Okay, welcome back to the Regenerative Health Podcast.

Today I'm speaking with Chris Staffer.

Now, he's an obesity medicine specialist and family medicine specialist from Washington State in the United States.

And I came across Chris's work and very opportunistically when I've been going through some CT scans in my clinical practice and going through them with the goal of basically asking the question if the patient in front of me has any visceral fat and where essentially their fat is located.

And we're going to go into in this topic in depth in this podcast about the harms and why it's important to identify visceral fat.

But in doing so, I stumbled upon Dr.

Dr.

Staffer's website called Revitalized Metabolic Health Health.

And it's got some amazing images of visceral fat and a really well explained I guess concepts and explanation.

So Chris, thanks for coming on the podcast.

Yeah, certainly.

And thank you, Max, for the invite.

So we're going to kick this off with a very simple overview of what is visceral fat and why should your patients and why should the listeners care about it?

Yeah, so as I explained to my patients, there are different types of fat.

And uh you know, the one that people are most conscious of, most concerned about is is the the pinchable fat, the the fat that's visible on the on the outside, the subcutaneous adipose tissue.

Uh we sometimes call that uh white fat.

And um but when you when you get down to it, that's actually um not the concerning fat.

Um and and more so we should be concerned about the invisible fat, uh the visceral fat, which is basically the lion.

People think of it as uh being around the organs.

That's how they know it.

And um I describe it to people as it's the fat it's the fat that causes the protrusion of the abdomen, and uh as opposed to the pinchable subcutaneous fat.

Um so visceral fat lies beneath the abdominal muscle layer.

It's uh it's not something you can grab per se, but you know it when you see the classic um male pattern beer belly.

Um and that's that's visceral fat.

Uh another way of thinking about it is when you when you lie flat, uh the subcutaneous fat tends to fall off to the side thanks to gravity, whereas visceral fat keeps that belly uh that that hump in the belly.

And uh, and so that's that's an indication of it.

Uh and then of course there's also brown fat, which uh which people may know is uh is a more metabolically active uh fat.

Um and uh we think of that with being triggered by cold, and that's what keeps uh babies warm so that uh they don't become hypothermic when they can't control their temperature very well.

Yeah yeah, it's it's crazy how um simple this concept is, but widely, I guess, misunderstood or or not not um not really understood, which is the the fact that people kind of grab their love handles and and you know worry about the fat that they can actually hold, but not really realizing that if anything, that's probably that's benign, if not protective, of of of longevity, whereas the the real problematic fat is is what's making that abdomen tall and and and tight.

Yeah, for sure.

You know, one thing uh uh if you look at people uh in in public, for example, and you you look at you look at a guy with uh with a jiggly belly, you know, we think of the classic uh Santa Claus.

Um the American Santa Claus.

I don't know if you guys do that too.

Um and uh I've had people describe it to me like, oh my husband has is he's obese, but he's soft.

He's got soft fat.

And and it's like the cuddly bear.

And uh, and that's a lot of subcutaneous fat.

And uh versus the really taut belly, you know, it's like a looks like a drum.

You know, so I have a guy, one of my patients, uh, who's diabetic, has has a very profound, you know, pregnant-looking belly.

And I struggle to pinch any fat on his belly because it's so tight.

And uh and that gets into the whole concept of the um personal fat threshold.

So he's he's a guy who has a very low personal fat threshold.

His body doesn't want to form a lot of pinchable subcutaneous fat, and and he's exceeded his capacity for that subcutaneous fat.

And now any excess energy goes right to visceral fat.

Uh so it's very interesting how that plays out.

Yeah, it reminds me of uh reel I saw on on uh Facebook, and it was this uh overweight guy who is like doing backflips on his roller skates at the skate park, and extremely athletic and very mobile looking, um, agile looking.

And as you as you watch his body perform these acrobatic feats, you can see just all this jiggling happening.

And when I when I looked at him, I immediately thought this is someone who is probably got a six-pack and a very athletic body with a whole bunch of subcutaneous and and not much visceral fat at all.

Maybe let's talk about the personal fat fat personal.

We'll talk about um you know, why is the body kind of laying down this fat?

Yeah, so it so I think of it as uh a function uh mainly driven by genetics, uh, although I think there are definitely some environmental factors that that play into it as well that influence it.

Um but you know, if you look at uh different populations around the world, my my classic example for the for the low personal fat threshold is the Southeast Asian population.

I always pick on China.

Uh you don't see many obese Chinese people, and because their genetics don't allow it.

Yes, there are some, no doubt.

And I think I think it's changing more and more over time due to epigenetics.

You know, the the activity of genes is being influenced by the environmental factors.

But then you look at a population like Samoa, American Samoa, or or just the United States of America in general, uh, where there's a lot more obesity.

And and the difference appears to be mainly genetic in that there's a determined capacity for fat storage, subcutaneous fat storage.

