Understanding Metabolic Health

Episode 12 - Understanding Metabolic Health

Dr. Eric Chehab: Welcome to IBJI OrthoInform, where we talk all things orthopedics, to help you move better, live better. I'm your host, Dr. Eric Chehab. With OrthoInform, our goal is to provide you with an in-depth resource about common orthopedic conditions that we evaluate every day. Today, it's my pleasure to welcome Dr. Inbar Kirson and Dr. Lynn Gettleman Chehab, who will be speaking about metabolic health and its effect on orthopedic conditions. As a brief introduction, Dr. Kirson grew up in Israel and Canada and attended Brandeis University in Boston, where she earned her degree in biology. She attended Rush Medical College here in Chicago.

And after graduating from medical school, Dr. Kirson began residency at Lutheran General Hospital in obstetrics and gynecology. By the time she completed her residency, she had received numerous awards for her compassion, excellence, and care and teamwork and caring for patients after residency. She entered private practice here in the Chicago area and developed a subspecialty interest in caring for patients with metabolic disorders.

She pursued advanced training and education and obesity medicine, and is among the first in the area to earn board certification from the American Board of Obesity. She has since mentored many other physicians who have since entered the field of metabolic health. She recently joined IBJI to spearhead our OrthoHealth program, a metabolic program to help patients move better and live better.

My other guest is my wife, Dr. Lynn Gettleman Chehab, who grew up in Evanston. Lynn earned her degree in psychology at the University of Michigan. She traveled abroad and attended the London School of Economics, where she earned her master’s in international history. Her calling, however, was medicine and soon enrolled at Stanford University School of Medicine.

After earning her MD, she began her residency in pediatrics at the University of California, San Francisco, and completed her pediatric residency at Mount Sinai, New York. She further training at Columbia University School of Medicine as a fellow in urban and community health, where she earned her master’s in public health and worked on several projects, promoting healthy eating in underserved areas.

Since arriving back in Chicago, Dr. Gettleman Chehab has worked in the school-based health clinic at our alma mater, Evanston Township High School, which is one of the very few school-based health centers to provide access for kids with significant obstacles to healthcare. She has worked with the departments of public health in Evanston and Skokie, leading the charge for residents to ‘rethink your drink’, a public health campaign to promote water consumption in place of sugar-sweetened beverages.

Dr. Gettleman Chehab is a born leader and a trained one, having completed the prestigious presidential leadership scholars program founded by the George W. Bush and William Jefferson Clinton foundations to develop today's and tomorrow's leaders. Dr. Gettleman Chehab was the inspiration behind IBJI’s OrthoHealth program, and with her and Dr. Kirson's expertise, patients will benefit from their collective knowledge, compassion and teamwork. Inbar and sweetheart, welcome to IBJI OrthoInform.

Dr. Inbar Kirson: Thank you.

Dr. Lynn Gettleman Chehab: Thank you. We’re excited to be here.

Dr. Eric Chehab: So when we talk about metabolic health, first and foremost, what is metabolism?

Dr. Inbar Kirson: So, metabolism is pretty much every chemical process in our body that keeps our body alive. So everything that our body does on a daily basis and metabolic health is really the absence of metabolic disease. Our metabolism is working at its best when we have normal blood sugar. We have a stable appetite and energy, and we feel at our best and we have minimal belly fat and we can move easily. And all those things kind of indicate that we have optimal metabolic health.

Dr. Eric Chehab: So that's a great way of introducing metabolism because I've always thought of it as the amount of energy where expending, but when you talk about it, in terms of every single chemical process in our body that really broadens the definition.

Dr. Lynn Gettleman Chehab: We tend to think of metabolism is what we eat and how we burned those calories.

And we've always thought of that energy-in, energy-out, like how much we eat and how much we exercise, sleep, emotion, mood. [It] goes way beyond just what we're eating and how we're exercising affects what our body does with energy. And I think that's really important and it affects whether we burn calories or whether we store calories.

And it's so much more complex than just eating, eating less and moving more.

Dr. Inbar Kirson: I totally agree. I think that one of the things people often forget is the energy-in, energy-out model came from determining calories in a food, and then how much we burn when we use our bodies. The problem is that the determination of calories in a food is done through a bomb calorimeter and a bomb calorimeter is basically a box that they put a food into and then do a process to determine how many calories.

