The Science of Obesity— WHY– This was a talk that I gave at Scottsdale Weight Loss Center On Thursday, October 11th, 2018.
Obesity is a Chronic and Serious Disease that now affects 40% of our society.
Craig Primack MD
Scottsdale Weight Loss Center
480-366-4400
Craig Primack: First of all. Thank all of you for coming. A big thanks to, you guys all know, Ashton. Big thanks to Ashton. We couldn’t do this without her.
Ashton: Thank you.
Craig Primack: I give talks all around to doctors. I’ve been doing it for about, since about 2010 as part of a big society called The Obesity Medicine Association. We’re a group of about now we started about 1800. We’re about 2300 primary care people, specialists who treat weight around the country. I give all these talks and I said a couple months ago, “Why am I not doing any of that here?” And so here we are.
Craig Primack: I prepared a whole bunch of stuff, and we’ll just kind of see where it goes. I’m open to questions. I love when people stop and say, “Hey, what’s happening?” I like just to be more of a … Oh no, I know. I’ll go in and out of it.
Woman 1: Okay.
Craig Primack: Thank you.
Craig Primack: Exactly. But you know it’s just a big open discussion hopefully and when you come home or when you go home tonight, you’ll have learned something about what we think, or I think is the reason that we’re having this probably of weight in our society today. So, with that being said, just a few things we’re going to talk about. So the science behind the weight probably and what we now believe is that obesity, the disease is there. This is not a personal veiling although many of our unfortunate primary care colleagues say, “Diet harder. Exercise more.” And that has not worked. If it really worked in our society, none of us would be here today. It doesn’t work by itself. Maybe that’s the better way of saying it.
Craig Primack: Your body is working against you and we’re going to go into some of the science behind that. At least the theories of science behind that. I planned out another one coming up next month, and so I kind of said, “I want to turn some science part and then I want some kind of take home tool. Is there something I could take home from today and learn that I can implement tomorrow and the day after and the day after. So that’s some take home tools, overcoming willpower problems. Because if we use just willpower, we use it up. A lot of people call willpower the bank account, right? And when the bank account runs out so does the willpower.
Craig Primack: Next month is Wednesday. I had 5:30 there, but I realized Wednesday at 5:30, there’s actually already a class, so we’re going to go at 6:30. If you want to come for the 5:30 normal class, that would be wonderful also. For those of you who have never been to class, it happens here in this room. There’s usually the wall up. We’ve studied, interestingly enough Dr. Ziltzer and I, we’ve been very interested in why we put all these pieces together for so long, and we’ve studied people who come to class, and when there isn’t class and people don’t go class, what kind of weight loss do you see. We see 50% more weight loss when people attend classes, and that’s for a lot of reasons.
Craig Primack: There was an interesting study years ago that looked at, well, it’s really four groups. In one major group people went to class and the other major group they didn’t go to class. Inside each group half of them wanted to be there so half of them went to class, wanted to be there. Half of them didn’t want to be there. In the other group are the ones who didn’t go to class, half of them wanted to not go to class and half them actually wanted to go to class. Of the four groups who lost the most weight?
Woman 1: The ones who wanted to be there who actually did it. The ones that actually went and wanted to be there.
Craig Primack: So the ones who went to class and wanted to be there. Any other thoughts?
Woman 2: The ones who didn’t want to be there.
Craig Primack: It was actually the ones … Did we talk about that yesterday? Or today?
Woman 2: No, I just …
Craig Primack: It is actually the ones who went to class who did not want to be there. There’s a lot of theories. We don’t know for sure. It was a study done and they didn’t look at that. We think one of the reasons behind that is someone who’s comfortable going to class has been to a lot of classes, they’ve already learned those things and now they’re going to class. The person who’s never been to class, they have now more to potentially learn at that pace.
Craig Primack: Then overall if you want to put on a piece of paper or whatever, if you have questions, suggestions, anything for future nights, as I start to put these together. I’d like to do one this month. If you guys are interested I’d do another one next month. Nothing in December. We all have things going on. Another one in January and go from there. I have a lot of little talks I give. The next I think we’re going to talk about is medical therapy and all the different drugs we use and why we use them and so forth. So that kind of being our introduction, let’s get started.
Craig Primack: Do we have a weight problem? How much of a weight problem? That’s the question, right? It’s a lot. Three out of every four people in our country are overweight now. Three out of every four. Let’s look at that. So when did it start? That’s the interesting … the slides I’m going to show you, if you been to weight loss conferences like I’ve … they’ve been showing these slides for years, but I think they’re fascinating. So if we go back. This is a picture of … Oh, it’s missing the bottom. Well I’m going to have to talk you guys through it then. This is a map of the United States in 1985. The white we have no idea what was going on in those states. The light-
Man 1: We still don’t know what’s going on.
Craig Primack: We still don’t know what’s going on in those states.
Man 2: They look like red states!
Craig Primack: I don’t know why my Mac is cutting off, but there’s actually a top and a bottom to this. And so the light blue which is Illinois, you can see a couple over here. Is that a little better? Okay. And then the dark blue is between 10 and 14%. So 14% and down is the whole country in 1985. We’re going to jump ahead five years. This is 1990. We’re starting to fill in the ones that we didn’t know about we’re starting to fill in. They’re actually, if you look at light blue to dark blue, there’s now a lot more dark blue five years later. But still we didn’t have some data on the early ones, so maybe it’s still we can say some things. Let’s go five more years. So this is 1995. Every state in the country is either 10 to 14% of 15 to 19% in five years. It keeps going.
Craig Primack: 2000. We have a new category. We’ll call it light brown. Light brown is now over 20%. Five more years. What’s happening? Uh oh. Now we’re 2005. Oops, I think I skipped two. Nope, 2005. So now we have orange states, which are these in here. Orange states are between 25 and 29. But guess what. We now have dark, I think maroon states. The southeast. You know the kind of the heart of the problem with weight in our country. So these states are greater than 30%.
Craig Primack: Again we’ve gone from 1985 where we started to 2005 here. It gets worse. Even more of them fill in over 30%. There isn’t a state now less than 20%. If there was one that’s the leanest, if that’s the word we want to use, Colorado, actually. I have a friend there who says he’s proud of that piece. Yes.
Woman 3: Are these percentages you’re saying that percentage of … are these persons overweight or the percentage of all people?
Craig Primack: All people in the state, how many of them are overweight, or actually the true obesity so BMI of 30 or above.