And once you reach that capacity for fat storage, your body says, uh-uh, we're done, we're full.

Uh, we can't take anymore.

And and this is this is developed by the whole process of insulin resistance.

You know, I like how uh one of the examples that Dr.

Jason Fung uses is it's like packing a suitcase, and you can just you can shove one more item of clothing in there, and one more, or one more, or the the Japanese subway.

You can shove one more person into that train up to a point, and then and then the train just can't give, or the luggage can't give anymore.

There's no more room for anything.

That's the personal fat threshold, because then any excess energy has nowhere to go.

There's no uh fat depot that will accept it in the periphery, and so then it ends up uh being shoved into the viscera uh because because that energy is driving higher and higher insulin levels.

Look at insulin as or look at it as a situation where your body's desperately trying to find a home for that excess energy, it's got to shove it in somewhere.

If it stays in the bloodstream, that's that's energy toxicity, that's diabetes.

And so the body, as a protective mechanism, shoves it into the viscera, whether that's the the muscle, the liver, the around the heart, uh, or the the actual viscera uh around the in the in the abdominal cavity.

And that's overflow energy.

It's it uh it's it's your body's strategy to get it out of circulation so that it's less harmful in the in the immediate moment.

Um but of course we know that visceral fat is the more harmful, the more inflammatory uh fat over time.

Yeah, so so let's talk about that because I guess uh what we're getting at is that someone can be rolling around potentially with a normal body mass index, BMI, but the the allocation of their fat stores predominantly being visceral, as you mentioned in that in the Chinese population and in potentially Indian and subcontinental populations, and and obviously in lots of uh Anglo Anglo populations as well.

Um, and that person, although having having a normal BMI, is at very much increased risk of what you and I's doctors called cardiometabolic disease.

But what what I I explain to patients is you know the the the boxing dice of of nursing home risk factor.

Risk factors.

So yeah, speak to that a little bit if you could.

Yeah, I mean you know, visceral fat uh super complicated, uh, of course.

That's um while it's considered um metabolically active, it's it's more active in a negative way.

And um, you know, we talk about we wave our hands into this black box and say, oh, it's cytokines and all these other hormonal factors we don't fully understand.

Um and uh but it but it's but it's a fascinating uh look at our physiology.

Uh you know, visceral fat has a lot of macrophages.

Um and uh it's thought to be a uh a tool to help with the immune system.

So if so if something permeates the gut, the gut wall, hopefully those macrophages uh intercept and and serve some role in in terms of uh uh immune protection.

Um visceral fat is associated with insulin resistance.

This is a very consistent finding uh throughout research.

Um and so uh contributing to the the typical cardiometabolic disease.

Uh you know, this brings me to uh one of the concepts that I hammer home with my patients is recognizing that modern medicine looks at everything very distinctly.

You know, we we think of well, there's hypertension and there's a medication for that, there's specialists for that, oh, and then there's heart disease.

Oh, well, we have medications for that, specialists for that, and on and on and on.

Every disease per se has its own specialists, its own regimens, and it just results in a very compartmentalized system of healthcare.

But ultimately, all of these disease processes that we're or these diagnoses that we're familiar with in modern healthcare, and it makes up 80 plus percent of healthcare, uh, is it's all just different symptoms, different manifestations of insulin resistance.

Um, what we call the Western disease.

And uh and if you can, if you start thinking about it like that, uh it very much simplifies the whole field of medicine.

And you recognize that, oh, well, fatty liver and uh PCOS, polycystic ovarian syndrome, um, and and even most cancers and dementia, they're just they're different symptoms of the same disease, and they show up in different people at different times and in different organ systems.

And and that's a really important concept.

Uh, it took me a long time to to really grasp that.

Um it was it was when I was working with all these patients in the hospital as a hospitalist and recognizing like, wait a second, this this person with a stroke is no different than this person with a heart attack, is no different than the diabetic with end stage renal disease, whatever it's the same disease.

Uh, but of course we treat treat them so differently.

And and uh modern medicine doesn't really grasp that that concept.

Um and let's face it, it's it's probably uh driven a lot by the finances of of healthcare.

You make a heck of a lot more money by by partitioning out into the different specialties and specialty clinics for each one, specialty hospitals, even uh for for different problems.

Yeah, absolutely.

And and that fracturing, I think, leads to eventually suboptimal care or suboptimal advice, which is hey, we can potentially uh solve or would reverse the underlying disease process and therefore you know spare you a visit to each of these individual specialists if we if we just attract the root cause.

Let's let's talk about this this idea of why the or how the visceral fat is is putting down.

You made this distinction between genetics, genetic predisposition, and some lifestyle factors.

And uh absolutely it seems like certain people are really predisposed to essentially filling up their subcutaneous stores very quickly and then spilling into into um into visceral fat.