The food burns in that box, but your body is not that box. And your body has lots of different chemicals and reactions that happen on a daily basis that interact with that box per se, or with that food and determine the outcome of that food in your body. So I often like to describe to patients that your body is like a symphony, multiple instruments.

Imagine then, you know, hundreds of instruments on a stage. And when we're looking when Lynn and I are examining patients and looking at their metabolism, we're looking for those few instruments that are out of tune. And we know that even though there isn't one that if we fix that a-ha moment happens where we suddenly correct your metabolism.

It's fixing all the ones that are out of tune. So even though the symphony might be functioning at, you know, okay to an untrained ear, when you have a trained ear like Lynn and I, that symphony, when we tune up all those different reactions in the body, suddenly the symphony sounds bolder and beautiful.

And your body's metabolism is working well. It's an analogy in the works, right.

Dr. Lynn Gettleman Chehab: But I also like what you mentioned about the calories-in, calories-out model. I always think of like burning the peanut in biology class. And like, we're obviously way more complex than just burning a food. Like you said, in an empty box.

Dr. Eric Chehab: Taking the symphony analogy, are there some instruments that can't be changed and some that can so much the F the symphony?

Dr. Inbar Kirson: I think it's like the basics that can't be changed. Right. So genetics can't be changed. Your environment can often not be changed. Um, some, uh, stress situations can't be changed. Like a lot of times. Assess a patient for their level of stress, because cortisol is our stress hormone, and that can impact your metabolism, but the source of stress can't be removed.

So all we can do is talk about to the patient about how to manage that stress. So we can't change the source, but we can help the patient manage the source and genetics. We can't really change genetics, but can we change our behavior, our lifestyle, our diet, so that we can minimize the impact of genetics. We can do that.

Dr. Lynn Gettleman Chehab: Yeah, absolutely. I mean, I've spent most of my time working with underserved populations and poverty's something we cannot change, and access to healthy foods is something that we cannot change. But as Inbar said, there are things that we can help people with, that they do have control over like their sleep. You can't change what your stresses are, but you certainly can change how you respond to those stress.

Dr. Eric Chehab: I've often heard you talk about the toxic environment that comes with poverty. Can you explain more about that?

Dr. Lynn Gettleman Chehab: The toxic environment would be, if you live in a lower income neighborhood, you often have very poor access to healthy foods. You don't have a grocery store in your neighborhood. And you're likely to come from a home where somebody might be working long hours. And I always give the example if you're a single [parent] and you're driving home from work and you're passing five different fast-food places where you could feed your whole family for $10 and give them a toy, and not feel guilty about leaving your child for that long, that's going to be your choice. And that's why it really drives me crazy when people look at the condition of obesity as a choice. I would say for 99.9% of people, it is not a choice. It's part of what the hand they've been dealt genetically.

It's part of the environment that they were born into, but it's not a choice. I have to pick their immediate needs first. And when you live in an environment, and what we call a ‘toxic environment’, where it's not safe to go out and exercise, and it's not easy to buy healthy foods and you don't have the time to prepare foods, I mean, that's a big thing about what we talk about. It's it takes a lot of time to eat healthy.

Dr. Inbar Kirson: I think the other thing that a lot of people forget is that if we look at the American society, one out of eight, or 12%, are metabolically healthy. Over 85% of our American population is metabolically unhealthy.

But the people that we determine that a society looks at as unhealthy are people who have obesity. And it's unfortunate that that is what has been, you know, linked together because obesity is not the only outcome of being unhealthy metabolically. And so, you know, when you're metabolically unhealthy, you're at increased risk for diabetes, heart disease, cancers, lots of other diseases.

And we have plenty of patients who come in who don't have obesity and are still metabolically unhealthy, and we can help those people as well.

Dr. Lynn Gettleman Chehab: Right. And what I like, I think the most about our program, is when we are addressing metabolic health and what we recommend to our patients are things we all should be doing, regardless of weight, so everybody can improve their metabolic health. Even if you already are starting at a good set point, but everything we recommend are things that we all should be doing. And that's what I love about our program. It doesn't single anyone out and make people blame themselves. What I love working with children is saying to them, ‘Okay. You're going to be the example in your family and everything that you're doing is going to make your parents healthier. Your brother healthier, your sister healthier.’ And a lot of times the child will say, ‘Well, they're not heavy.’ And I'm like, ‘It doesn't matter. Like it's all about what's going on inside your body and losing weight and burn.’

