Technically, all these things are processed, right? They're in a bag. This did not.

[Podcast Host]

So she has for you that are not watching this, which you should, because her outfit is fabulous. We've got. What do we have?

[Dr. Michelle Pearlman]

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

[Podcast Host]

Wait, peanut butter powder?

[Dr. Michelle Pearlman]

Yes.

[Podcast Host]

Let me see that.

[Dr. Michelle Pearlman]

So it's literally just pulverized peanuts that is super easy that you can kind of mix in with like a Greek yogurt or cottage cheese. And it adds typically about 8 grams of protein. Or you could add it to a shake.

[Podcast Host]

But that's fake news, fake protein, because it's plant protein. So if it says 8 grams, it's probably closer to 4 maybe.

[Dr. Michelle Pearlman]

So that's my little peanut butter powder here. So, yeah. So fiber is very important. Protein's very important. These are all things that are travel friendly, except for at the airport. These are a little bit too big. Unfortunately, to get through.

[Podcast Host]

No wonder.

[Dr. Michelle Pearlman]

So, yes, these are technically all processed because they're not coming from that naturally, but they are healthier alternatives to most of the stuff you're going to find at the nearest 711 gas station or at the airport. And many of these also contain fiber. Now, these are not high protein sources. You're not going to get your protein requirement for the day, but they will give you at least some protein towards your daily goal.

[Podcast Host]

The fiber component, insoluble versus soluble fiber. You said 25 to 30 grams. Do you believe? Is that enough? Should it be higher?

[Dr. Michelle Pearlman]

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

[Podcast Host]

I know, I thought I was doing so great. I used to eat. Do you remember? They still have them. They're just these. They're fiber wafers. This was in college and I just thought, this is such a great idea. I can eat this. Have some peanut butter.

[Dr. Michelle Pearlman]

Yeah.

[Podcast Host]

But it really. I just felt terrible.

[Dr. Michelle Pearlman]

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

[Podcast Host]

The percentage of soluble versus it depends on the person.

[Dr. Michelle Pearlman]

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

[Podcast Host]

Whole food. Yes, whole food again, now we're talking about the food matrix would have an appropriate proportion of soluble versus insoluble. Yes, broccoli is insoluble fiber mostly. Lentils, nuts, is there. Should someone say if they have small intestinal bacteria, overgrowth, Are there certain fibers that people with gut dysbiosis should use versus other fibers?

[Dr. Michelle Pearlman]

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

[Podcast Host]

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

[Dr. Michelle Pearlman]

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

[Podcast Host]

And the way someone would get short chain fatty acids would be through just the consumption of fiber.

[Dr. Michelle Pearlman]

Exactly, Dietary fiber. And our microbiome takes care of it for us. That's a beautiful thing about the human body.

[Podcast Host]

How do we define microbiome?

[Dr. Michelle Pearlman]

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

[Podcast Host]

I know you're big into muscle. We were going to do push ups and he's already trained the gut muscle excess. Yeah, we Talked about the GLP1s, which some of the weight that is lost is also muscle. The other part of the gut microbiome is what it produces. And like you said, short chain fatty acids. Do you think that there are specific foods that are helpful for the mitochondria, for the myocytes, beyond protein? And I am truly curious because I haven't really, other than neurolithin A, I haven't thought so much about the interplay between the postbiotic after we eat and what we make and its effect on muscle. And as someone who's very clearly, by the way, if you guys are not seeing this, she is jacked. Are there foods that you think, okay, this is my muscle plan for muscle sparing on a GLP1?

[Dr. Michelle Pearlman]

I don't think we know. You know, it's interesting when we look at the clinical trials, the Dietary guidelines are very general in the GLP1 study. So they're telling people to eat protein, you know, to eat anti inflammatory foods. But beyond that they're not giving specific dietary plans. So I couldn't tell you whether someone's eating more plant based versus animal based on a GLP one. That's not how they created the clinical trials. A lot of nutrition studies also, they're just really hard to interpret because they're relying on dietary recall.

[Podcast Host]

A lot of epidemiology.

[Dr. Michelle Pearlman]

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

[Podcast Host]

So no supplements that you think. Okay. Aside from creatine.

[Dr. Michelle Pearlman]

Creatine. Creatine for sure. Yeah.

[Podcast Host]

Nothing that is kind of you're interested in right now or on the top of your mind when it comes to mitochondrial health.

