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The 5 Most Important Articles in Obesity Medicine Craig Primack MD


Everyone, welcome!  Thank you for being here.   

This is the first time Scottsdale Weight Loss has done a Zoom meeting. Obviously, we’d love to have everyone in the classroom and we’ll talk about classes as one of the aspects of this talk is about … To give you a little background, this talk has come together over about two years which I think for me makes it exciting.

So I belong not only to discuss the Weight Loss Center obviously, but I am the president of a large society of weight loss physicians and nurse practitioners and PAs.

We’re the Obesity Medicine Association. We have about 3,000 members in the US, a few members outside the country, but we put together … We come together and have two meetings a year and about 50% of the people or up to 50% of the people that come to these meetings are brand new.

They’re medical people who are interested in treating weight in their own clinics, and they just don’t know what, where to even start and so our society teaches them how to be weight loss physicians, nurse practitioners, and PAs and such.

And I said, if you were starting out in this field, what five articles do I quote all the time and if I’ve ever seen you in the office, I’d probably have quoted at least one or two or three of these articles and somewhere form.

And so what did I want them to know? So it’s going to be a little more directed towards the science side. I think I’m pretty good at distilling it down to information we can all understand and so that is the background on getting us started. Let’s go.

The Five Obesity Medicine Studies

So my objectives today is this list of five studies is my list I’m saying today. It’s going to change, it may change even next week if something New comes out and in this field.

They say in any one field in medicine whether internal medicine, cardiology, obesity medicine or such, there’s more data written or more stuff written in one month than any one person can read in the year.

And so you have to kind of pick and choose what you’re going to do. I want these medical people to be able to discuss why someone with obesity cannot just simply eat less and move more. If it were that simple, this would not be the other worldwide epidemic we have right now going on in our country.

Obviously, we all know about COVID-19 and coronavirus, but this is another epidemic going on hitting epidemic proportions over the last 20 and 30 years. These are the studies I think people need to know in this field of obesity medicine as a base, to be able to have a conversation on why this is a disease.

I have certain soapboxes that I like to talk about and obesity being a disease is one of them. Way back in 2013, the American Medical Association came out and agreed that this is a medical disease, many other societies that treat patients along, around our country has come out and also said that we have to I think, take another step and another look at this and say, “It is chronic.”

Meaning, it doesn’t just go away in three weeks of dieting, and six weeks of dieting and a couple months of dieting. It is serious. People who have weight to lose are at risk for other diseases, and there’s actually over 200 of them that we can list but the common ones I think we all know, our blood pressure, diabetes, heart disease, sleep apnea, and even several cancers just to name a few.

And the last thing and I think the piece that gets lost when someone just starts going off on a disease piece is it is treatable and some of the things I’m going to talk about today is certain things we have to think about when treating it and certain reasons we do some of the things that we do.

There was one time that we’re going back, obviously in the 1400s where people believe the earth was flat and that’s the analogy and I’m going to go into this analogy even more with a medical piece, but they believe the earth was flat, and everybody believed it.

The sailors would go off and they’d get as far as people can see and it looked like they fell directly off the earth. That is also the analogy of people going and trying to go to the internet, go to their best friend and say, “Hey, what is the new supplement you did this week? What book have you read? What guru says that I have the magic vegetable or something that we found in South America to treat your weight this time?”

And we asked everyone who’s become a patient in the clinic. When you started, how many diets have you done before? And some people and you may be one of them have said, “I’ve done all of them.” That is what we’re going to try to stay away from in the future.

So the first study is the number one study, I can actually tell you the room I was in 2011. So this study came out in around Thanksgiving time in 2011 when I first heard the data in this study, that’s how crazy it is.

So it comes from The New England Journal of Medicine which is kind of, one of the Bibles you can say in medicine and it’s called long term persistence of hormonal adaptations to weight loss. So long-term.

In this study, we’ll talk about being a year. Hormonal adaptations, so the hormones that control our hunger and what they do when we lose weight. Sumithran is the main author.

I think I can use my pointer a little bit. And so people call this the Sumithran article. Have you heard of the Sumithran and so forth? And so just to give you a little background, the people who are in this study, there started out to be 50 of them.

Their age was about 54 and a half years old on average. The ones so only 34 people finished this day. So it was a rather small study, but as you’ll see, it was not an easy study to do because they had to draw blood a lot of times.

And what they’re trying to look here is that people who are the total people versus the people who completed the study versus those who did not complete the study. Was there any differences that would account for some people dropping out or not?

So the average age was 55 to 56. Their weight was about 95 kilograms. Their body mass index was about 35 and I think across the board, we can see that’s normal or at least in this study, it goes across the board.

They did have high blood pressure in the 135 range as the top number and you can see their fat percentage was over 50% of their body weight, 52%, 51.6% or 50%.

They did a 10-week weight loss and it was an aggressive weight loss program. For eight of these weeks, they replaced three meals with meal replacements. This is well, actually, for those of you who obviously come discuss the weight loss, they were using an older form of Optifast when they did this.

That was a different, it was a 440 calorie or 470 calorie … and they did two cups of low starch vegetables equaling total with the meal replacements and the vegetables and 500 to 550 calories per day.

They did that for about eight weeks. If at the end of these eight weeks, they lost 10% of their weight, they were transitioned over about two weeks to start on regular food.

The counseling that was happening at this point was not to continue losing weight, it was to then for the next year, maintain that weight and to maintain it, they really gave two specific instructions and taught people how to do this.

The first was low glycemic index carbohydrates, so ones that let the blood sugar go up less than others and low fat. That was really the … told exactly what to eat during this time, they were told about how many calories they needed, and to keep their carbohydrates in the low glycemic index kind and …

They were also told to do 30 minutes of exercise most days of the week and they went to the clinic every two months or so during this year, but in between, the dietitians would reach out to them every one to two weeks and talk to them about their diet, give them different choices, help them out if they were straying a little bit.

And so at the end of this, 68% of the people crossed the 10% barrier and went into the maintenance… When we look, and so we’re going to look at baseline. So that’s before they started the diet.

Week 10 which was that eight to 10 week transition, and then from week 10 to 62. 62 is a year after, so 52 weeks after the 10 weeks. And you can see they lost about 13 and a half kilograms.

A kilo versus a pound is 2.2. If you say 13.5, you double that to about 27, add roughly another two pounds and they’re losing 29 to 30 pounds in this 10-week period.