I always talk about is the side effect of our program, but it's really about reducing 80 million different diseases. And I don't even think I'm exaggerating when you're older or in the future and making yourself feel better immediately–

Dr. Inbar Kirson: Yeah, completely. I think that's true. Also when I see the parents, right? I mean, we say the same thing. ‘You're going to be great examples for your kids. You're setting the tone in the household.’ This isn't about, you know, providing a diet for you, relative to your family. It's about the entire family. And I think that's what is unique to our program at OrthoHealth, is that because Lynn and I have the expertise that we have, we can treat the whole family.

And that is a great way to impact the health of an entire generation of people.

Dr. Eric Chehab: So what happens when a patient is referred to the OrthoHealth program? What's a typical visit like?

Dr. Inbar Kirson: I think every patient has a different experience obviously, but I think the first person they will see is our health coach, Donna, who is wonderful and establishes a nice rapport with the patients. Usually she makes a phone call ahead of time also to just kind of make that first contact so that patients feel supported and they also feel like they know where they're going, which office they're going to, that they're not getting lost and things like that.

Because it can be confusing. And to know what phone call, you know, where to call us if they need anything before their appointment, patients will first see the doctor. So me or Lynn and we take a very detailed history. We do a physical exam. We assess their metabolic health. The history, the physical exam and through any blood work that they may have had, or blood work that we order.

And that gives us a bigger picture about where they are in their metabolic health journey. And then once we have all that information, we can start to design a plan that's specific to that person's body to improve their metabolic health. On that first visit, a lot of this plan is kind of laid out, but the patient will start their program with the dietician on that first visit.

And the dietician spends a good half hour really detailing out strategies for the patient, developing a meal plan, helping them find different meals. Like we have a lot of patients who pick up their lunch or do a lot of takeout. And so what are the choices that you can make at a Jimmy John's, at a Chipotle, at a Panera Bread, like the common places, Subway, that people visit and frequent and make those substitutions first before we start to move to more complicated pieces.

So we take them through this process one step at a time to make it reasonable and sustainable for them.

Dr. Lynn Gettleman Chehab: I think one thing that is really nice, both for adults and for children, is it's really patient driven. So the first thing I will say is, when I have a child come in, okay, I'm going to be the weird lady who asks you 80 million questions, and you're going to be like, why is this weird lady asking me 80 million questions?

Once we're done, I'm going to think of a few simple things that should be really easy for you to do that are going to have a huge impact on your health, but your job is to be brutally honest with me. And if you can't do that or don't want to work on that, now you have to tell me because there are so many things we can do and I can give an example.

A student I had who drank three Mountain Dews a day and I'm like, ‘Alright, dude, cut out the Mountain Dews.’ And he said, ‘I can't, that's the one thing I look forward to every single day.’ And I said, ‘Alright, could you pick one time during the day that you have that Mountain Dew?’ And this was a child who wasn't sleeping well, wasn't doing well in school, was really upset about his weight.

And I said, ‘Pick one time, cut out the other two and come back in a couple of weeks.’ And he felt better, was sleeping better because he probably wasn't getting all the caffeine and was really happy about his weight. And then he was motivated to do some other things that I had suggested in the beginning.

But the point is, if I would've just said, ‘No Mountain Dew, see you in three weeks,’ he would have just walked away and never came back. The point is that we meet the patient where they are, because there's so many different things you could do.

Dr. Eric Chehab: It almost sounds like the snowball. You do something small, roll it downhill, have some relatively attainable targets for patients to meet, pick up a little bit more momentum, all of that leading to success.

Dr. Inbar Kirson: Yeah, I think so. I think it also depends where the patient is with adult patients. Oftentimes they've been through so many other programs that they are looking for something comprehensive. They're looking [for], ‘Tell me exactly what I should eat right now.’ And so in those cases, we will give them as much information as we think they’re able to accept in that moment. But we also recognize the patients who can't do that and who need a little bit more of a gentle approach. And so everybody's a little different, it's very individualized.

Dr. Eric Chehab: Yeah. It's not just about diet. Obviously the program is not about that. Some of the other pillars, we talk about our sleep and sleep hygiene, stress management and then exercise, but not exercise to burn calories.