[Dr. Michelle Pearlman]

I don't think anything is going to replace the foundation, which is Whole Foods.

[Podcast Host]

I agree with that.

[Dr. Michelle Pearlman]

Fiber, protein. We got to just keep it simple and focus on those things.

[Podcast Host]

Thanks to one of the sponsors of the show, amp, because I can walk two doors down and get a great workout. And if you've ever walked into a workout and thought, am I lifting too heavy? Am I not lifting enough? Where is the weight? I can't find anything. And is this even working? You are not alone. Seriously. The uncertainty is one of the biggest reasons why people do not see results and they stop. Strength training is an essential daily routine and AMP was founded to introduce it into everyone's life, home and ambition. That's exactly why I've been using amplify. What makes it different is it removes the mental noise. AMP AI uses your resistance to adjust sets and reps in real time. So you are always training at the level that your body needs. No second guessing, no wasted time. And by the way, it has everything that you need. Your body responds to progressive stimulus and you need to do that correctly. You don't want just random workouts that you find out online or you find online. It mounts to your wall, takes up almost no space and gives me access to hundreds of movements from strength training to high intensity work. I am telling you, I love this technology. It is beautiful, it is on my wall and it is a system that meets me where I'm at, regardless of the day. If I need some recovery, it's there. If your goal is to build muscle, get stronger, no more guesswork and be consistent, go to AMP AI. Check it out. That's AMP AI training Should be effective and it doesn't have to be complicated hormones. How do you think about the interplay and I suppose not the direct interplay between the GLP1s, but ultimately people and patients, they want outcomes.

[Dr. Michelle Pearlman]

Yeah.

[Podcast Host]

They want to physically transform. You have been utilizing, studying and prescribing hormones for a long time.

[Dr. Michelle Pearlman]

Fair to say actually not that long. So you had initially asked me what is my kind of day to day look like or what sort of patients are seeing me. And the initial practice was set up for weight management. It actually wasn't until about a year and a half in where so my sister and I are in practice together. And what were we noticing? We were noticing that our most successful, happiest patient was our middle aged man who I was working on his nutrition, his exercise programming. He was on a GLP1 medication. My sister was managing his testosterone. This guy was hitting PRs and marathons. He had four, five pounds more muscle, now 40 pounds lighter. And we sat down and we said, if we can do this for women, I'm sorry, for men, why can't we do this for women? So we actually tried to find gynecologists and specialists in the Miami area to send our women patients to to optimize their hormones. And a couple things we found. One is the really good ones were already so busy they weren't accepting new patients. Or if they were accepting patients, my patients were going to have to wait three to six months to see them. The third was some of these providers were still not on the bandwagon of hormone replacement therapy to the point that they were telling my patients, my 45 year old patient, that I see you have osteopenia, but hormones have nothing to do with bone health. And I said, okay, it's one thing for a provider not to prescribe hrt, it's one thing to gaslight my patients patient and give them misinformation. So my sister and I said, okay, if we can't find the providers in the area to see our patients soon and optimize their hormones, we're going to take care of it ourselves. So we took a course with Dr. Rachel Rubin. She taught us everything we needed to know about hormones. She's absolutely amazing. Whenever I have a question about anything, I just use one text away. And then now those are my happiest and healthiest patients because we're not only helping them improve their cardiometabolic health, getting them and maintaining a healthier weight, we're treating their sleep disturbances, we're treating their hot flashes, their Night sweats, all these things that are incredibly important for optimal quality of life. But we found it serendipitously with our middle aged male patient who was killing it.

[Podcast Host]

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

[Dr. Michelle Pearlman]