And I think that genetic example of lipodystrophy really kind of tells a lot because it's again, I like these I in in in clinical medicine and and or just in general in science, it's I feel like it's really useful to have that in extreme example because it's a it's almost like an epistemological proof of concept that you can derive um a lot from.

So yes, speak speak again to to this personal fat threshold concept because I guess the real key question is to what degree is it modifiable by our our our our our life choices yeah uh so basically um you know we're we're talking about uh uh again the capacity for your fat depot to expand.

And um and people with a high personal fat threshold, um, they can they can increase their their fat cells, the number of fat cells, rather than than just the increasing the size.

So we know that if if there is no capacity for increasing the number of fat cells, you just overfill these fat cells, there actually develops uh uh hypoxic state in that fat cell.

There's oxygen can't reach the inside of that cell.

And there's you know cell death, necrosis driving inflammation, and that's that's part of the whole picture of insulin resistance and and the inflammatory state with with uh visceral fat, or or or I should say the uh you know exceeding the personal fat threshold.

Um there's this also ties into um uh seed oils.

So uh seed oils, omega-6 fatty acids, polyunsaturated fatty acids.

There's a lot of different ways of referring to these.

Uh they actually inhibit the ability of fat cells to uh replicate.

And in so doing, that limits your personal fat threshold, preventing your fat cells from dividing, increasing in number.

And so that's one environmental factor that that we know of that theoretically uh reduces your personal fat threshold.

I don't know that there's any study that really uh I uh uh hammers out you know what the personal fat threshold is um and and and the effect of seed oils on that, but but it's uh but it's certainly a a strong uh theoretical connection there.

Another factor that I know from experimental evidence seems to preferentially expand the visceral fat depot is circadian rhythm disruption.

And there's a lot of uh a couple of mouse studies showing that you you feed two groups of of mice same diet, but one is essentially being fed during that the active phase, which is uh obviously when the mice are supposed to be sort of their their nighttime, their inactive phase when the mouse is supposed to be sleeping, uh and you you do that for a couple months and you look at their fat tissues, yeah, they get this uh macrophage infiltration, they get expansion of all all the visceral compartments.

And um, you know, I wonder whether whether we're if we're shoving nutrients into a system during uh the time of day when that um the the the the product the burning, I guess, or the metabolism is not optimized, then the body might just uh yeah essentially go into this mode where it it uh does the the best of bad um bad options and and uh stores it in visceral fat rather than potentially letting the blood glucose rise.

Um yeah, very conceivable for sure.

Yeah.

I was gonna say, you know, uh one area uh that's really interesting to me also is um looking at the procedure of liposuction.

Um so you know, my my I have a bunch of patients pursuing weight loss, and you know, they get to a certain point and they're like, Oh, I want to do a mommy makeover and get my liposuction and all these other things.

And and I say, No, please no.

Um, because what we know about liposuction is you're removing that that fat buffer, that fat depot.

You want the ability of those fat cells to expand.

And if you do liposuction, you're removing that that buffer.

And so there's a study from Brazil.

It's I think it's the only study of its kind, unfortunately, and it's it's a relatively small, I can't remember how many few dozen uh subjects, but basically uh women who had liposuction when they regained weight, it preferentially came back in the uh as as visceral fat, basically, in the abdominal fat versus the peripheral, the subcutaneous fat.

And uh and so it's very telling that that the the peripheral fat is uh actually beneficial, uh favorable in terms of health, even though aesthetically we all want to get rid of the that pinchable fat, I get it, but but metabolically that that peripheral fat is an important uh buffer against uh metabolic disease.

Yeah, great, great, very interesting point.

And maybe a reminder for the listeners that the the fat tissue is.

acting like this endocrine allin and subcutaneous fat um secretes these adipokines, adipinectin, obviously the leptin itself.

So we we actually want the the the sufficient amount of of subcutaneous fat.

And obviously it's an energy store for if we're going through potentially like uh a hectic period or hospital admission, severe infection.

That's like the store that you that you want to be um build building up.

I I guess the the question that actually two points.

One um one is going to be with respect to um metabolically healthy obese and uh and and whether we actually want to cultivate that subcut.

But the other point that I before I forget is to look into the physiology of babies.

And um there's there's obviously human pro babies are the most uh fatty primates uh that that exist very very good some interesting some great papers by Stephen Canaan and Michael Crawford who basically analyzed the the subcutaneous fat distribute the fat distribution of babies and it's it's it's almost all uh subcutaneous and essentially contains a whole bunch of medium chain fatty acids that are really readily um metabolized into ketone bodies um the the obviously the the the corollary being that um for the to power the brain that we can they can use that fat to uh to to to run the brain they can turn it into ketones that run the brain so I guess the the the why I raise that is do you think in aging and maybe advanced age uh it would be helpful to have more subcutaneous fat in in a situation where you're trying to maintain brain energy yeah interesting um not entirely sure um I don't know I mean I think I think the more relevant part is is just staying beneath your your personal fat threshold in terms of cognitive health in the long run uh because again if once you hit that you exceed that threshold that's driving insulin resistance and then uh you know 80% of Alzheimer's is is driven by insulin resistance um yeah I don't I'm not uh I'm not certain about the uh the signaling hormonal signaling and all in terms of uh would would increase subcutaneous fat be beneficial hard to say yeah yeah it because you you obviously see people you also see things like this the um the sumo wrestlers and they they're obviously jiggling around like Michelin men and and and you wonder you know if they is their lifestyle of potentially like obviously massive calorific intake but but uh a lot of exercise also helping them potentially stay under a a disceral personal fat threshold but lay on lots of uh subcutaneous fat.