Exercise to activate those chemical processes to make you more efficient. So let's start with sleep. Obviously, you guys know the importance of sleep, but tell the listener. Some of the things about sleep that are really, I find amazing in terms of athletic performance in terms of academic performance and just in terms of overall wellbeing.

Dr. Inbar Kirson: Yeah, we know that if people don't sleep well, so let's start with the fact that when people sleep, that's time for the body to repair, right? It's time for the body to quiet down to repair itself. In many cases, prime, fat-burning hours. Because you're not eating. So your body has to live off of something.

So it's pulling from fat cells to kind of live off of that energy. So that's really valuable and that's part of the motivation to get people to sleep better. We know that sleep deprivation doesn't allow for good academic performance. We also know that sleep deprivation makes you a lot more jumpy with regards to your relationships.

And so that creates more stress. So there's a lot of spiral effect of sleep, but I try to explain to people that if you don't sleep well and you don't get a deep sleep, you keep your cortisol level high and cortisol is our stress hormone. And we have cortisol because cortisol allows for the mobilization of glucose, which is sugar, so that we can run from a lion.

So we have energy to run from a lion or to run from a fire or to chase after something. Well, the last couple of hundred years, we haven't had to run from a lion or chase after something. And what's evolved over time as we have this chronic level of high cortisol. And so if we don't allow that cortisol to drop overnight and give our body a break, we constantly maintain a high insulin and blood glucose level, and that doesn't allow for fat burning.

So there's so many aspects to sleep and we're not even mentioning the health aspects of sleep in terms of cardiovascular disease risk and things like that. So sleep is a big pillar in our practice and we do partner with the center for sleep medicine and engage people in referrals with them that allows them to get the comprehensive approach to sleep along with some behavioral changes that we implement.

Dr. Eric Chehab: And I imagine sleep is critical for the kid–

Dr. Lynn Gettleman Chehab: Yes, it's especially critical for mood regulation. We know that, um, I try to promote sleep with mentioning how it's really important for sports performance. So especially in a place like IBJI, we do have a lot of student athletes who come to see us in the OrthoHealth program.

I always say sleep is your secret weapon. So in addition to what Inbar was saying about lowering your cortisol, and it's your repair time, that's when your muscles repair, is during sleep. It's also when you have memory consolidation. So whatever you're doing, if you're doing basketball or football or any type of sport where you're learning plays or learning patterns, that's when that happens.

And I like to mention a lot, the Stanford sleep study, where with the Stanford men's basketball team, they increased their sleep from six hours to eight hours a night. And within six weeks their free-throws went up significantly. Their three point shots went up significantly. Almost more than I think, than what you could do with steroids in that time. And definitely more than what you could do with coaching in that time.

But I always say, it's your secret weapon. It's going to make you do better in everything, in sports, in school. And that's what I like about OrthoHealth. Like that's the immediate effect that you see with this program. Like even if you don't see a weight effect for a little while, like people come back a couple of weeks later and they feel better, adults and kids are a little bit different for impediments to sleep. For kids, it's mostly putting away the phone, put your phone out of your room. But it's amazing how even parents who know that it's very helpful for them to have a doctor say that, right?

Dr. Eric Chehab: Yeah, for sure. Even our children.

Dr. Lynn Gettleman Chehab: Even to our children, exactly.

Dr. Inbar Kirson: Don't even go with my children. I go to sleep before my children.

Dr. Eric Chehab: And then, um, stress. So stress is another component that we help patients manage. And you mentioned that some of these stresses just simply can't be removed. So what are some of the strategies in general for helping patients manage stress so that their symphony that their orchestra can perform.

Dr. Inbar Kirson: Yeah, I think there's a few things it's really finding the time in the day. Even if it's five or 10 minutes for yourself and doing something kind for yourself and something that brings you joy or something, you know, practicing gratitude. There's lots of different things that we have suggested. It really is individual to the patient, but simple things like taking a 10-minute walk outside, or oftentimes it's, you know, you're rushing home from work and you have to walk in the door and you've got a bunch of kids and you’ve got dinner to put on the table. And I tell people, pull into the driveway, take a walk around the block. Don't even go in the house yet. Don't even change your shoes. Don't do anything. Just go take a walk around the block. And that just gives you the five minutes to just decompress and make the transition from one stressful event to another.