It's interesting because, you know, as women reach middle age and that's, you know, mid to late 30s, right, and early 40s, we start to see body composition changes as, you know, where maybe the BMI or the weight is pretty similar or 5 pounds up. But people often, you know, my women come in and they say, I have a belly I've never had before, right. My body has changed, my skin has changed. This is just very different for me. And, but my lifestyle hasn't changed. Why is this happening to me now if I'm doing everything I did when I was 20 and 30, right. And I say the problem is your physiology is vastly different. Even though you didn't change, your body has changed underneath the hood. So that, you know, is a big thing. What do we see with hormone replacement therapy? Well, a lot of people would argue, well, if I gained weight during perimenopause, if you just give me back some of the hormones, won't I lose the weight? We just don't see it. HRT is not a weight loss strategy. Now if someone's gaining weight because they can't sleep and you fix their sleep, then maybe it will help in that regard. But in many of my patients, I may actually see a little bit of weight gain. Why? Because we're helping with bone and muscle, especially if they're on testosterone. They may actually gain a little bit of weight even though their body composition is changing. Their BMI or that number on the scale may not be going down. But what we're seeing actually more and more in retrospective studies, studies currently is the secret sauce is the combination of HRT and GLP1 therapy. And you had asked me earlier, what are we seeing with lean tissue or muscle changes? And I'll tell you, I can tell exactly the point that I start a patient on a GLP1 on hormone replacement therapy because their lean mass losses start to kind of go straight and then they start to gain muscle when I'm optimizing specifically my, my women on testimony, testosterone. So that's really cool to see when you're actually tracking the data that matters.

[Podcast Host]

Do you have a number in mind if someone is coming in? Because again, there is still surprisingly no aside from hyposexual Desire disorder. No other FDA approval. Dr. Amy Perlman is sitting in here for testosterone. Do you think about. Okay, so the patient comes in, they're on a GLP1. We know that they don't do anything magic for muscle loss. And I've just been reviewing some of the data. So I'm excited to hear kind of what you were seeing. When it comes to muscle health, from my perspective, it helps with improved muscle health, not decrease muscle health health. Because people will say individuals are losing more muscle mass. It's. Perhaps the rate of weight loss is accelerated with the GLP1s, but the quality of muscle seems to improve.

[Dr. Michelle Pearlman]

Yeah, absolutely. I mean, people will blame everything and anything on GLP1 therapy, but what do we actually see in the data? So when you compare diet and exercise, GLP1 therapy and bariatric surgery. Surgery, the absolute percentage of lean tissue loss is the same across all 25 to 40% of losses you're going to see across all three modalities. But people are losing more weight now on GLP1s than they've ever been able to lose before with diet and exercise. So of course the absolute number is going to be more than just diet and exercise. But like you mentioned, is muscle mass. Is that the holy grail? I would argue it's not, because I'm tracking that right. But if I have a patient that says, okay, I've lost 30 pounds, yes, I've lost five pounds of muscle, but I feel stronger now than I did when I started. How many clinics do you think are testing hand grip strength? 6 minute walk tests, a get up and go test. Because ultimately that's what matters is performance, is strength, not how much muscle mass you have, but the actual contractile forces you're able to, to, to, you know, have. Right. Frailty and fracture, what matters. That's my issue, actually, with DEXA scans. We're looking at bone mineralization. We're not looking at how strong are your bones in actuality. So I think that's where we're missing the boat when it comes to, you know, talking about frailty, fracture, muscle mass. Metabolic health is not just what are you made of, but you know, how strong is your muscle and how productive can you be to reduce your risk of frailty and fracture?

[Podcast Host]

You are highlighting the diagnostic gap that as healthcare providers, this should be standard. Someone goes to their provider and they get blood pressure checked, they get weight checked, but they don't get hand grip strength, which we know is one of the greatest indications of longevity.

[Dr. Michelle Pearlman]

And it literally takes 30 seconds or less even.

[Podcast Host]

It might even be. I don't want to say that it's more important than blood pressure, but the indications. When we think about strength and survivability, muscle is underutilized under diagnosed. It's not part of the normal conversation. Yeah, and I'm really glad to hear you say that.

[Dr. Michelle Pearlman]

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

[Podcast Host]

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

[Dr. Michelle Pearlman]

Yeah, so one thing is we can't, you know, we have to track in order to see someone's progression. So for instance, people who see me in clinic, I see them on a monthly basis and I use a medical grade bioimpedance scale called the saca and I'm tracking every month now, I will have patients who see me, let's say out of state. They'll send me their data from, let's say, a withing scale or the Hume scale. So I have, you know, the body fat and the muscle, the trends are important. The absolute numbers, not so much, but the trends are really important. So if someone's, let's say, on a GLP1 medication, even though I previously mentioned like that mass is not the end all, be all. It gives me data to say, okay, you lost two pounds of muscle this month. How much protein are you taking in? And I know you're telling me you're having chicken breast for lunch, but can you please weigh it out? I need to know if it's, if it's 2 ounces or 6, because there's a big difference there. So it gives me a platform to better inform myself and the patient to say, okay, are you getting enough protein? Before I even delve into the hormone piece, the exercise piece, as, you know, like, exercise is so incredibly important for longevity. If we could package that up in a pill, you and I would never have to work another day in our life. Right. Exercise is so important. But I have so many patients that, let's say, see trainers, or they're on this Orange theory bandwagon, or Barry's boot Camp, and they're doing endless kind of circuit training, moderate intensity, and they're not making gains. And so I will actually talk to a lot of trainers. I'll have a phone call. I'll have a zoom meeting.