And then they gained over the next year about 5.5 kilos back, so about 12 pounds during their maintenance base. Their change in weight in percentage was 14% lost and they gained about 4.4% back and their body mass index and points went down just under five points, and they gained about 2% or two points back.

And you can see if we go to the bottom, that they lost about 10% of their total fat percentage and gained about four and a half percent back. So they were very successful in the first 10 weeks and really, pretty decent over the next year keeping off their weight.

This is a graph of their weight loss. The people who are in black are the completers in this study, the 60 some people that went through the study. So their weight when they started was about 95 kilos and over that eight weeks, it went down to about 83 kilos.

During that transition period, it stayed mostly flat, and then slowly but surely, over 18 to 26, 36, we see it coming up a little bit and then over here being the end of the study.

If I was a shoe company, and you saw the shape of this curve, this is what we call the Nike swoosh unfortunately of weight loss. Rapid loss and slow gain throughout the second piece of that.

This is really where this study starts to say, “What’s going on here?” So not only did we measure weight because that’s just what’s going on. We wanted to measure hunger hormones.

I’m going to take a step back and talk about hunger hormone for a second. There are a hunger … Our brain, the hypothalamus is really what’s controlling our appetite.

There are sensors throughout the body that go to the brain, that are sending chemicals through the blood to the brain. One of them comes from the stomach itself. It’s called ghrelin, that’s the one that’s up here in the top A square.

Ghrelin itself makes people hungry. Right before a meal, that actually peaks. When you’re sitting at the table waiting for food, when you’re at the restaurant, and you see that people next to you get their food and it’s been 20 minutes and you go, “Whoa, I’m really hungry now.”

Our ghrelin is kind of peaking at that point. That’s the only one of the hormones we’re going to talk about today that actually increases hunger. All the other ones happen after we eat, they can either decrease hunger or increase fullness, depending, but they don’t cause more hunger.

And the other ones that we measured here, this one is called PYY, or Peptide YY. This one is called Amylin and this one is called CCK. I guess I stirred it out. So ghrelin comes from the stomach, PYY and CCK from the biliary tract CCK.

When you give that hormone through an IV, it actually makes the gall … And then it comes the pancreas. So insulin is another signaling hormone. And then the fat itself has a chemical called leptin that we’ll look at.

So let’s look at what happens. So in the study, the black is a baseline. So they studied these people even before the study started and if we look at the black and the ghrelin, they ate at time zero which is right here.

30 minutes after the meal, the ghrelin which tells you you’re hungry is going down. 60 minutes after the meal, it’s at its lowest, and then slowly it starts to go back up. So in our number two, it’s up a little bit, and our number three, it’s up a little bit more and then by the next, the fourth hour is kind of back to where it started.

And if you haven’t eaten a couple hours, we start to get hungry, we eat again. Well, as people lost weight, so blue’s attendance. So now they’re at their lowest weight, this hunger hormone…

And so as we lose weight, the hunger hormone goes up, it still drops as you eat, but it never goes as low as it does when you’re in the black range.

And at week 62 where they’ve gained some, but not all the way back, it’s somewhere in the middle. So it’s not as high, not as much hunger as it was and again, dropping down and falling the same here, but never as low as it was when we’re at initially.

PYY is doing the exact opposite. So this would be fullness, and our fullness starts out low before we eat. We eat at 30 minutes and our fullness peak and then it kind of maintains itself over the next couple hours.

When we lose weight and we’ll combine here the 10 weekend and the 62 week weights which remember are lower and so the fullness hormone is lower at each time, at 30 minutes, at 60 minutes, at 120 and so forth.

When we look at Amylin, another of these fullness hormones, what should happen is it goes up and then it comes down and we can see it, the fullness doesn’t go up as much, it comes up, but again, not as much and it never, even at the end of the year, does it come back to baseline.

And CCK does the exact same thing, it matches it and then comes back. We call this area over here area under the curve. So the time that you’re feeling full is less. Not only do we measure the hormones, but we asked people in this study, “How hungry were you?”

And a related question is how much desire you had to eat. So we can be hungry and eat just about anything potentially, but the desire to eat, we may say, “You know what? I’m not really hungry, but if you gave me chocolate, my desire to eat it would still be really high.”

What they do in a scale like this, this is called a visual analog scale. So they basically take about 10 centimeter line and 50 as at one end, and that’s the most hungry you can have, then it goes down to zero which is in the middle, intermediate hunger or sorry, zero hunger, and then it would go negative to be not hungry at all, or absolutely full.

And what we see here is the hunger starts out before you eat a meal is high, and at 30 minutes comes down nicely as though it should, again, before you die it and then starts to come back up and hunger.

So about no 240 minutes later or four hours, your hunger is back to where it should be and we’re ready to eat again. [crosstalk 00:15:30] people lose weight, their hunger stays higher, starts out higher.

If we use hunger scales, maybe it’s an eight or a 10 instead of a six. It comes down a little bit, but again the entire time, the hunger stays higher, and so does the desire to eat. Both of them are higher than they were…

So really what this is showing us is that a relapse of lost weight which is the regain that people get during a diet. There’s really a strong physiologic basis. It’s not just the fact that I’m tired of dieting, and the chocolate, the ice cream, the food that my family has is really any different from us, we have this little voice in our head saying quietly, “Eat, eat, eat.”

And at the end of the year, he’s still saying, “Eat.” And the more we lose, the stronger he gets. And so it’s not just simply the result of these voluntary habits coming back, right? Just like food or such, it’s this little hormone inside of us saying the drive to eat and the drive to eat is one of those hormones like survival because it’s what kept us alive over the centuries.

All of the changes in hormones, except one called pancreatic polypeptide changed in this direction to facilitate the regain of weight. So it increased hunger and decreased fullness.

At a year, the hormones that were … Oops sorry. The hormones that were controlling appetite that encouraged weight regain do not yet go back to the levels before weight loss. We don’t know what happens in year two, three and four, but at this point we know in a year, the fullness is lower and the hunger is higher.

And so we have to come up with long-term strategies needed to counteract this change and prevent relapse or weight gain. So that is study number one. Study number two was done from a journal called Obesity and it’s called Brain Imaging Demonstrates a Reduced Neural Impact of Eating.

So basically, we’re going to look at scans of the brain as people are looking at pictures of food and seeing what happens. So they used something called functional MRI.

The MRI machine as you know uses strong magnets to take pictures of the brain, or in this case, the brain and the more a part of your brain, so Different areas of your brain are active at different times. If you show a picture of food, one area lights up, and you get a give a dye through an IV in your arm.