Right.

Well then we have the uh the obesity paradox you know in certain situations people who are uh obese live longer than than uh thin cohort or a comparison uh and you know some of that uh unfortunately is driven by um just just a um in an issue of like like a C O P D patient with caquexia you know they're they're wasting away so so that skews the data um but uh but yeah there there there is this obesity paradox that uh that we don't fully understand.

I guess it it makes it even more important therefore for people to actually know where their fat is because someone obviously could listen to this be like oh yeah and my BMI is high I've got a big basis complex but I'm I'm all good.

Well I think the the this the message is definitely not um the message is like let's find out where your fat is right identifying the the tofies thin on the outside fat on the inside um you know that's that's that's super important to understand.

So let me look let me share the screen and you can like quickly talk through some of these CT hands maybe.

Yeah certain um I was gonna say it's there's also you know the the classic marathoner who who looks fit and of course we say oh you're you run marathons regularly you must be so healthy and so on well then we have all this research that shows uh marathon runners you know with a with an age matched cohort compared to their age matched cohort um they have actually more cardiovascular disease than the sedentary uh age matched cohort uh and it's probably driven a lot by cortisol by inflammation and uh and that the fact that they they probably have a lot of visceral fat even though they don't have that pinchable father yeah yeah so so maybe explain like we've got I'm screen sharing now people can see essentially uh slices of of a CT scan so can you can you talk through these two patients that you've uh that you've shared here on this blog right so so on the left you see uh a lot of gray and uh so the white is the dense bone the the grayish uh material is is like muscle and um and you and you see little fragments of intestine that that appear there as well and then the the blackish well the true black uh you see a couple areas on the left uh is it's yep exactly that's air that's air in the intestine and then the the mostly black but with you can see a little streaking in it uh that represents fat right and so then you know these cross-sectional images are beautiful in terms of determining well what's in the abdominal cavity and what's outside of and so you can see on the top there's the abs and then on the the very top is that subcutaneous that pinchable uh fat the route the the benign fat and then go on the other side of those abdominal muscles and you start seeing a little bit of uh fat in the uh mid-abdomen that's distributed around the the intestines um but not a whole lot on the left compared to what you see on the right which is pretty extensive with that streaky black uh material um much less muscle mass on the right and uh unfortunately much more visceral fat um for this individual what what's your obviously there's there's a and there's a bit of an anatomical um nuance but obviously there's this scarpus fascia line that that runs here do you do you have any comment on or like advice to your patients about like deep subcutaneous fat or are you mostly just discussing what's inside the the visual cavity yeah I know that there's uh it's a it's an intermediate uh risk that that deep subcutaneous tissue deep subcutaneous fat um I admit I am not I I don't get routine imaging on my patients like this um I would love to now although when I when I come across patients who have imaging in the hospital I I do what I can to track down the the image and I'll I'll take a screenshot of this and uh and and talk walk through it with them put it in their chart even um so so yes there's definitely some risk with that deep subcutaneous fat uh it's considered like I said it's considered intermediate between the sub Q and the and the visceral fat.

But I'm I'm focused on my my efforts focused on getting my patients to to look at and be concerned about the visceral fat primarily I I saw one paper that seemed and and I I'm not sure I think it was in a more like 60 year old kind of cohort but it seemed like there was a an association with potential dyslipidemia only in the males rather than males and female females with respect to deep subcutaneous so um if so that that's an interesting finding Dr.

Sean Mora talks about deep subcutaneous as being an issue uh but uh yeah I I I think there's obviously nowhere near as much data about that as there is on on on visceral fat.

Sure.

The the thing that strikes me and and I show these images like I said in the beginning I I whenever I go through images with patients I'll get up this website and one thing I I strikes me about the contrast of the patient on the left and the right is that how muscled and well muscled this patient is on on on the left.

You can see his in his erectospinal muscles his um all his the the muscles is like axial muscles his abdominals his obliques like they're all they're very dense and they're very well they're pronounced and there's no like um I guess grey haze there's not to that would suggest any fatty infiltration it's it's a very very um you know robust uh CT lean muscle lean muscle lean muscle and and it makes me think about obviously get getting to the guy on the right with sarcopenic obesity where the the body is so metabolically sick that uh it's it's you know it the metabolism is so diskewed that you're getting essential you know atrophy of of the muscle tissue as well as profound deposition in the individual visceral cavity.