[Podcast Host]

Oh, no.

[Dr. Michelle Pearlman]

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

[Podcast Host]

You know, we're doing cardio.

[Dr. Michelle Pearlman]

Exactly. Like, where do we. Where do we build muscle? Not in the gym. We build muscle outside of the gym. But, you know, with recovery and fuel. But you need to actually make sure you're resting in between sets. You're doing progressive overload. And my patients kind of just follow whatever the program is if they don't have the knowledge to start talking to their trainer about it. So I kind of fill that gap and have that conversation. And I've had patients that switch trainers, and all of a sudden they start gaining muscle. So that's really key when it comes to the hormones. It depends on what their symptoms are. Right. If they're having hot flashes and night sweats, we're going to start with the estradiol and then progesterone, if they still have a uterus, if, you know, a lot of my patients don't necessarily realize the importance of testosterone. They as, you know, we, as women have more testosterone than we do estrogen at all phases of our life. So they'll say, oh, I don't want to look like a bodybuilder. And I say, do you understand how

[Podcast Host]

hard

[Dr. Michelle Pearlman]

to look like a bodybuilder? Right. My goal is not to give you male doses of testosterone, but if someone is worried about bone health, if they're worried about muscle health, if they want to improve their cognition, their libido. Right. Testosterone can be very, very beneficial in that regard.

[Podcast Host]

But.

[Dr. Michelle Pearlman]

But we have to start terming Just like GLP1s are not just weight loss drugs. We have to stop calling hormone replacement therapy as. Or testosterone as just libido enhancers. They are brain hormones, they are heart hormones, they are muscle and bone hormones. So it depends on what the person's ultimate goals are. But I look under the hood and if they're eating the protein, they're doing the resistance training, but they're struggling with bone and muscle health. I will say I really think we should give testosterone a try.

[Podcast Host]

How do you think about dosing for testosterone?

[Dr. Michelle Pearlman]

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

[Podcast Host]

You are the first physician, I think, that we've had on that is maybe a year ago. I think Kaisertrex is a great. Yeah, great.

[Dr. Michelle Pearlman]

I'm on it myself.

[Podcast Host]

Okay.

[Dr. Michelle Pearlman]

Yeah.

[Podcast Host]

Talk to me about Kaiserrex, the oral testosterone.

[Dr. Michelle Pearlman]

So, you know, a lot of people are worried about taking oral hormones. And I get it, because same thing like oral estrogen, that can increase, even though it's a small increase, risk of clotting. And the old oral testosterone formulations caused liver issues. Now, the nice thing about Kaiser. Exactly. Yeah. So the nice thing about Kaisertrex is we absorb it through our small intestine. Right. Now, we do have to take it with fat in order to optimize absorption, but it's a very easy pillow to take. Now we don't have the, you know, the doses approved for women, so I will start at the lowest dose possible. And it is a little Bit higher than what we're going to get with the cream. But it. Yeah, it depends on the person and what sort of formulation they want or they're willing to take.

[Podcast Host]

I really think revolutionizing the ability to take hormones because a lot of guys, whether they are traveling or they don't like injections, really struggle. Also, women, from a perspective with testosterone and just any kind of hormone, people have kids, you know, it might be too much of a risk for transference.

[Dr. Michelle Pearlman]

Yeah, yeah.

[Podcast Host]

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

[Dr. Michelle Pearlman]

So the lowest dose is 100 milligrams.

[Podcast Host]

And that's once a day with food.

[Dr. Michelle Pearlman]

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

[Podcast Host]

And the women do a lot better on that.

[Dr. Michelle Pearlman]

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

[Podcast Host]

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

[Dr. Michelle Pearlman]

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

[Podcast Host]

Do you have an expectation of how much muscle you want them to gain? We're talking about just the perimenopausal. Woman where you're like, okay, we're on a GLP1. You've changed your body composition, you're going through recompense, you've lost 10 pounds of fat. I want to see you put on. Or do you have an expectation of the amount of muscle mass that you want them to gain?