And this dye goes directly to the places of your brain that are more active. When the neurons in your brain are more active, they use more energy, and more sugar. And so this dye goes to those places and we can see that.

In this study, there were 30 women, 50 of them were lean, so body mass index normal 18 and a half to 24 and 15 had what we’d call these class two or class three obesity with the body mass index from 35 up to 50.

In the functional MRI machine during this time, they were showing pictures of food. So 10 of the pictures were savory type foods. 10 of the pictures were sweet foods, and 20 were kind of non-appealing, low calorie foods, a lot of vegetables and sometimes occasionally, they threw in a picture of an arrow.

Either one up or down or to the side, just to kind of say it wasn’t food at all and see what the brain did. Each of these pictures were shown for three seconds which is all the time the machine needs to categorize what’s happened.

And so then, they did two cycles of this. The first was fasting. So both groups came into the machine and they hadn’t eaten all night long. So they all should be hungry and they wanted to see what, how they reacted to these pictures of food and then they were fed up breakfast, a standardized breakfast, 337 calories.

We’ll talk a little bit more about that specific breakfast, and then the test was done again. So the first thing is we look at the lean versus the ones with weights, and they ate about the same breakfast, 300 calories versus 302 calories.

So we’re making sure that the groups are not significantly different. Their hunger when they were fasting, interestingly enough, when they were fasting, the lean women had more hunger than the other women, but they both had kind of mean hunger after they ate.

So it went down in both groups, and then their fullness when they’re fasting about the same 41 versus 39 and again, in the other, roughly the same. These are pictures. So I have to describe what these are. The first picture, all of these are in the lean women and the first picture up here, the first one is a part of the brain controlling the reward areas of the brain.

So when food lights up, more I’ll call the appealing foods. It’s the chocolates, the ice cream, the pizzas, things like that, light up more. And so first, this is when they were fasting, and they got a baseline and then the second in the B is after they had breakfast, and the third in the C is the difference.

So it’s hard to tell much difference when you go from A to B, but when you look at C, it shows you that there’s a lot of difference. So what it shows in A and these parts of the brain, they saw hunger.

In B, it went down so that the difference was a strong difference. When you look at other parts of the brain, here’s the striatum, the nucleus accumbens, again, areas that are in the reward centers of the brain.

We see a little bit here and a little bit here, but when they did the subtraction, it seems a little bit less than it did in this one and we see some changes again here, and strong in the cerebellar areas versus that.

So what it really is saying is the thin women when they went from hungry to full, their brain did also show that they were also hungry and full. When we go to the overweight women, this is again before while they were fasting.

We see a nice signal. We see pretty much the same signal after they ate breakfast and so when they subtract it out, there was actually not much difference between A and B in this C photo.

And the A to B in this one, there’s small differences, but again, they’re not calling significant differences. When we go into the fourth photo, A versus B. Again, pre-meal, post-meal and again, not many differences.

And so what we’re seeing here is even though they had the same breakfast as the thin women, the brain’s hunger and reward did not shut off. That’s when someone has a lunch and they say, “Oh my gosh, you know what? I’m already thinking about dinner.”

Or you have dinner and you’re thinking about that snack later on even though you’ve just eaten and that’s what we’re seeing here. This one takes the C of both of them. It makes the C of the thin women versus the overweight women and subtracts it out.

So you can see in this area, there is a big difference in the two and in this area and this area, there is a difference. So we’re seeing a difference between the thin women and the overweight women.

So what, kind of the summary of this one is in both the fasted and fed states, people who struggle with their weight had greater activity in these reward areas. They just had more signal than those who were lean always.

People who struggle with their weight do not decrease their brain response after eating the same as those who have a normal BMI. So if someone says just stop when you’re full, and your brain is not telling you the fullness the way that someone else is, it’s a request you can’t follow. After [crosstalk 00:23:43]

Speaker 2:                              [crosstalk 00:23:43]

Craig Primack M…:           … Showed sustain hungry activity. So this uncouples effective brain response that we think we should have. If we eat a certain amount, we think we should be full and what we’re seeing is that is not exactly what we see and it may explain why some people who struggle with their weight reported underlying drive to eat continuously despite eating and despite potentially being full a few minutes, before or after they just ate and then wanting to eat again.

And it does validate that feeling and says, I do have people that come in and say, “My brain is just not the same. My hunger is not the same as someone else. That person just stopped eating when there’s food left on their plate and I have to have more.”

So this is study number three. This is really changing gears a little bit. This is again, a New England Journal of Medicine article and I think it’s a really good overview about some myths about weight, presumptions and facts that we do know that are still sometimes some people think are are questionable.

So the first thing is the Federal Trade Commission says, “If you want to make a claim …” So if you say, “Okay, this supplements, this diet, this medicine does what we think it does.” So it helps you lose weight.

It should be competent and reliable scientific evidence, tests, analysis, research and other evidence conducted and evaluated in an objective manner using procedures generally accepted to give accurate and reliable results.

So a lot of scientists putting their brains together and doing a good study. And really, these things are only true even if the person tells you believes it and they used a lot of what I call pseudoscience in their explanations.

It’s only true when it’s really supported by confirmatory randomized studies. And a randomized study, there’s two groups, there’s a group that gets the supplement or such an a group that does not or gets the placebo, and you don’t know if you’re getting it or not.

And so they’re really saying things that I believe are super strong. And then here are the myths about obesity. There’s seven of them. We’ll go through a couple of them here. Myths are beliefs that are held true by people even though there’s a lot of evidence saying that they’re not true.

And so the first one I think is a really good one and it says small, sustained changes in energy intake, or burning will produce long-term large weight changes.

So that’s someone who says, “You know what? If you just cut out 100 calories a day, every day for a week, you’re going to lose 700 calories. You do that for five weeks and you’ve lost a pound.” Or you can be a little more aggressive with it and you say, “Okay, cut out 500 calories today, do that for a week, that’s 3,500 calories, and then at the end of the week, you’ll lose a pound and if you just keep doing that.”

It really doesn’t take into account two big things. The first is that our metabolism if it does and it probably does, the first time you lose only take 3,500 calories. Our bodies are extremely good at surviving in the family.

And so what happens is as you lose more and more weight, that number goes up, and it can go up in some studies as high as 7,000 calories a pound. The second is as you lose weight, and you lose a little muscle, and so we think it’s about an 80/20 proposition.

