Weight Loss As Regenerative Medicine

Doctor Mok, I found it interesting that you talked about weight loss as being a regenerative tool. And with part of the peak performance programs that we have at Allure, there are more than one approach to weight loss. So can we talk about some of those, how we can approach it by more than one angle?

Sure. So when we're talking about weight loss, we're talking about doing a medical intervention for weight loss. Most important thing is the things you're doing yourself at home. And we're assuming that most, most people are seeing us already working on that and failed or working on that, not getting the results they wanted to. And with for about the last 10 years, every quarter, I would try to find some innovation that could get us closer to helping people lose weight, potentially curing obesity. And we were doing a bunch of different things over the years and all of a sudden a big drop, giant cannon dropped on this and made it really accelerated things. And that's what the discovery of these medications that we call GLP1 agonists, glucagon, like peptide 1 agonists, these medicines were originally developed for diabetes, which they worked very well for type 2 diabetes. And we noticed that people were getting like we, like me, like scientists were noticing that people were losing more weight than they would have expected with successful treatment of diabetes. And we also know other diabetes medications such metformin have a favorable effect on your weight. These SGLT drugs do as well. So multiple diabetes medicines help with weight, but this one did more remarkably so. So I did some weight only trials with people that were not diabetics. And again, somebody that's not a diabetic, these don't meet the threshold. So it's not like a switch turn diabetic, your glucose gets higher and higher and higher and higher. There's a definition or cutoff that we call diabetes could be measured by a glucose level glucose tolerance test or something called hemoglobin A1C or it's homa test. So there's a lot of ways we measure it. But the year before that you were not metabolically healthy and you weren't quite meeting the definition of diabetes, but you were harming your organs. So it's good to get on this sort of early. And that was a reason for, you know, making these medications available to people that were overweight or obese because even though they have diabetes, those that organ damage is still, still occurring because of the way more canc heart disease, more neurocognitive decline. Alzheimer's is commonly referred to as diabetes type 3 now, so we do semaglutide and then tirzepatide. So semaglutide is known as Ozempic Ogovy for the brand names. And then triazepatide is mangernal and Zeppelin. And semaglutide came out first. And one of the issues with it is very expensive. It's a shot you gotta give yourself every week. So some complexity to it. And we use the logic, what if you didn't need to take it all the time, could you cycle it? What happens, interestingly, is is the dose that you start at is 1/10 as high as the weight maintenance dose, and the weight loss dose is actually a lower dose than the maintenance dose. That's because our bodies get a tolerance to the drug. We also commonly call it tachyphylaxis in medicine. And when you get a tolerance to the drug, you got to use more and more of it to have the same effect. And then there's a ceiling of how much you can take. And that's. That's six semaglutide, that's 2.4, 2.5 milligrams. But the weight loss dose is 0.25 milligrams. So you start on this low dose every four weeks, you escalate until you get the final dose. The weight loss stops at that point. And you just maintain that's how the company set it up, is you would take this escalating dose, lose all the weight during that time. Once you get the highest dose, the weight loss slows down and then plateaus. Then they did a study showing if they take them off the weight loss drug and told them to resume their prior activities, which was avoidance of any dieting and avoidance of any exercise, they would gain the weight back up. Now, that seems absurd, but they took people that weren't dieting, exercising, and they said, okay, you're going to reduce your calorie intake by a certain amount of calories a day, something like three or 500. And you're going to walk 150 minutes a week or do some exercise 150 minutes a week. And when they stopped the study, they said, well, stop walking, stop the extra, stop the dieting, go back to your old stuff. And what we saw were the people that lost the most weight, they kept the weight off in general. And the people that lost very little weight got it all back. And what happened? Very likely, we don't know this scientifically, but likely the ones that lost a lot of weight, they were pretty strict about walking and exercising. And eating less. And when they were told to come off of it, they kept on walking, exercising and eating less. That's probably what happened. I don't have any evidence for that, but that seems to be the case looking at the data. The other thing is that if you're on year two, year three, year four, the weight loss is pretty much stopped. So we did an internal experiment with employees. We put people on a 13 week run in of Semaglutide. Why 13 weeks? That's how the medicine was supplied for us. And we saw people lost about 14% of their body weight in that 13 weeks. So that's considerable 1% per week. And the range of weight loss was varied based on how much they weighed. To begin with, it was mostly women, very fewer men in our company, mostly as women. And then we took them off of it and then we gave them metformin, which is a diabetes medicine that helps with weight and it also raises GLP1 levels. Interesting. Which is a target of the semaglutide. And then they were allowed to use semaglutide again as needed. Where we had a bottle of semaglutide in the office and they felt like they were kind of falling off the wagon. They can give themselves a shot or go through another four weeks and stop it again. That worked very successfully. At one year, everybody kept their weight off. Then we started doing a bigger group of people. We do a cycle of semaglutide, 13 to 16 weeks, depending on how it was supplied. An eight week holiday where they lost tolerance to the drug. They would lose the tolerance of the drug in eight weeks and then you start out at this lower weight loss dose all over again. The second time, the weight loss wasn't as dramatic as the first, third time, not as dramatic as the second. But we're still getting this stair, stepping downwards of the weight that we don't see with continuous use of the drug that you have become tolerant to. So that's my preferred method because it saves a lot of money, it saves a lot of shots, seems to work as good or better. And whenever we're looking at things in healthcare, the proper dose is the least, the lowest dose that's effective. So if I can use half the drug in a year and it works just as good, that's the proper drug and dosing to use. So we've