[Dr. Michelle Pearlman]

I would say my goal for each and every one of my patients is when they hit their weight loss goal and they're in maintenance mode. That's when the actually, that's when the hard part begins, is gaining muscle, because the easier part is losing the weight. Weight. The hard part is regaining some of the lean tissue that was lost. I want each and every one of my patients to have more muscle than when they started. And that's doable. But it requires, obviously that daily, consistent effort. Protein, protein, protein. Not just exercising, but progressive overload, consistent resistance training. When we go on vacation, our muscles don't care. Our muscles, they're like dying. That's a really hard thing for people to realize is I have people, businessmen and women who travel for three months out of the year during the summer. I hear only poor people stay in Miami over the summer. My sister and I are always here over the summer in Miami. But people will travel for a couple of months and they may go on cruises or they're walking around in Europe and they literally stop resistance training for three months. And they assume they're going to be able to maintain all of their muscle mass. And that's just not the way the body works. So I want people to feel strong. You know, a lot of my patients, they have the financial means, they have a great family support, they retire, they want to travel the world and do whatever they want. I know you ask, you know, a lot of your guests on here, what does forever strong mean to them? And to me, it means being able to do whatever whenever you want, you know, and to have nothing hold you back. Whether that's mentally, physically, it doesn't matter. It is freedom. It is independence. And people work their butts off their whole life for what? They retire at 65 and then they can't travel because they're too frail. That is awful to me. One out of two postmenopausal women develop osteoporosis. That doesn't have to happen. Once they fall and fracture and they break a hip at the age of 70, their one year mortality is outrageously high. These things are preventable. If we talk to people in their 20s and 30s when they're still able to build bone and when Building muscle is easier. These are the times the conversations should start, not when we get their first DEXA scan at the age of 65. We have missed the boat in another realm when it comes to that. And I'm sure you saw that, you know, when you were doing geriatrics as well. Well, we are missing so many things that can be prevented.

[Podcast Host]

You mentioned something about the maintenance that you have patients that are on maintenance now. GLP1s. There is no guide. There just are no guidelines for a maintenance strategy. Take me through your maintenance strategy.

[Dr. Michelle Pearlman]

Yeah, so I always ask people how do they define success as far as their health and wellness? And oftentimes they'll tell me a number on the scale, like, oh, I want to hit 130. And the reality is there's nothing magical about 130. 130. They were happier because they were 22 years old, without a husband and without kids and had less responsibility. So I really want to figure out like what is really their ultimate goal. Right. But sometimes it is weight based. Once they get to their goal, then I tell them, okay, before we start tapering out or tapering off the GLP1 medication, the majority of my patients, honestly, they've done so well and they're thrilled and they're happy and healthy. They say, doc, if I need to continue this medication weekly for the rest of my life, I will absolutely do that to help prevent the yo yos of the weight up and down for the rest of my life. So for a lot of my patients, they're basically still on the weekly dosing for weight loss maintenance. But I do have some patients that say, okay, I don't want to inject myself every week. Can we try to at least space it out? So my weight man maintenance strategy for those folks is I start to space it out. Let's say they are initially doing weekly dosing. I'll say let's space it out to every 10 days or let's space it out to every 14 days. It's typically going to be the dose that they reach their goal on. So if they're on Zepbound 15 milligrams a week, I'll say, let's keep you on 15. Let's space it out to every two weeks because at least at higher doses, some of the medication is still in your body at that point. And then I'll tell them if, tell me when you start to feel more hunger and cravings. And they'll say, oh, you know, at day 14, I feel fine, so I'll keep them every two weeks on that. If they say, well, around day 10, I really start to struggle with portion control, then I'll say, okay, then why don't we do injections every 10 days? So it's a very dynamic thing. Just because someone reached their goal at one dose doesn't mean that's going to be the dose, the frequency, the regimen that they're going to be on for the next couple of years and beyond.

[Podcast Host]

Okay. And you found that that way of doing a dosing strategy is really successful.