I think the other thing that people don't realize is the connection between stress and sleep, that your stress goes up significantly in your ability to tolerate stress and the space that you have to, um, to absorb stress goes down, if you are not sleeping well. And so really targeting that sleep and stress together is really crucial.

Dr. Lynn Gettleman Chehab: Yeah, and I was going to say, it's interesting for a lot with adolescents and it's – stress for them is really interrupting negative thoughts. I just think with social media, and we've just heard all about Instagram and the negative impact on kids and stress it's unplugging a lot. Like that's a big thing that we suggest is to get off of screens and that stop.

Stress that happens around comparing yourself to other people. We also have Donna our secret weapon or health coach who is really good about just suggesting breathing exercises or just simple ways. Like how do you break those thoughts and how do you let go of those thoughts? And those little exercises can go a long way or what Inbar set, just having 15 minutes or not even few minutes where you just think of what your five things you're grateful for. But those are all things that really decrease stress.

Dr. Inbar Kirson: Yeah, and another one big one that happens for our, or that we suggest for our patients, is to keep a piece of paper by your bedside with a pen. And so as you're trying to fall asleep, if you're having trouble falling asleep and you're ruminating about all the things that happen during the day or all the things you have to do the next day or whatever you're stressing about.

Write it down. It's like dumping it out of your brain onto a piece of paper and your brain can say, oh, I let go of it. Now I can sleep. And it'll be there in the morning and I don't have to worry about it overnight. And it helps quite a bit. So people do that. And I think Donna, I mean, so the one thing about OrthoHealth is that patients will have a touch point every one to two weeks with someone from our team, whether it's.

Visiting us in the office, me and Lynn, or seeing the dietician by tele-health or in-person or with Donna touching base over the phone. So people feel really supported and we all communicate about what's happening with the patient. So when the patient comes in to see me or less, We know the conversations they've had with, um, Donna and with Lydia.

And we all communicate to make sure that the patient feels like we all know what's going on and can support them in what they need. Um, so the first thing I might say is how did you know, how did the wedding go or something? And I didn't even know there was a wedding, but Donna got that out of a patient.

And so we can really address all the things that are happening for a patient and help them. Right. But I just had that

Dr. Lynn Gettleman Chehab: example of, oh, I heard you have.

Dr. Inbar Kirson: That's great. And the patients love

Dr. Eric Chehab: it. So, and then just to move forward, the last pillar we have diets sleep and stress and then exercise. And it's funny. It was the exercise part that really, I think, as an orthopedic patient is what makes losing weight. So off-putting and nearly impossible. And part of the inspiration behind OrthoHealth was listening to one of Lynn's lectures talking about the principles of good sleep, good stress management, good diet quality, and reasonable exercise, not exercise to burn calories, but just simple movements. And I thought, ‘Boy, that would be music to the ears of an orthopedic patient because someone with a bad hip or a bad knee or bad back cannot exercise in this way that we have in our mind where we're trying to burn calories and sweating like crazy and going really hard.’

They simply can't tolerate it. So explain more about what the benefit of exercise is, and what's needed again to help tune this orchestra to help make the symphony sound good. Is it crazy exercise? What level of exercise do you think in general is required?

Dr. Lynn Gettleman Chehab: You hit on like the myth that you can exercise your way out of weight. And so people blame themselves when they can't exercise when they have an injury. And we usually add in exercise. Last that's the last thing that we, we add in an exercise is important, but the idea that you have to get up at four in the morning and be on your StairMaster for an hour is actually detrimental because people, I think in our culture of the 24-hour gym sacrifice, sleep and good eating for an exercise that exhausts them. And then they tend to actually not to move a lot during the rest of the day, but we start very slowly with exercise. We do think it's important to move. Moving is important for sleep. It's important for mood it's important for managing stress, but the idea that you have to go out and run a marathon to get those benefits is so not true.

And then we also look at, and I'm going to let Inbar elaborate on this, but muscle and muscle tissue and fat tissue are almost opposite. Like excess fat tissue is very, very inflammatory when building up muscles very anti-inflammatory. So we look more in ways to like, how do you maintain muscle build muscle mass, but in a way that's not going to hurt you.

And in a way, that's not going to be detrimental to everything else we're trying to help patients.

Dr. Inbar Kirson: Yeah, I agree completely. I think that, you know, I try to remind people that if you look at the physiology of someone who has obesity and has abnormally functioning fat cells, because that's, what's happening is that the fat cell is dysfunctional.