And so if you lose weight for every pound, you lose 80% will be fat and 20% will be muscle, but that is the muscle that you’re carrying around for it that when you lose some of that muscle, your metabolism slows down also, and so you actually have to drop more.

So making small changes using that kind of math doesn’t always add up. I think the second is another one that I like which people say, “Let’s set realistic goals. Let’s lose five or 10 pounds and otherwise, if you don’t hit your goal of 40 pounds, 50 pounds, 110 pounds, that you’re going to become frustrated and then you’ll lose less weight.”

And what they found was exactly the opposite. If you set a big goal for yourself, you are going to do better than someone who just kind of goes, “Oh, if I can lose a pound here and a pound there.”

Three days into the week you say, “Okay, now I’ll get serious, I’m coming from my way in.” So the last two days we get on the diet and such. When you have big goals that are down the road, it seems to work a little bit better.

The third one I think is again another interesting one. Large rapid weight loss is associated with poor long-term weight outcomes, then slow gradual weight loss. So what that is is the person who says, “I don’t want to lose fast. I’m happy with slow and steady.”

And what we find that I’m going to show you another study about this is the more weight loss you lose in the first month, and the second month predicts better your weight in the next four years and eight years.

And so faster is actually better in the world of weight loss. If you go back to that Nike swoosh thing that we see all the time, we see the initial downward in a nice aggressive diet lasting at least six months.

If we don’t do more things on top of that, sometimes that’s when we see the plateau. So the more weight you can get off in that six month period, the better we’re going to be again in the next couple of years.

The next one is about steady stage of change and so there’s been a lot of psychology that’s gone into, “If someone isn’t really ready to lose weight, they probably shouldn’t start.”

And I believe that in the sense that if someone, a friend or family member is pushing you do weight loss, instead of, “You have to do this because of this, it probably doesn’t work.”

But if on your own you say, “You know what? I’m not sure how much weight I want to lose, but I am coming into the clinic.” Just coming into the clinic means that you’re at enough stage of change that you’re going to say, “Okay, I am going to make changes that will work here.”

Then we get into a little bit about childhood physical education classes in their current format. And so they’ve obviously changed a lot through the years. My son is a sixth grader, and they have three 45-minute periods per week.

I think as they’re younger, they actually have an hour each day and now it’s getting to three times a week and it plays an important role in preventing or reducing childhood obesity and that is actually probably not true.

There are some really good reasons for having PE in school. Number one, actually kids probably learn to have a break like recess or PE and number two, unfortunately, the things that happened in your home at lunchtime and dinnertime and at breakfast are probably much more important than a 45-minute class in school.

And then the last one I’ll talk about is the the breastfeeding piece. Dr. Ziltzer and myself if you see Dr. Ziltzer, we both are trained pediatricians also, and for many, many years, people have said that breastfeeding is protective against later on obesity.

And what we think that there is something called a publication bias. And so if the studies showed that breastfeeding was better for long-term obesity, they published the study and if it didn’t show it, the study didn’t make a journal.

Now there are benefits to breastfeeding especially in the immune system, bonding with the mom and the baby, but about long-term weight, it probably has much more to do with your genetics and the way that your family eats at each meal time than with you were breastfed or not.

For a long while there was that study that said, “The kids who were smarter were breastfed.” And so I said, “We’ll go around to all of your friends and if you think they’re smart, or not so smart and ask them if they were breastfed or bottle fed, and you just can’t tell, you can’t tell the difference.” There is no piece that does that as we’re adults.

Those are the myths. So presumptions. Presumptions are unproven, yet really commonly believed. And so the first one is about eating breakfast. And so regularly eating versus skipping breakfast is protective against obesity.

And I think what the studies will show us are many people do very well with breakfast and then there’s a subset of people who probably do better if they don’t eat breakfast.

And So if you’re someone who wasn’t eating breakfast when you come into the clinic, we’re going to push very hard for you to eat breakfast. For someone who is eating breakfast, sometimes maybe we work on some intermittent fasting and such and try a non-eating breakfast to see if that works any better for you.

Not every single person that’s in another study I’m going to show you, not every single person can be treated the same. Number two here is early childhood is the period during which we learned about exercise and eating habits that influence our weight throughout life.

Probably early childhood does have a little bit to do with some eating patterns, but when you’re a child in your parent’s home, you’re really at the guidance of what your parents are buying in the store and such.

It gets more into the genetics into our teen years and our early 20’s more about how we’re going to be as adults. The next one is about eating more fruits and vegetables, than eating fruits and vegetables, that is the as the sole way of losing weight is going to change what we do.

And that’s kind of saying that just changing carbohydrates without calories just eating green things just going on a vegetarian diet by itself without losing calories is the thing that makes weight loss happen and it doesn’t.

Whatever the dietary change you do, the whole goal by it is to decrease the calories we take. The last one I think I will talk about and this one is the weight cycling or yo-yo dieting one which is the next one or the fourth one here that is increased with … Is associated with increased mortality.

And the truth of the matter is some people will say, “I’m not going to start a diet because every time I go on a diet, I lose weight and then I gain some back.” And so they say, “Well, I shouldn’t do it at all because that’s worse than me.”

And what we’ve found is it is always healthier to be at the lower weight and so the more time you can lose weight and stay at the lower weight the better even if you do drift up eventually, then working on getting it back down, but the fact of moving back and forth especially in animal studies which is where we’ve seen it mostly does not make your health worse.

The third section in this are facts about obesity. These are things that we say that they are proven. There’s been enough studies, enough things in the medical literature say these are true.

And so I think this is an important one for everyone to hear. Although genetic factors, your parents, the family you’re born into, has a very large role in your later on weight, it is not your destiny.

Calculations show that some what we’ll call moderate environmental changes can promote as much weight loss as the most efficacious pharmaceutical agents. The two biggest things that fall into this is regular exercise, as well as seven plus hours of restorative sleep.

Those are the two most common changeable factors that can go against your genetics. The next one is diets. Very effective to reduce weight, but trying to go on a diet or recommending someone go on a diet does not work well in the long-term.

So what they’re really saying here is if you do decrease your energy. So some people don’t like the word diet because it says I’m going to do this diet for a period of time, and then I’m going to do something else.

But the fact is if you do restrict your calories, restrict carbs, or restrict fats or such, and then do it for a period of time and then go off it, yes, you will probably gain your weight back.