Woman 3: So, more than 20% of all people in all states are obese.
Craig Primack: Correct. But we’re not done. 2015. So the colors changed a little bit. When we go through there’s a light green or there should be a light green, which is less than 20% and actually there are no less than 20% states. The next one is the next green, so think of Colorado and California and Utah and so forth. Those are 20 to 25%. We get to the yellow states. There’s a lot of them. Florida, Arizona being us down there, 25 to 30%. Again, we’re in 2015. So this is still three years ago. We get to the kind of orange middle of our country states. Those are 30 to 35%. So if there’s a 30 to 35, I’m going to give you more one. Now we have over 40. Actually, greater than 35%, our southeast.
Craig Primack: And then the latest state … or latest time we have data is last year, 2017. Well actually these now fall in here. So now even more states greater than 35. Ouch. We have a problem going on in our country and despite everyone trying, everyone in this room trying and most of the people I know trying to lose weight as a population, we’re not doing it.
Craig Primack: Here is a state by state numbers. I have Arizona. 29.5 last year percent of our state having obesity, BMI 30 or greater. The number one worst, heaviest state? You look vastly you’ll find it.
Man 2: Louisiana.
Woman 4: Oklahoma?
Craig Primack: Oh West Virginia. It’s actually right there. You can’t see it. Sorry.
Man 3: Thousand.
Ashton: You tricked us.
Craig Primack: West Virginia at 38.1% of West Virginia. No state in 2017 had a prevalence of obesity less than 20%. 20% and up. Two states, including DC and two others had between 20 and 25. The two others are Hawaii and Colorado, as I talked about. 19 states had between 25 and 30. 22 states between 30 and 35 and then those seven mostly southeastern states of 35% or greater.
Craig Primack: Why? Anybody have any thoughts?
Man 2: Conspiracy.
Craig Primack: Conspiracy. That has actually been come up many times in the last 30 or 40 years, conspiracy. What else?
Woman 5: Processed food.
Craig Primack: I’m sorry?
Woman 5: Processed food.
Craig Primack: Processed food. Good one. What else?
Man 4: Sedentary society.
Craig Primack: Sedentary society, absolutely.
Woman 6: Technology.
Craig Primack: Technology, yes.
Man 2: Blame it on the iPhones.
Craig Primack: iPhones. Steve Jobs is at fault? ?
Woman 7: Just trying to figure out what makes those certain states here. You know, the worst.
Craig Primack: Maybe it’s the fried fat food, fried food, high carb foods. Maybe it’s genetics.
Woman 7: I thought maybe it’s the cold states, but it’s not.
Craig Primack: It is not just the cold …
Woman 8: Maybe it’s also more working couples? And so less time to prepare foods and then to the fast food and eating out kind of thing more.
Craig Primack: Yes. What else?
Woman 9: So, since families like move all around the country, that if you don’t pass on skills so people don’t do things themselves, like fix their house or do their yard, they pay people to do it and stuff, so they don’t, they’re not active.
Craig Primack: Absolutely, and I’ll take it a step further, don’t even cook. You know? Cooking the way it happened, you know, 30 minutes. It’s a meal. What do we have a meal now in? Two minutes 30 seconds, microwave, beep… beep. Right? More often than not or drive-thru or pick it up and take it home. Any others?
Woman 10: Kids.
Craig Primack: Kids. Absolutely.
Woman 10: Busy lives.
Craig Primack: Busy lives. Soccer moms.
Woman 10: Eating off their plate. Yeah.
Man: High fructose corn syrup.
Craig Primack: High fructose corn syrup. I’ve heard that one a few times. Terry?
male: Marketing. Commercials.
Craig Primack: Commercials.
Woman 11: The portions at restaurants are ridiculously large wherever you go pretty much and like you literally have to walk in and cut a meal in quarters because that’s really the portion you should be eating at most restaurants.
Craig Primack: Cheesecake Factory. Even a salad at Cheesecake Factory (I believe) is like 1500 calories. It’s a salad.
Man 5: Alcohol.
Craig Primack: Alcohol. Absolutely. I’m going to tell you. Oh, go ahead. Go ahead.
Woman 11: The thing is if it was all sociological, we would all be overweight, but the fact is we’re not all overweight. There’s just a certain percentage of us that are, so why?
Craig Primack: That’s a good question.
Woman 11: Willpower.
Woman 12: I think the cost of food has something to do with it because you could go to anywhere and get the biggie meal for $5, right? But you can’t go and get a healthy meal for $5.
Craig Primack: Absolutely true.
Woman 13: Rich people are fat too.
Craig Primack: Yes, they are. So I’m going to tell you what I believe is actually that you’re all right. I think that this is a genetic problem at its heart and we’ll talk about that as the next couple of slides. In a society that promotes it and it’s been discussed that there’s probably about 20, what we’re going to call “major” genes in our genetics that get passed down from generation to generation. If you have one of those major genes, the likelihood of you being significantly overweight as an adult is high.
Craig Primack: Or if you have, there’s probably 200, and we’ll call them minor genes. Some people have eight of them. Some people have 10 of them. Some people have 15 of them, but they’re different, and that’s when someone says, “Too much carbs. Not enough exercise. Too much alcohol.” All those little things make all of us different. We carry weight on the outside but it’s the inside we don’t see. And that’s the part that makes all of us different and that’s why it’s all of those answers I believe are right.
Craig Primack: Who are these people?
Woman 14: Indians.
Craig Primack: Indians. Yes, Pima Indians. Pima Indians from the southwestern United States. Their ancestors actually came to this valley all the way south, 300 BC. What kind of Indians were they? What were their … what did they do. They were warriors, farmers, what kind of stuff? Farmers.
Woman 15: Farmers Pima.
Man 6: For the most part.
Craig Primack: Farmers. We live in the desert here. Who grows stuff in their backyard? And we have irrigation. Who grows stuff to eat in their backyard? Almost none of us. So if you’re living here with maybe horses, no machinery, nothing else and you’re a farmer. Do you eat a lot? You don’t. And you go from famine to famine to famine. So what does your body get really good at doing? Living from famine to famine to famine. And what does that mean? So if one person’s genetics, they wake up one day and their genes say if I eat this little bit of food I can put more weight on, and my neighbor who doesn’t, and the famine comes and I have more strength to reproduce and live and do all those other things, and they can’t, my genes go forward a generation. And so what does that end up today? What disease, number one, besides weight?