Right.

And you can start to see on that that person on the right you can imagine it's actually difficult to find pinchable fat on the front of that belly because it's so taut with that the the inside fat.

This is a great example of that.

Yeah I I have a type 2 diabetic patient who looks very very similar and yeah minimal if anything uh under the subcutaneously but but very tight with the fat in there um inside the abdomen indeed and um and if we scroll down to the these coronal planes talk talk about what your what your advice is on these when you see them.

Yeah so so that individual on the right you know you see the see the fat spilling off onto the sides indicating that there's just so much pressure in that that tight belly it doesn't have space for all of that that fat and you know this is the this is the the older gentleman who's probably incapable of even tying his shoes he you know bends over can't even breathe uh you know and probably inhibiting the movement of the diaphragm you see the diaphragm on the on the left is being pushed up yep and uh so everything in the belly is is uh affecting the physiology of the rest of the torso and uh uh you know compared to that individual on the left again very lean you see it's very easy to to uh visualize the intestine uh as it's looping throughout there whereas on the right it's it's obliterated with so much visceral fat it's it's not even uh it's not distinct you don't have those distinct loops of bowel yeah and and you can just imagine this is someone who's probably a bit well maybe you can tell me but it's probably had you know possible hernias and in women in women like pelvic organ prolapse uh you know all or uh as you said probably trouble breathing or easily getting puffed because the amount of pressure that the abdominal cavity is pushing on all the other organs is is going to be huge.

Exactly the uh and then finally a sagittal plane I mean this is what you were mentioning a bit earlier but look at that protrusion of the abdomen.

Indeed right you can imagine this person lies flat there's no way that belly's flattening out that that visceral fat has nowhere to go and um versus a a very nice trim physique on the left you know also worth noting the look at the spines all the bony spurs on the right yeah ouch versus a a very good looking spine on the left maybe maybe it's a good time to mention like how many conditions are obviously related to this ectopic fat deposition because we mentioned outside medicine and type 2 diabetes and chronic kidney disease but and like it in basically any condition and I and I kind of sometimes I challenge patients to just do a PubMed search of you know whatever they're suffering from and visual fat and there's you can guarantee there's been a probably a specialty team someone in a specialty team whether that's surgery or oncology who has started to identify a pattern and then gone back historically overscanned and realized and published being like wow there's a finding here it seems like all my prostate cancer patients that uh end up dying or having worse outcomes have more visceral fat or all the battle and ovarian cancer patients that we that that end up going quickly are are loaded with visceral fat.

And they they seem to be publishing this literature but for some reason uh which we can talk about that that wasn't anything I was taught in medical school or or family medicine training.

I don't know about you.

Oh exactly you know what um this is a uh a tough confession for me to make but uh just oh what five years ago uh I was getting my certification in obesity medicine and I was doing it virtually it was during the the the pandemic all the shutdowns and so on so we had this virtual option which which worked out great for me uh because I was able to do it from home without traveling across the country but uh and I was listening to these these presentations and and the uh this presenter mentioned visceral fat visceral adipose tissue versus subcutaneous adipose tissue and I I just I still distinctly remember the moment I know exactly where I was and what I was doing and I like pause I'm like wait a second I'm pretty sure I know what visceral fat is don't I um this was not this was not something covered in my training uh you know it was mentioned in passing but but never stopped to actually analyze what is the the physiologic difference between the two that's something that was never discussed uh to your point uh it's not part of routine training and um you know it's and so so that was one of those moments like oh boy uh I I need to I need to dive into this uh because clearly there is a difference uh we just uh we don't we don't make it part of our routine education and and maybe that would be possible if it weren't so important as a biomarker risk factor for chronic disease and like that that is the issue that I have which is and there's something that is so obviously um and potently related to the poor outcomes and worse uh aging poor longevity chronic disease yet uh you know 99% of people have no idea about whether or not they carry visceral fat.

And to me as uh I don't know about you but as a I think that should be possibly one of the core functions of a family medicine physician if someone comes back from you know this this special medicine um appointment or you know saga it seems to me like the family doctor should be the one saying hang on yeah you have XYZ bronchiapsis X but but let's look at what else the scan shard hang on you're loaded the visual oh for sure yeah I started uh pointing out these CT scans um when I was working in the hospital and then like I said I do it all the time in clinic whenever I can and uh you know it's like Dr.

Sean Omar says like the visual is is what has gravity you can talk about it all day long.