If you continue to restrict your calories, you will probably maintain more of that weight. This one is proven regardless of body weight or weight loss, and an increased level of exercise increases health.

The human body is not meant to sit still. We’re not meant to sit in a chair for eight hours a day, 10 hours a day or 12 hours a day and not going to move. And so Anyone no matter what your weight is, the more active you can be, the more healthy you can be.

And the person who has a lot of weight to lose who is active is healthier probably than many people who are thin who don’t exercise a lot. Physical activity or exercise in a sufficient dose, age long-term weight maintenance. Absolutely.

And so there’s different levels of recommendations on how much exercise people should do. The first is if you’re not doing any exercise, we just need to start moving. The next recommendation is about 30 minutes of exercise five days a week.

That 30 minutes can be in a 30 minute block or it can be even in three 10-minute bouts. A bout of exercise is defined is roughly 10 minutes and so you can go for a 10-minute walk, you can walk out to the corner and back.

Later on in the afternoon you can do it again and a third time. If you didn’t have the energy, it was too hot in the middle today, you can do a third 10 minute walk later on. That is sufficient.

As we lose more and more weight, more and more exercise is needed to keep off that weight and so it goes upwards from a half an hour to an hour most days of the week. And that’s walking time.

And so if you’re doing other things, if you’re lifting weights, if you’re running, if you’re bicycling or doing exercises that are higher intensity than just walking, you can drop the time in that.

I think the next one which is number five, continuation of conditions that promote weight loss promotes maintenance of lower weight. So what works for you to lose weight, we have to figure out how to keep doing.

If that means it’s some meal replacements, and some activity and avoiding restaurants and skipping alcohol and that worked really well for you, then we should find which of these things we can keep doing for long periods of time.

For overweight children, programs that involve the parents and home setting promote greater weight loss or maintenance. We do treat children down to the age of 12 easily in our clinic and we have gone down to eight or nine years old.

We know at eight or nine years old, all the food is provided by the parents and so making a healthier household, having less food around for stress eating, for boredom eating and for food rewards does help a long time.

The next one is the provision of meals. So provision of meals really means prescribing meals and so if you’re using some of the what we’ll call frozen or pre-prepared meals, there’s a lot of companies that do it now, obviously, the freezer section of the grocery store, we know if it says it’s 300 calories, it is 300 calories or meal replacements for the same reason promote greater weight loss.

When left to our own devices, our eyes are bigger than our stomach. If we think we need to eat a little bit and there’s a little bit more on our plate, we will finish our plate.

When restaurants give us this much food, we tend to eat more food than we would be when we were at home. So a lot of people throughout this corona quarantine time have been losing weight just because they’re cooking more at home and it’s been a lot better than the big portions restaurants gave us.

I think the last one that I’ll go to here is some pharmaceutical agents or weight loss medicines can help patients achieve clinically meaningful weight loss and maintain that reduction as long as these agents continue to be used.

So if we’re going to start medicines, and it doesn’t have to be the same medicine, but using medicines that are going to quiet those signals that we learned about in the first study and that’s really what the use of medications are.

They’re quieting the signals that are telling us that we’re still having more hunger that you probably should continue using those again, if they’re working and if they’re not working, we need to try others.

Study Four

So study four, I wanted to find a good review study. A good, for people who have never learned anything about management, how do we manage it? In the Obesity Medicine Association, as well as our clinic, there’s really four pillars to good weight loss.

The first is some kind of dietary change, the second is activity, the third is behavior change or the classes that we have and the fourth urges the use of medications. And so let’s look at some of the data behind that.

This is the look ahead study. It was done on people with diabetes, and it was done for about 10 years. During that time, they studied these people at multiple times. There are so many articles published about this group of people, this is an amazing study.

And so if we go into the top left corner in A, this was weight loss at one year and a percentage, and this is increasing physical activity. So what it showed you is the people that did the most activity lost the most weight.

The people, the medium [crosstalk 00:40:54]. Oops. The people that did the medium amount of activity lost a medium amount of weight, and the people that did the little least amount of activity lost the least amount.

When we go to behavioral session, so as I was saying, so these, they did classes like we do discuss the weight loss, and this was just going and looking to see the number of classes you attended.

And so the first was if you went to the more classes, you lost more weight, if you went to the medium amount of classes as you’d expect, you lost a medium amount of weight, and the smallest amount of classes you attended, you lost the smallest amount.

This was another study that used meal replacements. One of them was Optifast, but it wasn’t the only meal replacement. People were in different groups and so it was the number of meal replacements used during the first year.

And if you’re in the highest group, you did lose the most weight. As we can see, as you’re getting the trend to this. If you’re in the middle group, it was the middle amount of weight and the less meal replacements you used, the less weight we lost.

And the last one I think is also that thing where fast weight loss or more weight loss than the beginning predicts later weight loss. So this was weight loss at four or eight years.

So this one is, these three are four years and this is eight years. If you lost in this line just a little bit of weight, 2% or less and the first month, at the end of four years, you lost the least a month.

If you lost over 4% of your weight in the first month, at the end of the four years you lost more. If you look at eight years, now we’re using two months to predict that. And so again, if you had over 6% weight loss in the first two months, at the end of eight years, you would have more loss.

And if you only lost less than 3% in the first, you had less. I think what it really is saying, if you divide our society into there’s about 10% of people that will never probably gain weight significantly no matter what they eat.

There’s about 10% of our society and the other side, no matter what dietary plan, exercise and, they will lose, but they will lose slow and the rest of us and most of the people that we take care of in the clinic fall in that middle 80% if we’re doing the things that we’ve had prescribed for us.

Taking our medicines, coming to class, exercising and eating less calories, again, with more meal replacements from this, we will lose weight appropriately. If we’re on the wrong plan for us in that first month, and we’re not losing a significant weight no matter or because and we’re doing all of those things, we’re doing the wrong plan for us.

And so this says, “If you’re on the right plan, you will lose more and if you’re on the wrong plan, you probably won’t lose as much.” Hopefully that makes sense the way I’m saying.

Medications for weight management or anti obesity medications.

We use these all the time in our clinic and this is just a little summary and I’ll go through each of the medicines that we use here.

The first is Phentermine. Phentermine is between 15 and really 37 and a half milligrams orally. Its mechanism is called a sympathomimetic or mild stimulant medication.

When it came out in the 1950s, it was really only for short-term use. Although many societies including the Obesity Medicine Association, the Endocrine Society and such believe we should be using these medicines for much, much longer.