Man 7: Diabetes.
Craig Primack: Diabetes. It’s hard to see, but this is Pima Indians today. By the age of 35, 50% of Pima Indians have diabetes.
Male: Wow.
Craig Primack: 50%. I don’t know if I have it …. hold on. Oh actually here’s an old timeline, but I’m going to go back. If you look at their relatives who were split away around 1850s or so, stayed south of the border Mexico, still farmers. What is the incidence of diabetes? So these are their cousins, their relatives.
Male: A lot less.
Craig Primack: A lot less. About 6% versus you come to the United States, you do the, we’ll call it American things, food is part of it. All the other things, 50%. The national Mexican average when it said that the Pima Indians were 6%, national average was 2.5%, so they are still more than the population they’re living with, but not as much as their cousins that live across the border.
Woman 16: So are you saying their genetics are predisposed that when there is more food they’ll store more of it and store more fat?
Craig Primack: Absolutely. Absolutely. And I think all of us fall somewhere between that piece. Six million years ago our earliest ancestors. 200,000 years ago modern humans came around. 6,000 years ago civilization as we know it kind of came around. So we’re talking generation after generation of famine and so forth. The things start to change. So 1800, the start of industrialization. That’s kind of, we’ll start saying that’s where the tide starts to slowly turn. 1879, the first electric light bulb. So we couldn’t have had smart phones, we couldn’t have had TVs or anything for sure before 1879. So we’re not talking that many years ago. The really kind of biggest push that started, I think, what we have today is industrialized farming. You now have tractors that can till thousands of acres so we don’t have to farm it with animals any longer, and so we can do much, much more food and when there’s a lot of food, certain things become cheap.
Craig Primack: Carbohydrates become cheap. Corn becomes cheap. Things like that. And then we get into the 1970s which is really, for all of us, in really the start of all of this. This goes to what everyone else was talking about, where I think all those things are right. Two worker families is what that means. You know. There isn’t someone home who’s spending that 30 minutes plus cooking for the family, and then bringing everyone together and sitting down as a family and eating. When there was one car families, not two car families. One working adult versus two working adults. Microwave ovens. It’s been said that there’s something wrong with microwaves themselves hurting our food. My personal belief, and it’s only my personal belief, microwave ovens themselves don’t do anything to the food. The fact that you can be hungry and have a full meal in two and a half minutes, that is the problem.
Craig Primack: Because you never go through the hunger cycle. For those of you who have been to Lisa Galper’s classes, hunger comes in a wave. It starts, it gets higher, higher, higher. If you do nothing around 12 minutes later it actually starts to get better. That’s 12 minutes. If I’ve already eaten at two and a half minutes, or I’m in a restaurant fast food and I’ve eaten my whole meal in 20 minutes or less, I never had a chance to heaven start to get full. And we’ll talk about full and hunger, that’s actually the … kind of the meat, if that’s the right word of the talk tonight.
Craig Primack: And then the low fat movement in the 1970s where fat was bad. The government was wrong. There’s a couple books out by a gentleman called Gary Taubes. One of them is called, “Why We Get Fat”. It’s probably a nice overview. It took his bigger book called, Good Calories, Bad Calories, which is about a 400 or 500 page book and brought it down to about 150 readable pages. He basically traces through this and there was a bunch of studies, some of them … one of them said, “Low fat is good for us,” and the others were like, kind of undecided, but the government felt we had to do something because people were dying with heart disease.
Craig Primack: What they knew was cholesterol in our bloodstream was bad. So you measure cholesterol. If we have high cholesterol, that’s bad. But how it got into our bloodstream, that was the mistake. It is not fat. When we eat fat it does not cause fat. When we eat carbohydrates it more causes fat. We now know that eggs are back to being an amazing food, where in the 1960s that was your power breakfast. 70s, 80s, early 90s, one egg a week. That’s what we were limited to. We’re back to eggs again. Things have come full circle.
Craig Primack: Oh, this is good. So obviously we talked about fast food. My next slide is actually much better than this. It’s saying things have been changing. This, on the right side, 1960, 210 colors fries 85 calories and 125 calories or something 120. 2011, up 250, 500, 2011.
Male: Jeez.
Craig Primack: I’ll show you in just a second the difference. Without doing the math quickly. How many calories difference do you think are between the two?
Woman 17: Oh my gosh.
Male: 1,000.
Woman 17: 2,000
Male: That’s not.
Craig Primack: You can’t see it …
Man 2: First of all, everybody in this room knows you don’t buy a … you always buy the diet Coke, because if you eat the-
Craig Primack: You do always buy the-
Man 2: You drink the Diet Coke, you can have the bigger fries.
Craig Primack: So you are 100% right. Because everyone knows who knows me says you’re never going to have the regular Coke because you’re going to have the fries. So really what it is is, it’s about 400 … you can’t see it on the bottom. 415 calories on this side, 1400 calories on this side. 1,000 calories in one meal difference. And this is lunch. So you go home, and if your lunch is this size, and we’re Americans, our dinner’s almost always bigger than our lunch. So we’re having even more calories then. And who knows what we had for breakfast. It was a bagel, it was a donuts, it was a fast food thing. That’s not everybody here, but at the times we’ve probably all done it. But our society is still doing it. That’s where we see it all the time.
Craig Primack: It’s hard to see, but this starts the genetic side of the talk. This is a head. And there’s this little organ there, about the size of a blueberry. What’s it called?
Craig Primack: It’s right behind the pituitary. It’s called the hypothalamus. When something is in the middle of the skull it’s completely protected. The rest of the brain is around it so it preserves it through time. If you lose the hypothalamus you don’t live. If you lost a little piece of your brain on that side of the temporal on that side, you wouldn’t … may not be normal, but you may still live. This organ is the one that helps us through times of famine. Its job is energy regulation. What happens? When our energy levels go down, so, and we’re in famine, the hypothalamus says, “Slow metabolism down. Turn up the hunger.” Why do we turn up the hunger? So we go out and hunt. We look for food. But where do we look for food? Our pantries. Our grocery stores. It’s not a lot of work to look for food nowadays.
Craig Primack: There are sensors from the body that tell the brain what it’s doing. So hormones. What are hormones? Hormones are chemical signals secreted by one part of the body they go through the bloodstream, past the blood brain barrier, taken up by the hypothalamus. They’re either, for our intents and purposes, they’re either saying, “I’m full” or “I’m hungry.” I’m full. I’m hungry. All day long. You can think of. It is the control center. I looked for a picture. I didn’t find it. There was a movie, about two years ago of, it was about a little girl and she had these emotions in her, and there’s this little control center in her head.