I have a fancy BIA scale that gives us a you know a um a number rating uh but it's just a number it's not a quantitative measurement uh it's a unitless measurement uh and we can watch it we watch it track down as they lose weight and and my patients appreciate that but but to show them this the the image of that I agree it's it's uh it's impactful for for individuals to see uh what's actually going on inside yeah that that's been my experience is really and I I will opportunistically use whatever image I can overseas CT abdomen pelvis is the most useful but um here we in Australia we're doing lung cancer screening for people that have have a long shit smoking history you can get the top of the abdomen on the CT chest you can uh if anyone's had a CT angiogram with a long limbs you can see stuff you can even see a bit of epicardial fat on a capsule school like there's there's a lot that can be done opportunistically I think if if you're looking for it as a doctor.

Correct yep definitely it's a good uh and and maybe as I was quickly say um and what Dr.

Sean Omar is doing is specifical um MOI scanning and I think that is a gold standard because it's not going to expose expose you as a patient to ionizing radiation but um if you've already had the CT for another reason let's let's use it but uh otherwise yeah let's get an MRI and have you have you used MRI imaging at all Chris I have not you know only in the same capacity if somebody's had you know like an MRCP I'll I'll snag that image for sure.

Uh I've reached out to my local radiology um team and uh talked with radiologists about it and they said look we can we we can get the software we know it exists to to quantitatively measure it but it's too expensive this isn't something we're doing often enough we're not gonna do it we're not going to invest in that and uh and so there's a bit of a challenge now I mean yeah you can we can get the MRI for you know uh w without getting them them to measure it so you know we could do our own measurement but um a little bit a little bit more hopes to jump through they're wanting justification for for all imaging studies really.

And uh we can play the game, but I uh I haven't I haven't really sold it to patients as as something that's going to be um if you know critical to their their success.

So I don't I don't put as much emphasis on it as as Dr.

Sean does.

But I agree it's a very a very uh poignant image to see.

Maybe we can talk about your strategies that you use to I guess reverse visual fat, get rid of it, and I guess reverse metabolic dysfunction in your patients in general.

Yeah well so you know I I say that 80% of the game is is nutrition and um and the you know the more the more I see patients the more I deal with this the more I agree with that.

You know so so definitely the the low carbohydrate real food diet avoiding the ultra processed foods that's absolutely uh fundamental um big emphasis on protein intake uh you know there there's there's research showing uh increased protein reduces visceral uh visceral fat etc um yeah there's some obvious things like avoid the seed oils the refined grains the the sugars the trans fats of course um um i'm uh when it comes to fiber i'm not a big fan of fiber but again there is um uh evidence that that shows it does uh reduce visceral fat um having to do with the short chain fatty acids being uh fermented in the in the gut and so on uh and and which which leads to the importance of the gut microbiome which I think is really the the frontier of medicine for the next several decades uh infinitely complex which is going to be one of the one of its problems as well uh although who knows with with AI capabilities uh there may be uh may be able to uh wrestle that down a little bit better and understand something um but uh that's one of those areas where you know incredible signaling between gut and brain uh bidirectional uh it's just a fascinating area um so I do talk a lot about uh gut health uh you know this is also one of those areas where we should probably be minimizing antibiotics you know doctors should be good stewards of of antibiotic use since um unfortunately people think those are the the magic cure for for every little uh respiratory illness um but those antibiotics are probably destroying the gut microbiome and also indirectly contributing to visceral fat.

In fact uh I came across a study recently uh um well they were their their hypothesis was that these poor teenagers who end up on minocycline or doxycycline for for long periods of time for their their acne uh they're probably suffering uh through subtle uh mechanisms and and developing increased visceral fat and so the so the study was looking at mice and uh and it certainly appeared that that that was a uh a reasonable concern uh because that was being demonstrated in the mice um you know as my uh practice is well the my the metabolic side of my practice uh definitely a uh higher percentage of women than men uh we we always talk about the the role of hormones in terms of determining fat distribution and so pre-menopausally um women have it made uh they're on the metabolic pedestal I say uh they're very much protected from from cardiovascular disease relative to to men of the same age unfortunately uh well in that in the in that state high estrogen they're distributing fat in the lower body the thighs the hips sparing the abdomen for a potentially expanding uterus it's a very smart design if you look at it that way then with the entermenopause well estrogen drops uh no need to worry about a baby coming anymore so now excess fat gets stored in the uh abdomen in the abdominal compartment and uh that's very distressing to women and uh and so if you if you consider the hormonal changes actually using estrogen supplementation in women um has been shown to decrease the accumulation of visceral fat and so you know we talk a lot about a lot about hormone replacement as as my patients are reaching that era of their lives um I'm also a big fan of fasting uh it's been a it's been a tool I've utilized for for many years uh and uh and I try to coach my patients into that although there's always that initial resistance but they usually come around and uh and gradually work into it but that's an incredible incredibly powerful tool in terms of reversing the visceral fat.

So that kind of that's a brief overview of of the nutritional approaches that I employ.

And uh and we and we go into all sorts of strategies in terms of um how to do those best.

But yeah definitely 80% of the game.