Although in the 1950s, they weren’t studied that way. The advantage is it is an inexpensive medication and the side effects, they say side effect profile is strong which yes, a little sleeplessness in the beginning and you shouldn’t use it if you have active heart disease.

And it is not exactly true anymore that there is no long-term data as we’ll see as we go down this list. The next is Orlistat. Orlistat is a medicine that’s been on the market for a long, long time.

I actually have not had even five people probably in the last couple years who have abused this medicine. Orlistat was Xenical or there’s a new … The new name for it as they brought it down to 60 milligrams a day instead of 120 is called Alli.

It’s used three times a day before meals. Really what it does is it blocks the absorption into the intestine of the fat that we eat. And so if you’re not absorbing the fat, you are passing it through your stool.

Yes it is for long-term use, it’s also used in the European Union which has slightly different guidelines than the FDA in the US. The people who are in the placebo group lost 2.6, but on the drug, they lost about 6.1%.

It is not absorb and it does have good long-term data, that is true, but for me and most of the people that I have had that have taken it, the side effect profile is the reason that they don’t take it.

When it was at full strength, 120 milligrams, it actually wasn’t expensive medicine back in the day. It was about $140 a month 12 or 15 years ago when we did use it a little bit, but the side effect profile.

So this fat that we pass is called steatorrhea, that’s the medical term. And unfortunately, we believe and I’m going to be the physician here that we believe we’re passing gas and we actually have an accident.

And I had a woman that happened to in her work office and again, never said she would take this medicine again. Lorcaserin, also known as Belviq. Some of you were on this medicine that went off the market earlier in the year or the end of last year, and so I won’t spend any time on that.

There is a medicine called phentermine with topiramate. Trade name is called Qsymia, but in the clinic, we do use often phentermine and topiramate individually. Phentermine is the same phentermine we use up there, but in slightly smaller doses.

And then the second is topiramate is an anti-seizure drug that has these actions. It is for long-term use and as you can see here, the placebo which is not very good, which we would like to see.

So it really teased out that this was a really effective drug, 9.8% in the full dose that is the strongest as you’ll see of all these weight loss drugs, and so really robust or strong weight loss, good long-term data.

Unfortunately, it is expensive when used as the trade drug. And here, teratogen means that there is a slight risk if a woman were to become pregnant on this drug of increased cleft lip and palate of only six out of a thousand.

So it is there, but it is a small risk. And so if you’re a woman who is of reproductive potential which is the terms that they use, it’s recommended to use two types of birth control while you’re on this drug.

Naltrexone with bupropion. Many of you know is Contrave. It is an opioid receptor antagonist. That’s the first part to Naltrexone. It is blocking you the receptors in the brain where opioids go to, so where Vicodin and Percocets would act and then it uses bupropion which is an antidepressant that works on dopamine and noradrenaline.

It is for long-term use both in the US and in Europe. As we see its medium strength, so it’s got about 5.4% weight loss and a pretty again, placebo group that didn’t lose much.

So this is kind of a real number I believe. The biggest differentiator of this one versus some of the others is it does reduce food cravings especially nice long-term data, medium expensive.

Our price in the office is cheaper than most people can get in the pharmacy and I guess they’re talking about side effect profile because about one in three people do get some nausea when they take it, sometime severe.

The last one of the common ones we use is called Liraglutide, some people call it Saxenda. It does require titration, meaning, your start low and build up. It is the GLP-1 receptor agonist. GLP-1 is another of those hunger hormones or fullness hormones that we find.

It’s naturally found in our small intestine like those ones we saw in the first study, it goes through the blood to the brain and tells us we’re full. It is used both in the United States and the European Union.

It probably is the second best one here with the 7.4%, but what you try to do is you take the drug dose minus the placebo, and so we’re seeing about 4.4% weight loss on the full dose.

The side effect profile overall is pretty clean. It has long term data that we like. It is super expensive and that’s its biggest downfall. Some insurances cover it in Arizona. In Arizona, we have overall lousy coverage, and it can be up to $1,250.

Although if your insurance covers it, I’ve seen it, obviously for much, much less and it is an injectable medication. Next slide.

So these are medicines that affect weight gain. So not only do we want to sometimes put people on medicines that cause weight loss, but we want to stop medicines that cause weight gain.

And so the first class here is the diabetes medicines. Insulin that many people use for diabetes. The sulfonylureas which are being much less to use over the last five to seven years are very, very weight gaining and then one called Pioglitazone is also used quite commonly that’s a weight gainer.

There’s a class of medicines called a DPP-4 inhibitors. There are many different ones in this class. Those are weight neutral, they don’t put weight on or take weight off, but then there’s the ones that help weight loss.

Some people in our clinic will be using Metformin specifically for its weight loss benefit. The GLP-1 agonists like Liraglutide or Saxenda that we talked about, and then there’s a medicine class called Sodium-glucose co-transporter or SGLT2 drugs, those also cause some weight loss although not as much as the GLP-1 agonists.

Although sometimes when put together, we get a synergistic effect with that. One of the other classes of medicines that cause a lot of weight gain are the antidepressants or mood stabilizers.

Tricyclics that some people use for sleep or pain cause some waking some more than others. Serotonin reuptake inhibitors. So those are antidepressants. The one in the class that has the most weight gain is paroxetine.

Mirtazapine is another antidepressant and lithium also. Ones that are weight-neutral is citalopram or Celexa. What you’ll see is Venlafaxine here is weight neutral, but you also see it over here as weight loss.

So that means in some people, it does nothing, but in some people, it also causes weight loss. Sertraline, or Zoloft is weight neutral for at least about a year and psychotherapy can be weight neutral also.

And then Venlafaxine-bupropion which is one of those two medicines that is an anti-depressant, but it’s in the contrary or fluoxetine which is Prozac. We say in the short-term.

So between six months in the year, some people do see some weight gain, but they initially had weight loss. Many of the anti-psychotics cause weight gain, many of them are significant.

There’s two that do not, ziprasidone and aripiprazole. Some of the anticonvulsants. Ones that a lot of people know about is Gabapentin. Gabapentin is used a lot of times as the pain modulator.

Unfortunately, yes, that does cause weight gain. Sometimes using it is still better than having the pain, especially nerve pain that some people have and so it’s not something you should just stop, but it is something you should question with your doctor.

Lamotrigine or Lamictal is weight neutral. Topiramate is the Topamax that we use in the office as a weight loss and it’s also used for migraines as is zonisamide for weight loss, but it’s really also used for migraines.