You can't access the energy inside that fat cell. So if you try to move and you try to exercise, you will be exhausted really, really quickly. And it's once we have unlocked. That fat cell and we've altered the metabolism, not even lost weight, just altered the metabolism and the way the body is functioning, that suddenly the body can access the energy inside that fat cell and patients come to us and say, okay, I've seen you three or four times now, and you've never mentioned exercise.

Why not? I feel the energy. I want to move. And I said, great, let's start moving. Oh. So I wait for them to come too, because 80% of what we're trying to achieve comes from their diet, their sleep, and the things that we've been talking about only 20% comes from exercise. And I don't like the word exercise because we really talk about.

Just moving all day long, simple things like taking a 10-minute walk after each meal really improves insulin sensitivity and allows your body to body's metabolism, to work at its best and simple things like taking, you know, going to the bathroom on the. Level than the one you're working on or, um, taking your dog for an extra block instead of, you know, one block or parking your car at the end of the lot, instead of right at the front entrance, those are things that we just, we want you moving rather than exercising.

And when you feel the energy to exercise, then it's all driven by the patient. What can you do? What are you capable of doing? I think the other thing that's unique to OrthoHealth is we have access to lots of resources at IBJI that allow for different levels of movement for patients, if they're looking for instruction.

So we have everything from physical therapy to, you know, health performance Institute that offers classes and transitioning in between physical therapy and exercise. So there's all these options that we can provide for the patient. Um, if they want to take advantage. Or we'll give them simply YouTube videos to try at home on their own.

Dr. Lynn Gettleman Chehab: You know, I was going to say for my patients, TikTok. Yes, exactly. But the other thing too, that's important, I think with exercise is that when you lose weight, your muscles become a lot more efficient and people are like, okay, you know, I'm still running the same amount I've hit this, hit this wall, but you actually like, an example would be if used to burn 200 calories on a run. Once you lose more than 10% of your body weight, you might only burn 180 calories on that run. And people don't realize the importance of adding in resistance training, deep muscle work. And I think that's where we're really lucky to have IBJI because I can refer someone.

To a physical therapist, who's going to show them how to exercise safely in that when, I mean, exercise, not aerobic exercise, but to do more resistance training. And a lot of people don't know how to do that, and they don't know how to do it safely. Especially if they have injuries. It's really, really important to have an expert guide you through that.

Dr. Eric Chehab: I, this may be overly simplistic, but I heard an explanation of the benefit of resistance. Is that it helps your muscles become more receptive to any of the nutrients that are circulating in your body. So if you have nutrients circulating in your body, your fat cells and your muscles are competing for those nutrients.

And if you can do resistance training, your muscles become more efficient at taking in those nutrients compared to your fat cells. Okay. It leads to the continued benefit of better metabolism, lower weight, um, more efficient muscle work. Now, is that just wrong?

Dr. Inbar Kirson: Right? I haven't heard that explanation before. It could be true, but I think I think of it more as when you have a more efficiently functioning. Or you have a larger volume of muscle. You have more ability to be sensitive to insulin and insulin is the delivery mechanism. Getting those nutrients into the cells.

Dr. Eric Chehab: I mentioned insulin many times and let's talk a little bit about that before we go into that.

The simplest explanation I've heard about insulin is a growth hormone. Yeah. It just doesn't make you grow tall. Right.

Dr. Inbar Kirson: Right. And makes you grow tall up to a certain point and then it makes you grow wide. Yeah. Right, right.

Dr. Lynn Gettleman Chehab: I've heard this from embark. You think of insulin is the gatekeeper to the fat cell and insulin likes to drive nutrients into the fat cell.

And it likes to block the gate of accessing getting those nutrients out of the fat cell. So if your insulin is high, it's really, really hard to access your own energy stores. That's what we're talking about. Good metabolism is using your own fat cells for energy. And so, so that's what you have to think of.

It, it is a growth hormone, but it's a storage hormone.

Dr. Inbar Kirson: Yeah, exactly. It's a storage hormone,

Dr. Eric Chehab: But then does insulin affect the muscles differently than the fat cells?

Dr. Inbar Kirson: So what happens over time that we think, and insulin resistance is what we're talking about here. And insulin resistance is actually something we don't fully understand.