Male: Inside out?
Woman 18: Inside out. Yeah.
Craig Primack: Inside out. Yeah. And so this is what makes me think of it. So your body wants energy and so these sensors throughout your GI tract send these signals to the brain, “Send me more energy,” or “I’m doing well. Don’t send me more energy.” Where do those signals come from?
Woman 19: Hypothalamus?
Craig Primack: So they’re going to the hypothalamus. Where do they come from? What parts of the body?
Woman 20: Stomach.
Craig Primack: Stomach. Absolutely. Intestines. Fat itself. 40 years ago we thought the fat itself was just a storage organ. You put calories in there. It sits around ’till we need it. It comes out of there like our gas tank. Our fat is an organ like skin and all our other organs and it’s constantly talking to the body. Sometimes it’s saying nice things and sometimes obviously as we know it’s not. There’s this disease. We’ve all, maybe we’ve all heard. If you have a heart problem sometimes they call it cardiomyopathy. So “opathy” being the sick heart. There’s something called nephropathy. So kidneys sick. So there’s a term called adiposopathy, sick fat.
Craig Primack: The analogy for that is if you see a balloon and you keep blowing that balloon up, so each fat cell being that balloon, and you keep blowing it up, right at … I feel that point where you’re blowing the balloon, you think it’s going to pop if I blow anymore in it-
Man 2: One thin mint.
Craig Primack: Yeah. The … it’s about to burst, it’s sending out inflammatory signals to the rest of the body. Some of those same inflammatory signals that we see in rheumatoid arthritis and a lot of other rheumatologic diseases, TNF alpha, interleukin and things like that. And that is … when all that’s going out, that causes our blood pressure, our cholesterol problems, our knee problems, even and a lot of the other things that we see with weight, which is also why just losing a small amount of weight starts to change those things so that just bringing down that fat cell from overstretched to down maybe 5% is where it starts, we’re going to see health benefits at 5%. We’ll see more health benefits at 10% and all what we’ll call metabolic benefits are about 15%. Even if you have a lot more weight to lose, most people don’t have any more metabolic benefit after that.
Craig Primack: All these things send signals. If we start to think about the main signals, they’re called leptin and ghrelin. Leptin being from the fat. The fat, when we have enough of it says, “I’m full. Don’t send me more.” As you lose fat for famine that signal goes down. “I’m not full anymore. Send more food.”
Craig Primack: The other one is from the stomach, called ghrelin. When people do stomach surgery for bariatric surgery they’re cutting some of that ghrelin signal out. Unfortunately it tends to grow back in a lot of places which is why that isn’t recommended for everybody, but the ghrelin’s hormone comes up right before a meal. We eat food, and we’re not sure if it’s actually the volume of the food, but it’s probably the volume versus the nutrients of the food. Right after the meal it comes down. So what happens. We get hungry before a meal. And then after a meal it comes down. Well, when we lose weight the opposite thing happens.
Craig Primack: Wait, see what I got here. 2011. A study came out in the New England Journal of Medicine. For us, kind of the bible. The author, if you ever wanted to look it up for some reason was “Sumithran”. But it really said why I think this is a disease. And so this is what happens. Why I tell all of you this is why your body is rebelling against it. This is what happens. As you lose weight the one that tells you you’re full comes down. That’s not good. The one that tells you you’re hungry goes up. And it stays there. Every time you eat a meal we’re a little more hungry than we were at our higher weight. We’re a little less full than we were at that weight. Keep your weight off for three months, six months, a year. Pick a number. You could be 30 pounds, 50 pounds, 150 pounds. It doesn’t go back to normal.
Craig Primack: What does that mean? It’s a picture of me. I’m trying to be funny here. So if you’re standing there at your highest weight. The analogy is as you lose weight there’s this little guy yelling in your ear. A lot of like I’ve told you guys a lot of this. So this little guy yelling in your ear and he’s saying, “Eat.” You lose a little more and he gets louder. He’s really not just a little guy. He’s the devil. He’s yelling at us. By the time you get to your low weight and you stay there he’s yelling really loud. How do we counteract him?
Man 2: Eat.
Craig Primack: Sometimes it’s eat. Absolutely. But here we try to use a lot of other tool. Do I have it on here? Yep. So, the easiest way to talk about that is the things we do here. Diet with high protein, less carbohydrate is one form of I say of earmuffs. Exercise to make you feel good is another form. Sleep, which I harp about day after day after day is another form. And the last thing, which we do here different than a lot of of other do it yourself diets is medications. So what happens is these ear muffs from those four things go on and those signals are still coming but we can’t hear them.
Craig Primack: So what happens? Stop our medication. Signals are back. For different people that’s different, so I don’t want to say every single person always has to stay on medications. When we look at our different DNA though, some people need more of the exercise. So you stop the exercise, the earmuffs come off. Maybe for some people the exercise, the diet and the sleep is enough that they don’t need medicines. Every little person is … or every person is going to be different. We have to find with each of us what is the mix to keep those earmuffs on because the signals are continually there. Makes sense? Everything we try to do here really gets back to this.
Craig Primack: When I thought about putting this talk together, I wanted to talk about this and why, unfortunately, we have to keep doing and doing and doing the things that we do here. It’s not fun always. We know that, but when we don’t, the earmuffs come off and those signals say, “Eat.”
Craig Primack: What’s going on in our world to fix this? In 2013 the American Medical Association said obesity is a disease. What does that mean? Blood pressure is a disease. Right? There isn’t a primary care doctor who you go see and they say, “Your blood pressure’s high.” What do they first tell you? “Eat a low salt diet.” And how often does that work? Not very often. And then you go and you take a blood pressure medicine, and that does work. And you go back six months later and they say, “You’re doing great. Stay on it.” Six months later, “You’re doing great. Stay on it.” It’s a disease and we have to keep treating it. It doesn’t go away. Blood pressure can go away though, probably with weight loss for most of us, but not everybody. There’s people walking around at 98 pounds who have blood pressure problems genetically.