Antihistamines cause weight gain. Diphenhydramine is Benadryl. And so Benadryl is a medicine that you need to take if you have severe allergies, but just as a sleep aid, it is not a great solution.

Although these aren’t anti-histamines, they are weight neutral. So steroid inhalers like flonase or decongestants. If you’re on phentermine, we want you to be very careful with decongestants. Some people can be stimulated by decongestants.

Adrenergic blockers are really mostly what they’re saying is anti-blood pressure medicines. Propranolol can be a weight gaining drug. The class called ACE inhibitors or angiotensin receptor blockers, ARBs and calcium channel blockers are usually weight neutral.

Although occasionally you can have one that cause a little less weight gain a little more weight loss. I guess the last one in here that’s worth talking about are corticosteroids. So steroids are useful.

They are life-saving in many situations, especially allergic reactions in people with adrenal problems, but they also at the right dose unfortunately, or the long-term dose can cause significant, significant weight gain.

Targets for anti-obesity medications. I don’t want to go through a lot of this, but you can see the Naltrexone-bupropion work on different parts of the brain.

Really what the goal of this study was to show you is there’s a lot of different areas that these drugs work on. If you use blood pressure as your example, there are some people that have to take two blood pressure medicines or three blood pressure medicines, or four blood pressure medicines.

There’s even some people on five blood pressure medicines. What we really see here is that in the future, we’re probably going to have to stack medicines on top of each other, two medicines, three medicines, maybe even four medicines until newer generation medicines come out.

And so we want to find ones that work on different parts of the brain to kind of get a synergy between that. Surgical procedures for the treatment of obesity. A weight loss talk would not be sufficient if I didn’t give you a little bit about surgery.

Surgery is for many people a good long-term strategy. For others, it is unnecessary. Adjustable gastric banding or the lap-band for a long while was the most popular surgery done in gastric or in weight surgery.

It is now the least common and in Arizona, almost non-existent. The two that have taken its place are the sleeve gastrectomy as well as what we call the Roux-en-Y or gastric bypass.

The sleeve gastrectomy for a while has taken over as the number one most performed procedure, but it may not have the longevity of the Roux-en-Y gastric bypass. Although the gastric bypass is a more involved procedure.

As you can see, change in body mass index after three years, I wish this also had a six year number because it didn’t really show that gastric banding did seem to be pretty good. Although most people don’t think seem to get this, last thing even three years at the time.

Sleeve gastrectomy is the middle one, and the gastric bypass had the most one. If we see weight gain in these two surgeries, we probably start to see and not everyone has weight gain, but if you do have it, the sleeve gastrectomy is probably seeing some weight gain at two years and the gastric bypass at four years.

Although most people do keep off the majority of their weight, just they do not get the goal or stay at goal for extremely long periods of time. When you’re talking about Type II diabetes, the Roux-en-Y gastric bypass is the best for that.

The data on mortality at less and greater than 30 days was done from 2014. Now we’re in 2020, and the data is significantly better than it was back then. That being said, the one with the most complications is the Roux-en-Y gastric bypass because it is doing the most to your abdomen.

The sleeve gastrectomy, the middle amount, and the gastric band with less. When as reoperation rate, it’s actually a little bit different because reoperations in the gastric band were the highest because the band either slips or comes out of place by 10 years after getting the band, at least 50%, if not more people have actually taken the band out.

And another percentage of them because it’s adjustable don’t have any fill filling that and complications are kind of the same. The more aggressive surgery has more complications, and the less aggressive has less.

Four Pillars of Weight Loss

So there are four pillars of medical weight loss. When you put them together, people do better, diet, activity, behavior change and anti-obesity medications. When Dr. Ziltzer and I wrote the book that we did Chasing Diets, these symbolize the four legs of the chair.

If you just do diet, you’re balancing on one leg of the chair and you can easily follow. If you put two legs of the chair down, you’re stronger, if you put three legs down, if you’re doing all four aspects, you have the strongest base.

When prevention of weight doesn’t work, we do have to use treatment. Although obviously, prevention is the first strategy for most people, by the time people come to me, obviously, we’re way beyond prevention.

I think this is an important one and it’s now written in this article which I like. People who did not have obesity by body mass index, but do have elevated body fat, have elevated cardiometabolic risk.

So higher risk for stroke and for heart disease and should be treated irrespective of their BMI. So people at higher cardiac risk should be treated. And then as a general rule, more is better, going to more classes, doing more exercise or activity, having more meal replacements, and the better your early weight loss helps your overall weight loss.

This is the last study. Many people have watched The Biggest Loser TV show. And although I don’t love this study, truthfully, I think it is an important one because it’s talked about so so much in this field.

And so we’re going to talk a little bit about what’s called metabolic adaptation, six years after the season and I apologize, I don’t know exactly what season this was, but metabolic adaptation which is after weight loss, you see a slowing of your metabolic rate.

RMR is your resting metabolic rate, greater than what would be expected based on the change in body composition. So again, of your weight about 20% of it is muscle loss.

And if you just use the muscle loss to determine what your metabolic rate should be, this is lower than we would expect. It’s also known as adaptive thermogenesis, and unfortunately, this counters your weight loss and contributes the weight gain because even though we get pretty good and diet in the beginning, the diet softens up as we know from study number one, those hormones come.

And so if our metabolism is slower at the same time, we don’t lose the same as we did in the beginning of the plan. So there were 16 people in this season of The Biggest Loser. 14 of them agreed six years later to be in this study.

Six of them were men, and eight of them were women. And so if we look at their baseline, they weighed 148.9 kilos on average or 327. There was a big range, it went less or more of 89 pounds at baseline.

They lost during the 30 weeks of the competition, or TV show 58 kilos which is 128 pounds, but you can see, this is a great range. Someone lost an additional 89 pounds or lost than 89 pounds less.

That goes to show you that no two people are exactly the same. On this TV show, they were living roughly the same life. They would do the same exercise competitions, they would eat roughly the same food and some people lost a lot more weight, and some people lost a lot less weight.

And although they did have significant regain between between the 30 weeks or end of the show, and six years, they still kept off almost 12% again, on average of their weight, so it’s still significantly below their baseline.

These are plots. So each of these little dots here at 30 weeks or at the end of the show is a person and then they follow the same person out and these lines are the averages.

So if we’re looking at body weight change in kilos, at the end of the show, it was lower, and then six years later, almost everyone as you can see except for this one gentleman or woman sorry, went up.