Right? I mean, we're still discussing the details of insulin resistance, but in a very crude way, just kind of simplistic is that over time, if you have a lot of insulin in your bloodstream, bathing yourself, the muscles have receptors for insulin on the surface of the cell. Once the insulin receptor has been occupied by an insulin molecule, if you have an abundance of insulin in the bloodstream, it doesn't allow for the receptor to detach the insulin because there's just constantly insulin-bathing the muscle cell. And so it's constantly attached to the cell surface, the, um, fat cell, because it can grow, it can develop multiple additional receptors for insulin. So it never becomes what we call insulin-resistant. Whereas the muscle cell can become insulin resistant because there's a finite number of insulin attachments on the muscle cell.

And so once the insulin has saturated, the muscle cell, no new insulin can join on that muscle cell and allow nutrients to enter the muscle cell, but it can go to the fat cells. Yeah. They have an unlimited number of receptors.

Dr. Lynn Gettleman Chehab: I mean, if you think about how we're built, right? Like humans have been in existence for thousands and thousands of years, and we are built to defend ourselves against famine.

And only in the last hundred years, maybe in this country, maybe for a certain population, have we had feast and our bodies are just not equipped to handle it. So we have all these defense mechanisms to protect ourselves against famine and insulin is probably the best mechanism to do, to protect us against famine.

So that's the idea that it can there's no, as far as we know, there's no limit on how much it can drive nutrition into a fat cell.

Dr. Eric Chehab: So when we talk about insulin, when we talk about other factors of metabolism, sleep and stress and diet choices and exercise, we talk about food as medicine and how foods affect insulin.

Are there now medications that are available that can help change or modify the effect of insulin on muscle or fat cells or what are some of the medications that are coming around and how do they, what are their mechanisms?

Dr. Inbar Kirson: I think this is a really exciting time to be an obesity medicine specialist, because for the first time we actually have a pretty good list of tools that we can use with regards to medications to help patients.

And just recently, another medication was approved in July. We had a medication semaglutide, packaged as Wegovy. That was just approved and yes, we all don't like the name, but nonetheless, it is a very effective medication and studies have shown anywhere from a 12% to 18% weight reduction and the way it works is it just kind of levels out this.

So instead of having the rollercoaster of insulin in your body, it levels it out and keeps the level of insulin lower. So like we talked about, it allows the fat to escape the fat cell.

And Wegovy does three different things. It actually shuts down hunger at the level of the brain. It slows gastric emptying so that you feel fuller longer. And so you, you overall end up eating smaller portions, and it levels out that insulin. So metabolically, it changes, you know, physiology of our bodies. So this class of drugs is called GLP-1 receptor agonists, and we have four or five different GLP-1s that we can use. Now, we also have other anti-obesity medications, right?

We have appetite suppressants that just work at the level of the brain. We have some medication that actually, if you take, it makes pop and soda tastes nasty. And so it's a great way to help people who have addiction to pop and soda. And people are really amazed at how well that works.

Dr. Lynn Gettleman Chehab: Right. I think what's also interesting a lot about medication says that they're affecting the same pathways in your brain that affect other addiction.

Yeah. So an example would be Wellbutrin, which is an antidepressant, which is used for smoking cessation. That is one of the anti-obesity medicines. Naltrexone, which is what we use for opiate overdoses. That is also an anti-obesity medication. Anti-seizure drugs. Topamax is an anti-obesity medication.

So they all ignite the same pathways in your brain that ignite other addictions. And so there are different combinations of these medications, but as Inbar says, we have a whole arsenal of these more targeted therapies than I think a lot of people come into our office thinking of like the Dexatrim diet.

Dr. Inbar Kirson: That's actually a big one that people come in thinking about, ‘Oh, you're going to give me Fen-Phen’ (fenfluramine/phentermine) and I'm like, ‘No, I can't give you Fen-Phen. It doesn't exist anymore.’

Dr. Lynn Gettleman Chehab: Right. Right. So, so I think what's exciting is that these are newer targeted therapies that are really getting into the centers of your brain and centers in your body that metabolism affects what we want to eat when we want to eat it. Right. What we're going to do with it.

Dr. Eric Chehab: Obviously, the focus is not to be on medicines, but they can be pretty helpful to get things done.

Dr. Inbar Kirson: Yeah, absolutely. And I think that the other thing we need to kind of take a step back and realize is that obesity is a disease.