[Dr. Michelle Pearlman]

Yeah, but it will vary because I have some people that, you know, they're in maintenance, they're on injections every two weeks, then the holidays come around and they're traveling and they're less consistent with their protein and they aren't working with their trainer, then we have to say, okay, you gained 10 pounds over the holidays, let's get you back to every week. So I think that can be frustrating for people because people really worry obviously about that weight regain. There's a lot of anxiety that's invoked with that. But the reality is our bodies were only, you know, for most of us, not you, but for most of us, we are getting older, that we have to work harder actually in the weight maintenance phase. Now when it comes to exercise Recommendations, we recommend 150 minutes of moderate exercise per week for weight loss, but for weight maintenance, it's 300 minutes a week. So we shouldn't actually get more lax in the maintenance phase. That's actually when we have to work harder to maintain pain, which people need to realize with or without GLP1 medications.

[Podcast Host]

The dosing is like you said, it's different for everybody. Do you ever find that if a patient is like, okay, I want to come off this because the two year recidivism rate is, I think 73% of people end up going off the medication. Is there a place where instead of say staying on the 15 milligrams, do you have them in essence microdose ever or it's not just a really great strategy for you?

[Dr. Michelle Pearlman]

Not necessarily microdose where people are injecting every day. But I have some people that are on the minimal doses, like 0.25mg of Ozempic once a week or once every two weeks. Typically though, those are going to be the patients that were always on low doses that they were able to minimize their, their dose to 0.25 weekly, lose 10, 20 pounds and then we just maintain them at that. Typically you're not going to go from someone on 2.4 milligrams of WeGovy to 0.25 in their maintenance.

[Podcast Host]

Yeah. I've also found that if a patient does really well, that people do well on various doses, which is why compounding is so great. And that to do a maintenance dose, they. You can't just go back down to this small microdose. I found that that is not very.

[Dr. Michelle Pearlman]

And it's not gender specific, and it's not age specific. And I have some people who are my larger patients who are men that you would think would need higher doses, and they are actually more sensitive to the medication than some of my more petite women. So you just cannot predict it in advance.

[Podcast Host]

It makes me. It begs the question, are there things that people can do? And I don't think we know this answer to make these medications more effective.

[Dr. Michelle Pearlman]

Well, I think it comes down to, well, how do we also harness our natural GLP1 in addition to the synthetic medication that we're giving ourselves? We know that fiber and protein are very satiating. So if we focus on those two things, then we're really throwing everything at those satiety hormones to help with hunger and reduce cravings.

[Podcast Host]

You feel very passionately about this.

[Dr. Michelle Pearlman]

Yes.

[Podcast Host]

Did something happen? Did you witness someone get sick?

[Dr. Michelle Pearlman]

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

[Podcast Host]

and what are you doing about it?

[Dr. Michelle Pearlman]

So I had to actually beg my gynecologist to start me on hormones. I said, listen, I've had the IUD for years. I have no clue what my ovulatory status is, but I want to start on estradiol. I need to throw everything in the kitchen sink at my bones because I'm 39 years old and she's like, okay, well, yeah, I guess we can do that. Okay. So we started, you know, on estradiol. And I said, and I would also like to be started on testosterone, because there is data to support that that will also help with bone density. And obviously it's a musculoskeletal unit. The stronger our muscles, the stronger our bones. And she said, well, that's just not part of the guidelines. I said, f the guidelines. So I got the testosterone elsewhere. But it's crazy that myself in healthcare, as what I would consider myself an expert in hormone replacement therapy and in bone and muscle health, that not even I could advocate for myself to get what I thought I needed because the guidelines didn't say it. And you and I know the guidelines are often 10, 20, 30 years behind what we're actually seeing in clinical practice.

[Podcast Host]

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

[Dr. Michelle Pearlman]