Craig Primack: Now it’s considered not only a chronic but serious disease. What we’re trying to do is get primary care people and the medical community to stop just saying, “This is diet and exercise.” This is something we need to treat. I’m actually preparing a talk in November at Obesity Week, which is a week where the surgical groups come together as well as the research groups. I’m giving a talk. It’s about if your doctor does not treat you or refer you to someone who treats weight, it’s malpractice. Do I think it’s truly malpractice? I don’t, but I think we should start making that argument because there’s no … everything we’ve been doing so far is not getting primary care doctors, or even more specialists to do anything significantly about this. I think the only way to do that to our medical friends is to scare them a little bit. Maybe I’ll give that talk here next time.
Craig Primack: ABOM. The American Board of Obesity Medicine. That is a certifying body. We now have 20, roughly 2400 physicians in the country that are certified in obesity medicine. A specialty now all among itself. But 2400 people and really when you look at numbers over 100 million people in our country needing weight loss services of some type. A lot of people come into me and they say, “I just want to be normal.” Well when 70 some … 66 to 70% of our society’s overweight, that’s normal, isn’t it? We don’t want to be normal. We want to be … I don’t like the word abnormal because the opposite of normal is not abnormal, super normal. We want to be different.
Craig Primack: Oh, last but not least, another thing that is happening, but so slow, T-R-O-A. TROA. Treat and Reduce Obesity Act. This is a bill that’s been brought into Congress, a Congress last two years and so they brought it in the first Congress six … five, six years ago and they have like 100 roughly Congress people sign onto the bill, but it doesn’t go to vote. The next one .. so then it dies after two years if nothing happens to it. It gets reintroduced roughly three or four years ago, if I … I don’t have the years exactly right. It gets signed on by about 125 ish people and it doesn’t go to vote. Now we have, I think there’s over 150 Congress people have signed onto this bill in support of it.
Craig Primack: But what has to happen. This bill is actually to get it covered as a disease. So that you go in there with this diagnosis of obesity weight problem and that your insurance will pay for it, so that’s really what it’s for and what has to happen is the CBO, Congressional Budget Office has to score a bill before it can actually go to vote. Scoring a bill says how much is this going to cost the government for 10 years and it has never gone to vote at this point. Will it ever? I don’t think it’s going to happen soon unfortunately. When the government says, “We’re going to cover it.” And Medicare covers it, all the insurance companies start to fall in line after that.
Craig Primack: With Obamacare a couple years ago, they said anything that was … they grade recommendations. A is the top level of recommendation. B is still a good recommendation. C and D are weaker recommendations to do something medically. Weight treatment gets a B recommendation. It means it should’ve been covered under that law and it still has this carve out and exclusion, which is why the medicines we use for most people aren’t covered for the same reasons. Not fair. Not fair at all.
Craig Primack: You know someone who has diabetes on insulin nowadays, they’re spending $500 a month to treat diabetes with insulin which means with insulin treatment, unless you’re a type 1 diabetic, you will not be losing significant weight if that is your treatment. If we start using some of the therapies that we use here, and I do use some of those medicines for some of us that are expensive, but they’re not being covered for most of us.
Craig Primack: Why did we put together the program that we have here? Most people will call these four things … Cold?
Woman 21: Yeah.
Woman 22: It gets colder than hotter.
Ashton: It is a little bit chilly.
Craig Primack: These rooms are so crazy.
Woman 22: It’s okay.
Craig Primack: Because it’s either too cold or too hot. By cold there has to be two air conditioners in here. Maybe you can put up the wall. [inaudible 00:35:13] Let’s see. I put it up by one. We’ll see what happens. A lot of people call this the four legs of the chair. Have I told anyone that analogy before? If you have a chair and it’s … or you don’t have a chair yet. It’s January and you haven’t come to a comprehensive program. What do you do? You go to the gym. One leg of the chair. Stress comes into our lives. Stress has shaken the chair. What happens when you’re only balancing on one leg?
Woman 23: Falls down.
Craig Primack: Falls over. So you start a diet and you start exercise. There’s two legs of your chair. What happens is stress comes into our lives, shakes our chair. It’s a little better. You add the third one, behavior modification, which is really our classes. I like to call it trigger and learning from my mistakes type things. All of us do things that you’re like, “Oh my gosh, I should’ve done it differently that time.” That’s where classes come in for me. And then the last is the meds and accountability. You know with our AMP program coming in once a month for time after time after time, knowing that we’re going to get on the scale, knowing that we can walk and talk about what’s coming up, going on a cruise, going away for the summer, things like that that we know are coming up we can kinda strategize for.
Craig Primack: When you put all those four together, the four legs of the chair, we have a stable base. They found this is the four pillars. The society I’m apart of we have that as these are pillars they call it. I like the analogy of the four legs of the chair pretty well. Makes sense?
Woman 29: I have a question.
Craig Primack: One of the things I often talk about is … I’m sorry, go ahead, [inaudible 00:36:55].
Woman 29: In the beginning, when you were first, probably many years ago, meds were not a part of the program, correct?
Craig Primack: Correct. So meds have always been a very small part. So let’s go through the history of meds. 2012 we have a lot of new medications. The older medications, Phentermine, came out in 1959, but went through the fen-phen area. Most people were saying, “Don’t … scared of it.” So there were two medicines that were on the market when I first started weight therapy in about 2004 or five that were used regularly, Meridia. Meridia was actually I think a blood pressure. It was an anti-depressant that had a side effect of that, but it also increased blood pressure a little bit and if you didn’t lose weight but stayed on that medicine, that blood pressure increase was bad for you, and so it went off the market. There was also Xenical, which is now Alli, over the counter. Any of us can buy it. What happens when you take Alli or Xenical? It’s job is blocking fat absorption. If we eat fat and we blocked that absorption, what happens?
Craig Primack: You get diarrhea. I remember, and it was, by the way, at that time both those medicines were $140 a month and people were paying for them. And this medicine at $140 a month gave you diarrhea, and the type of diarrhea was what’s called steatorrhea, which is an oily diarrhea. I will tell you with that that type of diarrhea, you could not tell the difference between passing gas and passing this.
Woman 30: Oh no.
Craig Primack: Oh no is right. I remember very vividly one of my patients in an office sitting there. “I have to go home. I’m sorry.” And you think that woman ever took that medicine again?
Woman 31: No.