Well talk about I I 100% agree with the the idea of this this massive hormonal uh effect on fat distribution and and and you see it in in endocrinopathy like uh cushions uh where where patients um through excess of glucocorticoids actually get this quite pronounced like truncal and upper back fat distribution and um and when those are corrected or treated then that that can radically change the way that the body's actually laying or down or storing fat.

So uh it it it it makes you think about yeah people who've had chronic stress in their life um as a as a key contributor to to potential visceral fat deposition.

Sure.

Yeah the visceral fat has more uh glucocorticoid receptors than subcutaneous fat uh which makes it much more responsive to stress to high cortisol um etc uh in fact a fascinating study uh I don't know where this was done I was looking at um women and they were basically comparing how women react to stress and how that impacts abdominal obesity and the quote unquote high reactors had significantly more abdominal obesity than the low reactors even though they had the same body weight and uh so it's just a fascinating uh uh finding and uh and so you know another another core part of my approach with my patients and I I start on day one and I remind them like look you know it's argued that the number one cause of weight regain is stress and so you need to cultivate those habits those self-care habits do what you can to to effectively manage stress don't wait for it to be a problem and you and you need a a rescue you've got to cultivate those today and uh practice that basically so that when you do need it uh it's it's at the ready and it's going to be effective.

Yeah absolutely well I mean we we talked about three things already which is seed oils circadian disruption and stress as being potentially things that would change someone who would otherwise lay down safe circutaneous fat and direct that fiss release so I think it's a good message to to uh to show which is that um yes although there is a uh genetic preservation that the lifestyle choices a hundred percent um can influence that and and I've been very much or lately looking into photometabolism and effect of light on biology and uh obviously Glenn Jeffrey who's a researcher from UCL back in 24 showed that even 45 minutes of red light was able to significantly reduce blood glucose um post a um an overglucose tolerance and when you start looking the photobiology of of uh how the mitochondria reacts to full spectrum sunlight I've kind of come to the opinion that it's it's acting like a constant downward pressure on on a patient's blood glucose levels and therefore probably fat story too.

What what's your take on the injectable GLP1 receptor agonist medications?

Obviously you're probably using them with with your diabetic patients what's what's your your general impression of them mostly favorable um I I certainly preach the lifestyle changes before utilizing medications although you know let's face it there's such cultural pressure and um you know everybody's using them is kind of the the reality of uh of the situation and so so people come to me wanting them and um I'm I'm very systematic about about how I utilize them uh and I I basically tell them up front like look if you're not going to make lifestyle changes um you're not a candidate for this medication you'll just regain weight and so I need their buy-in before uh before we go hog wild on on the GLP ones um they're you know the nice thing is uh there's they're just synthetic forms of of a a hormone that we naturally make uh thus uh their their safety profile is is pretty awesome uh and um I've not run into any um any significant long-term effects that that won't that don't resolve when people reduce the dose or come off of them um so safety wise i i think they're they're pretty darn good uh and um and it's it's it's best done with in conjunction with the significant lifestyle changes so improving the nutrition you can really amplify the effect of that medication and so uh by no means am I blindly increasing the dose like oh it's been four weeks at the starting dose now it's time to go up oh heck no um I've never done that uh I'm I'm utilizing the lowest uh dose possible uh as long as we're making some progress uh and uh and increasing the dose only when necessary to break through a plateau uh assuming that they've been reasonable in terms of their lifestyle uh factors um you see a lot of people who who maintain terrible diets and are given these medications and and yeah they lose a lot of weight but but the reality is uh those are the ones who who exhibit the the significant weight regain and then you know a lot of doctors in the uh in the obesity medicine world especially they argue well obesity is a lifelong disease so so this this is gonna have to be a lifelong medication I'm appalled at that thought uh I don't know anyone who wants to be on lifelong medication and it's just such a terrible uh approach to patients it's like oh we're gonna stick you on this because it works and and we're never gonna get you off of it um like oh man that's not not so sure about that and while we do have some good long-term safety data although long term is is not terribly long um I mean the the first one came out in 2005 with exenotide and uh you know there's been I don't know six or seven iterations now and uh well as of let's see as of 2022 I think we had the the six year safety data on semiglutide or semaglutide however you want to say it uh and it looks darn good it was the only increase was the GI issues um but uh but I don't I don't think it should be a long-term medication and I'm I'm working on getting people off of it uh as quickly as I can once they hit their goal.

Yeah absolutely I think there's a lot said about it in popular culture and if in you know on both sides of the argument what what I what the value that I see particularly for these is patients who have significant visceral fat and the consequences the metabolic consequences of that meaning that they are a vascular path they've you know that they've started to chug up their their carotens and their their iliacs their their you know really high cardiovascular risk they're about to you know have another heart attack and um I think I think those are the most exciting indications um for for those medications.

Yeah to quickly reduce their their metabolic risk um I think that's that's absolutely where they should be used.