We look at fat mass change and the fat was lower at the end of the show and did go up, but over those six years so they gained fat back and fat mass change went up also significantly. Oh, sorry, this one was fat free mass.

So their muscle went up slightly, but as you can see, their fat went up more during that weight regain which again is what we have expected. Here is the resting metabolic change.

And so at the end of the show, the resting metabolic rate was lower than we thought, but over the next six years, even with them gaining some weight back, the resting metabolic rate on average went down.

As you can see, some of them went up, this person went up, this person, then this person went up, but if you take all of them together, some of them went down. We don’t actually know exactly why.

And so the metabolic adaptation was just under 300 calories lower than you’d expect, but at the end of six years, it was about 500 calories less than you’d expect.

This is the age when they first started the show. They were about 35 years old on average. They were a little bit older at the end of their 30 weeks and you can see obviously, they went up by an average of six years at the end of the time.

Their weight started in kilos, about 148. At the end of the show, they’ve lost a lot of weight. So they were down to 90.6 kilos. And at the end of six years, they’ve gained back on average a lot of their weight, but again, not all of their weight, they did keep off a significant amount overall and their body mass index did exactly the same ratios.

And I think what the interesting thing is here is metabolic adaptations started when they first started their metabolism a little bit better than we expect. And then they went down by 275 calories at the end of the show and fell an additional, about 225 calories six years later and their activity went up at the end of the show and for a lot of them on average stayed up despite weight regain.

Their sugars did exactly what you think. Sugar went up slightly, but came up a little bit more. Their insulin levels went down and then what we’re trying to see is these hormones control metabolism a little bit.

T3, T4 are your thyroid hormones along with TSH which is talking about how the thyroid is doing. And that hormone I talked about before called leptin. Leptin [crosstalk 01:04:15] when you start and then it went down.

So it started in the 40’s and went down to about three which [crosstalk 01:04:27] lost fat and then we’re up to about 27 at the end of six years. This is nice to say that the fat mass change was equivalent to the body weight change.

The majority of weight that they lost at the end of the TV show which is the correlation here was fat. It was at least 80%. This one, I’m going to skip and here’s the summary.

It again shows the magnitude of early weight loss was the best predictor of long-term weight loss. So the people that lost more weight in the beginning of the show did keep off more weight at the end of the six years.

At the end of the 30 weeks, at the end of the TV show, their metabolic adaptation was significant and correlated at that point with the weight loss. So the more weight you lost, the slower your metabolism got in relation, but it didn’t correlate with leptin which is the fat hormone.

T3, TSH or T4 are thyroid hormones. And so to really summarize the whole study, long-term weight loss requires a visual in combat against persistent metabolic adaptation.

So we have to find strategies for long-term against this metabolic adaptation that happens that counters our ongoing efforts to keep our weight off. These are just the five studies out if people were looking for references.

I want to give a little more history. Like I talked about the earth being flat in the beginning, depression treatment throughout, I call it the ages. And so the analogy here is 7,000 years ago for depression, we used trephination.

If you know what trephination is, they put holes in people’s skull and they found that in mummies and such. If you go to the 1600s, for depression, we use bloodletting and purging.

As we get to the 1920s, we use Insulin Coma Therapy. And so they use enough insulin in people to actually bring their blood sugar so low, they went into a coma to treat their depression.

Another one that was in the I think the mid ’30s was Metrazol Therapy. So this was a stimulant. Think of cocaine-like that they gave in such high doses that caused people to have seizures that was used commonly in the ’30s and ’40s, but were taken off the market in the ’80s completely even though it wasn’t being used anymore and I think this an interesting one.

In 1949, there was a Nobel Prize in Physiology and Medicine given for a depression treatment. Some of you have heard me say this, and it still blows my mind that the thing that got the Nobel Prize for depression treatment was lobotomy.

Remember, lobotomy is taking a little needle and probably going in through the eye socket, and scrambling a little part of the brain. This was not only a accepted procedure, it was a Nobel Prize-winning procedure in the 1949’s-ish.

Today, we use SNRIs and we use medicines. So between that time, science has changed. In the past, weight loss was something that we were made to feel guilty about. We did not see physicians, we did it on our own, we did the next crash course and science has changed.

So today in depression therapy, we used SSRIs. We used SNRIs, so serotonin and norepinephrine drugs. We use other various therapies including ECT, but it’s done obviously much more humanely than it was done in the past and then in the future, we’re using medicines and maybe even the present, medicines like Ketamine and hallucinogens like Iowaska and such.

What it says to me is that the treatment of obesity will again change. What we believe as a society and many primary care as well as specialist doctors will say to you not knowing what we do at Scottsdale Weight Loss, they’ll say, “You shouldn’t do that. You just need to start exercising again, and eating less.”

And again, if that worked, we would not be where we are today as a society. And so I think we are somewhere in the range of today and the way that we are treating people, but tomorrow, things may change yet again.


So as an overall summary of tonight, the brains, the hypothalamus, the control center for appetite and the body, all these signals that go of people with obesity is not the same as someone who has normal weight and to treat them the same is really malpractice.

Be aware of the myths of obesity treatment. Use science to back up your ideas and thoughts, real science, not just pseudoscience. Be open to new treatments, but be afraid obviously of unproven ones because there are a lot of them out there.

Last couple slides. Waterfall Plots. This shows you what I’ve kind of alluded to. So this top one is a low fat diet and this is a low carbohydrate diet.

And as what we can see is on this diet, each of these represents a person. There are some people on the low fat diet that lose a lot of weight. There’s some people in here who lose a medium amount of weight.

There are some people on the same diet that lose zero weight and there’s actually some people that gain 10 kilos on the same diet. And you can say, “Well, maybe it’s their diet.”

Well, it happened the same thing on the low carbohydrate diet. What that says, if there’s someone who says, “The way you are losing weight or the way that person is telling you to lose weight is the only way to lose weight for you.”

Tell them that that is not true, that some people do really well on every diet and some people do not. This is a small list of other studies that if I were to do talks or studies six through 10, I would do and then the last is I am social.

If you’ve never seen my website, it is and I have a LinkedIn site, I have a Facebook site, an Instagram and I’m joking, I do not have a TikTok site.

So let me find how I can find everybody here. Oh, there’s the group. Hi everybody and if you want to unmute yourselves, and I am now open for questions. So please ask away and thanks for being here tonight.



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