Craig Primack: No. So that medicine is essentially … it was prescription. They cut the dose in half and put it over the counter because people weren’t using it. Did that answer? Oh, I didn’t finish it. Fast forward 2012, we’ve now have four medicines come out on the market for weight which we can now pick and choose between. Also, I became part of this society that teaches people how to do weight loss. That was 2005, and Phentermine is backbone of our treatment because it’s been out since 1959, we know exactly what it does. It was cleared of all the problems that what happened in fen-phen days. Fenfleuramine was the other medicine. It went away. It is never coming back. It did work well on the brain. It didn’t work well with the heart. And so they took it off the market. It won’t come back. Some of you have heard of a medicine called Belviq. Belviq is very much like the Fenfleuramine, but it only works on the brain and it actually does not work on the heart. So it works very well sometimes even with Phentermine together and it’s been studied in small studies together.
Woman 32: And where is Tenuate in that?
Craig Primack: Tenuate came out in 1959 also.
Woman 32: 1959.
Craig Primack: Yeah. So Phentermine, Tenuate, something called Diethylpropion, which of you, you may know about. Sorry, Diethylpropion is Tenuate. Phendimetrazine also came out in 1959. Then there was really those two medicines in the 2000s ish that came out and then there was nothing ’till 2012. The FDA got very, very leery of releasing weight loss drugs, and so now every weight loss drug has to go through more scrutiny than the average drug.
Craig Primack: These three things I always call are my key three. There’s diet, there’s exercise, there’s sleep. The story I tell a lot is I had a gentleman who was doing all three of these and he’s losing weight. Then he had weird conference calls, 3:00 in the morning, 5:00 in the morning. His sleep went away. He had two of them and he lastly maintained well. I’ve seen other times the same thing, and then other times he was sleeping well, but he didn’t have to diet as well. He did these two things and he maintained.
Craig Primack: Then I start seeing people, “Oh my gosh, I’m now missing two of them.” Diet is off. Sleep is off. Maybe I still exercise, but exercise, probably the thing that falls away with diet. Maybe I’m sleeping. So you do one of them and we’re gaining. But if you do zero of them. Actually that’s when I see gain fast. I think we should all set, even though exercise is probably the only 10% of weight loss, there should be this little alarm that goes off. If we’re regularly exercising and we stop exercising, we need to start watching food. When we’re doing all of them, we tend to do much better. Questions? Yes?
Woman 33: I know you and I have had many discussions about staying on Tenuate forever. What kind of side effects, if any have you heard about long term? I mean, it’s been probably about less than a year or maybe a year that I’ve been on it. I’m happy to be on it forever. I’m happy to know you and come here forever. But I mean let’s just be real about the side effects. Can you-
Craig Primack: So there are no long … very long term studies on the drug besides clinical evidence, meaning people who’ve been using it for years and years and years. Phentermine, which is a more potent, as far as stimulant drug, there are studies that are 10 to 12 years long, clinical studies of the same person taking it for that long, we do not see any problems whatsoever. One of the big groups that treat weight called the Endocrine Society came out with a position statement in 2015 that says, “Yes we don’t have, for Phentermine and drugs like it, we do not have true long term blinded studies same person forever, but we can kind of say, ‘These drugs have been out since 1959. There have been people taking them for years and years and years. We have not seen any signal of any problems.’”
Craig Primack: Then you start to say, what’s the opposite? So what’s the alternative? Well, if I stop this drug and I start gaining weight we know that there’s problems with weight gain. So theoretical, there’s not even theoretical problems with those drugs long term. You know you can make it up that there is, but there is no evidence of it versus what we know, which is weight long term has problems. Will there ever be a study done? I sure hope, and the only person who’s ever going to do it are the people is the government themselves. It’s been generic since early on, so drugs get studied when they’re new and patentable, but the government does study things that’s off patent and such because they have a lot, you know if you can use an inexpensive drug like Tenuate, in a lot more people than some of the expensive ones, it would benefit them. In the shorter studies it works just a hair less than Phentermine with less stimulation.
Woman 33: What is Tenuate? What is that?
Craig Primack: Diethylpropion. It’s a stimulant much like Phentermine. For a lot of the times we use it in two ways. It’s a short acting one. So some people take Phentermine in the day and use a little Tenuate in the evening to get that last little piece so it wears off before bed. Other people use it up to three times a day or an extended release one that does the same thing as three times a day but in one pill. Phentermine for some people too stimulating, too much or sometimes we just choose Tenuate for whatever reason it works an then we stick with it. It’s an art as much as it is a science. There’s an interesting thing when I talk about drugs, I’m going to show that slide, but if you look at any drug if they do something called a waterfall plot, which they don’t do very often.
Craig Primack: A waterfall plot, if there’s 100 people in there, and then weight loss is here, they’ll show how much weight loss each person, so there’s a line. And you’ll find people that have that much weight loss and then it puts it all in order and then the weight loss goes down and down and down and you actually get to some people that don’t have any weight loss, and on the same drug you’ll get a few people that have weight gain. Before you put anyone on drug we don’t know where you’re going to fit, and so what do we have to do? We have to take our best guess based on who you are, based on what other medicines you are, based on your other medical problems, and experience over the last 12 years of doing this full time and say, “I think you’re going to do best on this one,” and we try it. If it works well, that’s the one for you. And if it doesn’t work well, we need to try something else.
Woman 34: Does Phentermine have a bad rap that why as I mention it to some people they’re like, “Well, he can’t be on it forever.”
Craig Primack: Phentermine gets that bad rap because of fen-phen. A lot of people got in trouble for being fen-phen. There were clinics of fen-phen. You just went in. You got your fen-phen and you left and then there was these heart valve abnormalities that went along with the fenfluramine. So it went through a problem. People who say that don’t know Phentermine. And my answer to those people are, “Thank you, but I’m being treated by a specialist who …”
Woman 34: Right.
Craig Primack: Yeah. Or nothing. Or you say nothing. Sometimes those people aren’t going to listen no matter what you say. The first thing that happens when someone goes into the emergency room for whatever reason, they go, “Oh my gosh you’re on Phentermine.”
Woman 34: Right.
Craig Primack: It’s not Phentermine.
Male: Wait, me?
Craig Primack: Yeah. Go ahead. Yeah.
Male: Oh, I thought you were looking at someone.
Craig Primack: Go ahead.
male: What about Metformin?