I think one of the biggest things is education, right? We have to educate ourselves. And this is where podcasts and platforms like yours are extremely helpful, right? Because you are educating the larger population on the metrics that matter. On muscle centric medicine, you always say muscle is the longevity organ. And. And I was never taught that in medical training or in fellowship or in the first four years of my career. I learned it because in my clinical practice, I was looking at the data and I was saying something doesn't make sense and things are not lining up. Right? And what are we missing? Why are all these women at the age of 40 coming in with osteopenia? Right? It's because no one had that foundational conversation when they were in their teens, right? These conversations weren't coming up in pediatrics, and they weren't coming up in their 20s or 30s. So we're picking it up and we're being more reactive than proactive. The nice thing is these things don't have to be super complicated or expensive, but it requires education through platforms like yours. It's talking about what are the metrics that matter. Muscle and bone, they are longevity organs. Right. We know that patients with osteoporosis have worsening brain function and cognitive abilities. So it's not just about having that six pack or being able to do a heavy bicep curl or 20 pushups. It literally affects our health span and lifespan. So I think it's reforming or rephrasing the conversation on what matters, not just getting people on an old school scale. Right. I don't care. When people say, what is my ideal body weight? I tell them I don't really know what that is. Right. But if you lose 10 pounds and it's 8 pounds of muscle, you nor I are going to be happy. £10 less. Right. So it really goes back to what are you made of and how are we going to improve your quality of life 6, 10, 20, 40 years from now? And a big part of that is the musculoskeletal system.

[Podcast Host]

Do you think we are going to get to a place where it's equal opportunity for muscle as an organ system? From the healthcare provider standpoint, I'm not

[Dr. Michelle Pearlman]

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

[Podcast Host]

The evolution has to come.

[Dr. Michelle Pearlman]

Yeah.

[Podcast Host]

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

[Dr. Michelle Pearlman]

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

[Podcast Host]

You make a really, you bring up a really important point with obesity, you don't necessarily have to work for that. Meaning in order to build strong muscles. There's only one way to get it. Anabolic agents, various other hormones, various other selective androgen receptor modulators are not going to take away the fact that work has to be done. And within that process of doing the work, the body systemically becomes healthier. That is a really good point. That it is medications, they have to be there. I mean, it would be the same as saying, well, you're gonna go lose weight and the way that you're gonna do it is through diet and exercise. And then people struggle, and then people struggle and it affects their confidence, affects all of these things. And then on the same hand, if we think about building muscle, the foundation is critical. You're not going to get away from doing the hard work.

[Dr. Michelle Pearlman]

Yeah. And no drug is going to change that.

[Podcast Host]

No drug is going to change that. If we can get people to do meaningful practices, meaningful ways to lean into the harder thing, and then they have access to other anabolic agents, just as they would have access to something to help them lose weight, this is what is going to have to happen. Otherwise, right before our eyes, as healthcare providers, as fellowship trained healthcare providers, we are watching the World Trade one epidemic for another.

[Dr. Michelle Pearlman]

Yeah, yeah. And it's a, it's a multi system approach. Right. We can't just do one without the other. It's kind of throwing everything at it. I think, you know, a big way that we can harness technology because a lot of providers right who don't have their own practice, they get 15 minutes. So how the hell am I going to have a nuanced conversation on what are you eating in a typical day? What are your portions look like, what does your budget look like? Your family unit? What are your baseline gastro symptoms? Okay, let me educate you all about nutrition. Now let's start a GLP1. How am I going to educate you on minimizing all these GI symptoms in a 15 minute visit? Right. That is very overwhelming. And then one of the reasons why I left my prior practice, that I would have patients say, I'll see you next month and I'd say I'll see you back in six because I didn't have the access. So where technology I think can be very helpful is integrating wearable data, right? The metrics that matter, whether that's at home, bioimpedance, testing heart rate, blood pressure, all of those different sensors, sleep. I use the OURA ring all the time. Looking at step count, how can we integrate that data into other platforms? So I'm actually, I'm also a tech entrepreneur. I'm building out a nutrition platform called Bite MD where it's actually going to harness all the things about GI health, nutritional intake and GLP1. So you're able to actually talk to an avatar. It's going to pick up what you're eating without you having to track, okay, I'm eating chicken. It's going to see you're eating chicken. It's going to see how fast you're eating the chicken. It's going to look at your emotional state while you're eating the chicken.

[Podcast Host]

Holy cow.

[Dr. Michelle Pearlman]

And then you're going to say, okay, I just did my Zepbound injection, 12.5 milligrams. I'm feeling kind of nauseous. It's going to start to pull up these patterns and it's going to say, okay, it looks like you're nauseated because you ate, you know, barbecue chicken at 8 o' clock at night, then you went to bed at 10. So how about the next time you do your injection, why don't we have a lighter dinner and eat it at 6 instead of 10? So I think it's using technology to fill in the gap of that nutritional coach where we know we're not going to find that in most healthcare systems.

[Podcast Host]

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

[Dr. Michelle Pearlman]

Thank you so much for having me.