switched from using it all the time to doing it in cycles. And during that eight weeks off, we put people on metformin. If they want to go on it, they can also Use berberine, which is chemically almost identical to metformin. That's considered a vitamin. And typically we're getting between 500 to 1,000 milligrams taken at night. And that helps them keep that weight off. It kind of suppress the appetite a little bit. And that combination has been really good. We've been doing that for two years and counting. It's been very successful. It's very exciting because now we have a way to reduce the cost. Now there was a period where we can get the drug manufactured by outsourced facilities that are kind of like a, kind of like a compounding method, but it was actually manufactured and there was a shortage of the drugs that was allowed for a while and that's pretty much been cut off. There's still some supplies left over, so we're still getting it. And I think after that's gone, we were using the commercial version or the compound, the true compounded version, which is made by a pharmacist individually for the patient. So it's still available in both forms. And that would change from time to time. So that's exciting. Another question was what's the difference between semaglutide and tirzepatide? So tirzepatide is another target called gip. And there's not great head to head comparisons. When they did the study for tirzepatide, the people did lose more weight, but they had different criteria for the study. So they're not head to head, but they're very close. And we've heard anecdotally that tirzepatide, relatively speaking, has lower side effects, potentially a little bit more effect. But the mainstay has still been semaglutide in our practice because it is a lot less expensive, more readily available, and for a while it was being manufactured in massive quantities, was really easy to get and it worked for most people. But people fail on that. We just put them on tirzepatide. And then now more and more people are interested in tirzepatide because the cost difference has become tighter. So it works a little bit better, costs a little bit more. Maybe it's worth using tirzepatide. But even with Tirzepatide, we're doing this stair stepping effect where we go on it and off of it to minimize drug, not just cost, but drug exposure and to get a better result by, by using this tolerance intolerance extinction process to get people through it. Now in our practice in Michigan, we have additional weight loss options. We've been doing for years. One is called Orbera Gastric balloon. It's basically like a balloon. It was almost invented like a breast implant. And we put it into the stomach with a scope through the mouth and we inflate it and we leave it in for six months. It's designed to last six months and people you typically lose about 20% of their body weight. So they actually, you know, you can argue it's more cost effective than semaglutide or tirzepatide but you got to get a procedure done although you're not getting cut. And that procedure has been very effective. We're doing a lot of those before semaglutide. Semaglutide did disrupt that market. We also have a gastric sleeve that's done endoscopically. So gastric sleeve is where you fold the stomach to make it smaller. And that gets done endoscopically or through the mouth. We put a scope down in the mouth. We deploy these specially FDA approved FDA cleared staples that pinch the stomach and make it smaller. People lose more weight with that than they do the balloon. And that is reversible but it's designed to be left in, you know, forever. It's a permanent surgery, but it is reversible. If there's problems in like a traditional gastric sleeve, the results are not as good as the open surgery but they're close. So that's a good alternative for somebody that made their insurance and pay for the open surgery, they don't want to have it. These are things that are not covered by insurance. The gastric sleeve and the gastric balloon. So those are options. And then also there's some weight loss devices that really were kind of hot before these GLP drugs but now are cool download because yes, you should do the GLP drugs first. Additional lifestyle changes and one's called the Emsculpt Neo. That's probably the most common one right now. The coolsculpting doesn't really change the weight at all, but it does shrink fat. Emsculpt doesn't necessarily change your weight at all unless you're doing some lifestyle changes with it. But it does shrink fat and tighten muscle. So a lot of people get their weight loss and they still got a little flap around their stomach and they want to tighten that up. And they'll do the M sculpt treatment which uses a heat to melt fat and electromagnetic energy to tighten up the muscle. It's very expensive machine we don't have in all the offices. And it's procedure takes about 30 minutes. One of my co workers says he thinks it's uncomfortable. I find it intense, but not painful at all. But it does feel weird. It feels intense. Muscle contractions, the heat doesn't really, you know, feel. I feel really, really kind of feels good. So those are the options we have. And again, the first thing is, you know, managing your lifestyle. When I see it with doing these six cycling semaglutide or tirzepatide is you have the opportunity to really change relationship with food because it does make you not crave stuff as much and not interested in crappy foods. So it has other beneficial effects as well. Appears to be beneficial for the brain, for the liver, the kidneys, for your mood. So the. These are pretty exciting. And I said they're here to stay. There'll be a lot more drugs coming out to replace them in the future that might even work better. But the obesity epidemic, we might be able to get, you know, kind of ahead of that because it really came on in the 80s. We didn't really have this issue prior to that time. And if you look at things that can extend your lifespan, you know, being fit is a big one. There's a lot of concerns regarding these GLP1 drugs and muscle loss. That's been very overplayed in the press. When you lose weight, you lose weight and you lose some bone density, muscle mass, because you don't need as much muscle bones to carry your body. But when we're looking at people who've lost weight with these drugs, the majority of the weight by far is the fat. And there's a typical amount of reduction in bone and muscle density as a result of being a lighter person. So it doesn't directly cause muscle atrophy or anything like that. Additionally, you can do things, preserve all of your muscle mass if you're starting to work out, which a lot of people do to preserve that. But then your weight will drop as much because you're not going to lose as much muscle and bone density, ideally just lose fat. There's not a drug that does that yet, but they lose principally fat. And if you lose weight through any methods, typically your bone density and your muscle density goes down, but doesn't go down as much as the fat loss.