Craig Primack: Metformin is an interesting drug also. So Metformin is started out as a diabetes drug. Then it was shown to be a very good pre-diabetes drug, and then interestingly enough it was actually shown to be a good drug for weight loss, initially in teenagers. Only about a year ago, a year and a half ago did they figure out what it was really doing. So we know in diabetes it’s taking your high blood sugars and bringing them down. The liver makes sugar itself, so when we’re sleeping the liver’s constantly making sugar. It slows that down a little bit so your peaks of sugar are now as high, but we found out one of those hormones that come from the stomach that I talked about before, this one’s called GLP-1. GLIP1 tells the brain, “I’m full.” If any of you guys, if we’ve talked about either Victoza or Saxenda, that is what that drug is. But Metformin is stimulating this hormone and telling the brain that, “I’m full.”
Woman 35: Why is sleep? Why does sleep play such a big part?
Craig Primack: So going back to those two hormones that I talked about, leptin and ghrelin. The easiest thing to say is when you don’t sleep, the leptin that tells us our full also goes down and the ghrelin that tells you we’re hungry goes up. On top of the fact that cortisol, our stress hormone, also goes up, cortisol takes tissues, we’ll call it protein and such, breaks it down, brings up our blood sugar. When the blood sugar is high the pancreas has to then make insulin and then the insulin takes and puts the sugar inside of our muscles and our fat and makes more fat. Makes sense? Go ahead.
Woman 36: Oh sorry. Go ahead.
Man 8: The, I think when you say sends it to our brains, are you speaking of the hypothalamus?
Craig Primack: So the hypothalamus is the receptor. That’s where all the signals go to. The different places that send the signals: the stomach, the small intestine, mostly, the fat, the pancreas and the gallbladder. Those are the big five.
Man 8: So if you were able to control the hypothalamus, then it would really take care of a lot of things.
Craig Primack: Yes. So the medicines we use actually, that’s where most of them work. They’re working on the hypothalamus directly.
Man 8: Okay.
Craig Primack: So Phentermine, Tenuate, Belviq, half of Contrave, GLP-1, so both Victoza and Saxenda, all working on the hypothalamus.
Man 8: Okay.
Woman 37: So they’re like tricking the hypothalamus to think-
Craig Primack: Yes. Absolutely.
Woman 37: So they’re telling … what exactly is it doing?
Craig Primack: They’re stimulating the fullness center is really what they’re doing. And so it … you’re fooling your body into thinking that I’ve had something to eat longer.
Man 9: Back to your commend about eggs.
Craig Primack: Yes.
Man 9: I love eggs.
Craig Primack: Yes.
Man 9: I was thrilled when the thinking on eggs changed.
Craig Primack: Yes.
Man 9: But some of the old ideas are still in my head so I usually eat two eggs whites in the morning with my usual oatmeal, then a complete egg in the afternoon. Any issues with this eating eggs with yolks?
Craig Primack: So yolks add a few calories, but they also add some good vitamins. So choline is a very good vitamin that comes in the yolk. I always eat my eggs whole.
Man 9: You don’t worry about the cholesterol in the yolks.
Craig Primack: No. We get it more through other sources.
Man 9: God bless you. Thank you.
Woman 38: [crosstalk 00:49:35] eggs in a day if you like …
Craig Primack: So best protein that you can take in is whey protein, animal protein. Second best is egg protein. After that, plant proteins come down the list significantly which is why I’m not a believer in pea protein, actually soy would be the next one if I had to go down the list. Pea protein’s another of a high quality proteins. They grade them on a scale one down to zero and whey and animal proteins come right at the top.
Woman 38: And so why do you put pea at the bottom? Because sometimes I give my little one like a shake with pea protein because she’s not a huge eater, but I know she needs the calories and she likes them. I’ll put you know PB2 and banana. We’ve talked about this. So I do pea protein because my big one has like a lactose issue, so I don’t give her the whey. So are you saying that I shouldn’t even give that to her because it’s not a good source of protein?
Craig Primack: It’s all people at different times. If you’re looking for weight loss-
Woman 38: Oh okay.
Craig Primack: So, when we say what makes a high quality protein versus a lower quality protein. It’s the amount of essential amino acids versus non-essential amino acids. And so animal proteins have the most essential amino acids versus non -essential amino acids. Animal proteins have the most essential amino acids. When you look at, I think there’s four branch chain amino acids. One of them is called leucine. Leucine is the one that triggers muscle building. If you go all the way down and you just ate that particular one you could put on more muscle without extra calories. Where we say if you’re having less quality proteins with less essential amino acids, essential means our body doesn’t make them. We have less amino acid. You’re just getting calories that you’re eating in without getting that muscle stimulus triggering that will keep our metabolisms going.
Male: Continuing on with eggs. So which would you say would be the better choice just in general. An actual egg or the carton of egg whites? The liquid.
Craig Primack: Eggs.
Male: The-
Craig Primack: Eggs. Chicken. Eggs.
Male: So the actual egg itself.
Woman 39: Pure egg. Chicken egg.
Craig Primack: Egg.
Woman 39: I get it.
Male: because you always say that the liquid-
Craig Primack: Eggs. Veggies. Not toast.
Woman 39: Are you thinking of it in terms of … because I get … I’m thinking I might be able to interpret what you’re saying. So I think that my mentality in the past, not right this second, but in the past had been, “I’m going to make a big giant omelet of egg whites because it’s going to be more food and I’m going to feel more satisfied because the calorie density of that meal versus having like a three egg omelet with full yolks. So is that what you’re saying you would maybe I’m assuming this is mom. Is this mom? Would do the carton because you’re a growing boy, young man and you know, maybe it would be better to have like the carton because then you can kind of go carte blanche and have almost whatever you want if you want like a big plate of food, like now I just do a big giant salad and I’ll put hard boiled eggs in them if I do that.
Craig Primack: I will say egg whites do have less calories than when you have a yolk in the same amount because the yolk has the cholesterol and more calories in it. But, so if you’re looking for volume, egg whites. If you’re looking for what may fill you up, I think it’s probably eggs.
Male: Okay, yeah that’s the –
Craig Primack: You’re eating a lot of-
Male: … that’s what I was trying to ask. Yeah.
Woman 39: Right. I agree now. I agree with that.
Male 10: You mention you were taking a look at the historical things. How people have changed over the years. I was thinking that people who are back in say the early settlers or the Indians, what was their lifespan then as compared to now? How has medication had that influence in general on our weight gain?
Craig Primack: So they live much, much shorter than we live now.
Male 10: So would medications that a lot of us are on have an influence over our gaining weight and how much they studied?