And so just like diabetes, just like high blood pressure, we would not deny people with diabetes or high blood pressure, medication gives them the advantage, the metabolic advantage to succeed in making lifestyle changes. I feel the same way. And I think Lynn does too about obesity medication. I don't hesitate to offer medication when appropriate to a patient.

I will respect that the patient doesn't want to, after a discussion about the pros and cons and what the risks are and whatnot, but to understand that medication is going to give you the metabolic advantage. And when you have that metabolic advantage, it's not that you can't succeed without it, but it certainly makes it a lot easier to succeed with it.

And in some cases you might not succeed without it. Right. Right.

Dr. Lynn Gettleman Chehab: But, but they all work better. Yes. Diet and lifestyle changes. Yeah. So diet and lifestyle changes are always the cornerstone of what we do, even in all the studies of these medications. They're much more successful when paired with a better quality diet.

Dr. Inbar Kirson: For sure. No question. Yeah. And I think it always has to be, because again, we maintain the motto that food is the best medicine we have. And so without the changes in diet and the other parameters that we're talking about, it can't be long-term sustainable change. So it's everything together that helps a patient achieve long-term sustainable change.

Dr. Eric Chehab: So finally, you know, when we started this program, the goal was to help patients lose weight as an orthopedist, because I wanted to offload patients’ joints. I want to offload their arthritic joint, their bad back. And you had mentioned something to me, Inbar, that was really an eye opener, which was patients will feel better without losing a single pound because of the anti-inflammatory effects of having a good metabolism, kind of blew my mind in a way, because I always thought of this as a mechanical problem.

Let's offload the knee. Let's offload the back. Let's offload the bad hip and. When you said that it totally made sense. Like we give anti-inflammatories all over the place. I remember medical school, a GI doctor, a gastrointestinal doctor’s writing down, ortho = NSAIDS (nonsteroidal anti-inflammatory drugs).’ And we give anti-inflammatories all the time, but people can have anti-inflammatories through their metabolism.

I think that's a wonderful thing. So can you dive a little bit more into that, um, effect of the program, the anti-inflammatory fact?

Dr. Lynn Gettleman Chehab: Well, I'd like to say, so I think we're really lucky because both of our dieticians are amazing and they promote an anti-inflammatory diet. So we know that certain foods like sugar–it depends–other foods probably depend on the person, not only lead to weight gain, but they cause a tremendous amount of inflammation. So reducing processed foods, reducing added sugars in itself goes a long way to reducing inflammation. Yeah. I agree. Completely and eating more plants. No, but really like eating more, you don't have to be in a plant-based diet, but we know that plants are anti-inflammatory.

Dr. Eric Chehab: Right. Eat like your grandmother told you, lots of vegetables and the dessert for last.

Dr. Inbar Kirson: And lots of protein. We need protein for those muscles. So inflammation is a big part of why people don't feel well. And why people ache and why people are ending up in an orthopedic surgeon's office to begin with.

And so it's really understanding the difference between fat mass disease and sick fat disease. So we have fat mass disease, which is the amount of weight you're carrying and the pressure and the, um, strain it puts on the joints. And then we also have the sick fat diseases. The fat cell, not behaving itself, not doing its job appropriately.

And as it grows, it releases a whole bunch of inflammatory chemicals into the bloodstream that actually lead to increased inflammation systemically in the body, but specifically in joints as well. Endless cases of people have come in, and within two weeks, will say, ‘I have more energy. My bones hurt last, my joints hurt less. I'm able to walk. I can stand up.’ Like lots of things. ‘I'm sleeping better. I feel better. I'm not fighting with my husband or with my wife or with my children.’ Like their, just their mood is different and they're super excited and super motivated to keep going because they feel that benefit already in their metabolic health.

And I think the other piece is patients are losing weight before their necessary, knee replacements, joint replacements, surgeries, and things like that. And we know that patients with a lower BMI who enter orthopedic surgery have better outcomes and better long-term success. So I think that's been a real reward working at OrthoHealth.

Dr. Eric Chehab: My guests today are Dr. Inbar Kirson and Dr. Lynn Gettleman Chehab of the OrthoHealth program here at IBJI. Lynn, Inbar, thank you so much for being here.

Dr. Inbar Kirson: Thank you.

Dr. Lynn Gettleman Chehab: Thank you for having us.