Craig Primack: There are a lot of medicines that we take for other reasons that do cause weight gain. Anti-depressants, anti-psychotics, diabetes medicines, even Benadryl has a small weight gaining property. There’s a whole list of them. I’m not going to go through all of them, but those are the kind of main ones we start to think about. Steroids for sure. All those kind of things. But they’re also doing good things or we wouldn’t be taking them. When I look at a medicine I think of yes it’s benefit is this, but what is its side effect and I’m constantly calling primary care people or such, “Can we switch them to something else that’s less gaining?” Yes. Either way.
Woman 40: So if the dopamine is low and the serotonin, then … okay where was I going with this [inaudible 00:54:33]? Then you’re lacking … what am I trying to say? She’s talking about the last night too.
Woman 41: What have you got [inaudible 00:54:47]?
Woman 40: Then you’re a certain personality or something, I guess. What’d you say?
Craig Primack: So dopamine and serotonin are different neurotransmitter than hunger neurotransmitters-
Woman 40: Yeah.
Craig Primack: They tell us we’re … it’s either reward and calm or if you think of the dopamine is more of the go out and hunt and the other is more, “I’m satisfied.” If you think of it in appetite terms.
Woman 40: So it’s hormonal but are there certain foods that you shouldn’t be on more than others or …
Craig Primack: I don’t look at it that way.
Woman 40: Not really, no.
Craig Primack: There may be some to that. I don’t look at it quite that way.
Woman 40: Okay.
Craig Primack: Yes.
Woman 41: So, we hear like on the radio you hear B12 shot as sort of like a thing to help you lose weight. So can you explain a little bit about the science behind B12 shots-
Craig Primack: Absolutely.
Woman 41: Why you choose not to-
Craig Primack: There is no science behind B12 shots. Every time they have studied B12 in a blinded fashion. You get a shot. One of them has B12. One of them does not have B12. Saline is what they normally use. You cannot tell the difference. Both people feel better. That’s not the issue, but if I’m going to charge you $20 for or whatever they cost, I don’t even know, for a B12 shot you want it to be doing something. Now if you have B12 problems, absolutely. There are some reasons that people should be doing B12. So B12 abnormalities for sure. Some people on Metformin should be looking at B12 if you’re on it for long periods of time. There are some other states with stomach issues and such where you’re not absorbing B12. But as a general rule if you’re just normal B12 is not recommended.
Woman 42: If you high cortisol from stress, are there vitamins like B12 would be good for you?
Craig Primack: Not directly. We need to figure out what your stress is and how much you’re sleeping, and that would do much better than any vitamin per se.
Man 2: Holistic medicines, the Garcinoba-
Craig Primack: Garcinia cambogia? Is a fad. It was happy for awhile because Dr. Oz put it on. It’s gone. No one should be using it. It actually never-
Man 2: Messed up your liver and was terrible.
Craig Primack: It didn’t do anything.
Man 2: Are there any others out there that might be worth checking?
Craig Primack: There’s a few but nothing that’s as strong enough as a good diet, exercise, sleep, and potentially the medicines we do use. On a scale of one to 100, are they at a three? Maybe. But is the three worth $25? No. Or more. I don’t think so.
Woman 43: I have a question. So are kids at the hospital, like PCH. Those are that are put on TPN, and cannot eat anything. They do not suffer from the same lack of hunger cues that our other kids do because they’re getting the nutrients. So then my thought process, my question is is it possible that the brain doesn’t have the same cues from the stomach as from the lack of nutrients? And as we grow older and we’re exposed to all of this, like you said, the high fat, high fructose, all of this, our brain chemicals change, like it does with drugs and alcohol and all the things that actually change the synapses and the chemicals in our brain that it changes it to make us crave more high fat, high sugar, high all of that. Is that a possibility?
Craig Primack: Yes, but I’m going to . There’s a lot there I’m going to take two parts. People in the hospital. We have to think we’re not those people. Most of the time if you’re getting TPN, so it’s liquid nutrition through a vein. There is something else going on in your body at that time that is probably knocking your appetite down or they’re giving your enough calories that you’re not needing it at this point. There’s something else. If you say-
Woman 43: So is it the calorie thing or is the stomach that’s making more [crosstalk 00:59:00]?
Craig Primack: The answer I think is yes. It’s both.
Woman 43: Okay.
Craig Primack: If you go towards us as adults and why we’re different than those kids, which we are. It is learned behavior. It is our metabolism that changes somewhere between the age of 25 and 30. It is the reasons we eat which is that whole category called emotional eating and the reasons of stress, fatigue, boredom, you name it. There’s about five of them and we all use them at some level or another. If you use it too much … so food is a drug. Food is a drug that works for a while and then we have to re-dose it. So then we eat it and then we have to re-dose it and that’s the problem.
Male: Your gallbladder. What exactly does that change when you have it removed in terms of when you lose weight. What did it … what changes-
Craig Primack: The gallbladder’s purpose is as fat comes by it squeezes and it mixes the juices that come from the liver that get stored in the gallbladder with your food to help digest the fat, fatty foods. When your gallbladder comes out, the vessels or the tubes where it already was kind of going through get … adapt to not having that. Some people it causes a problem so they don’t absorb fatty foods as well. Other people you’ll never know the difference.
Craig Primack: There’s a hormone that makes the gallbladder squeeze called CCK. CCK is one of those that goes to the brain and tells you you’re full. So if you’re having food going through the intestine, your brain says, “I’m full.” It makes perfect sense. They’ve tried a lot of these other things. Can we give some of these hormones as appetite suppressants?
Craig Primack: One of them, the GLP-1 going to the brain, it does work. Leptin which is the one that comes from our fat actually we have a leptin resistance, so people with a lot of weight have a lot of leptin because we have a lot of fat. But the brain doesn’t hear those signals as well. It’s almost like diabetes where we get resistant to insulin. Same type of thing.
Male: And then … did someone else have a question? Oh okay, I wasn’t. And then so as a follow-up. Does fiber supplements, such as Benefiber, do things like that help, not [inaudible 01:01:22] the process, but just make it easier to cut it?
Craig Primack: Fiber helps a lot. Fiber does two main things. Number one it’s a bolus of food going through your colon and intestines, so it takes up space that space tells the brain, “I’m full.” And the other thing we think it’s doing is being good fertilizer for the bacteria of our colon. Think of it as that. So the probiotics and prebiotics. Prebiotics is fiber. Probiotics is that good bacteria. (silence)