And and using medications as a as a bridge until their their lifestyle changes can can catch up, make a significant difference.

That's absolutely appropriate, I believe.

Yeah it's cool it's cool if it if it's um you know relieve some of the bariatric surgeons of their of their work because it never made sense to me to be cutting out you know anatomically normal organ uh for for weight loss and and it does get into that debate or that issue which is yeah if scale numbers going down but we're not tracking the body composition changes then yeah we absolutely don't want to be losing good protective subcutaneous fat or or lean muscle mass or bone mass evenly.

Mm-hmm.

Yeah well and then you know related to the bariatric surgery you know traditionally people always think oh well they they work because they're shrinking the stomach that's how the surgery works well turns out that's not true that may be a factor but the majority of the the effect of bariatric surgery comes from the GLP1 mechanism and uh bariatric surgeons now are are happy to admit that they're they very freely admit it because they can't deny it now.

And uh and I I I mean I tell people this all the time is why would you cut out a perfectly good organ uh or you know even any why would you manipulate it in any way uh we already have proof that it works perfectly well you eat food you gain weight that's a that's a functional stomach uh but now you're setting yourself up for a lifetime of of malabsorption nutrient deficiencies and and not to mention typical surgical risks of adhesions bowel obstructions chronic pain on and on and on uh and um and so so I I talk people out of surgery all the time and uh you know I when I worked in the hospital this this was was a very striking um uh thing that we'd have to co-manage with the surgeons and so so they'd let's say a a diabetic patient on 100 units of insulin per day comes into the hospital has their their uh uh well you name it like gastric bypass or the or the sleeve gastrectomy or whatever it is rue NY and the surgeons would always consult the the internal medicine service the hospital team which is what I was on and uh for co-management and uh like well what here it's mainly surgical right well the reality was that uh their management the management of their diabetes was going to change drastically overnight okay it wasn't because they were fasting or you know not eating because they're post-op because they did they already did that pre-op right and yet they still needed their hundred units of insulin um uh even though they they fasted for for eight to twelve hours whatever the reality was that that there was such a profound uh hormonal effect the glp 1 effect overnight that we would take them off in all of their insulin all of their uh diabetes medications um overnight and and we would just we would just watch them we'd slap on a slide and scale insulin and uh and make sure that all was stable uh but it was just profound that that there's such a dramatic decrease in their need for in uh glucose lowering medications yeah it's it's crazy and I guess the thrust of what you and I doing is we're stimulating GLP1 with lifestyle and with education for our patients to put them back in a situation where their metabolism can work properly um and it it it just goes to the the changes that have occurred in our modern w life and obviously gene nutrition is part of that um you know indoor living this the chronic stress you know all this you know alcohol consumption um processed food consumption sedentary behavior i mean it's all it's all playing a role so uh I feel like especially with it when it comes to those obesity doctors you know putting people on lifelong GLP1 therapy or cutting out um normal anatomy of of uh for obesity surgery it's like they're treating a disease without appreciating the context in which the patient developed the disease um probably for financial economic reasons too is because they don't they're not remunerated for caring about it right absolutely you can't treat a lifestyle disease with with medication you have to address that that root cause let's um so I'm just gonna make a quick like uh summary of the things that people can do and then I want to talk to you about your your innovative model so we've talked about uh um about dietary vaccines cutting could cutting out carbohydrates um processed foods increasing protein i i really like i don't know about you if you people can get in washington like wild venison i i think uh microf is if if people had an unlimited budget to uh to roll with then i would be getting them in as as wild um cord meats as possible so i love wild venison myself and wild seafood and obviously wild cord seafood and had some elk this morning amazing it's different it's a different feeling to grab to uh grain fed beef and and even beef itself I think yeah definitely um then obviously alcohol I mean alcohol is a big one and I've seen people I I had a patient lose maybe like eight to ten kilos by just going from like I didn't even maybe he didn't he went from full strength beer to like mid-strength low carb beer and lost like eight to ten kilos but he was drinking a lot of beer yeah um and then exercise what what type of exercise do you like to recommend for your patients yeah so I'm not a big fan of cardio uh I may be a heretic in the in the world of medicine but to me cardio makes you better at cardio uh and the the benefits are are lost very quickly now uh walking super valuable well what's the difference well walking is something that's uh that your body can sustain for long periods of time and and we we talk about this neat

NEAT, non-exercise activity thermogenesis.

It's it's the difference between the busy bee and the and the couch potato.

Uh and that that difference in activity levels has a huge role in terms of of how easy it is for people to manage their weight uh you know and other metabolic parameters.

Um so I'm a huge fan of any movement.

Walking is super valuable.

Um it's like I always say to my patients, like, look, bodybuilders have this figured out.

If they're trying to get cut for an event, they're not spending more time in the gym lifting weights.

They're they're walking, uh, because it has a profound fat burning effect.

And they've learned to take advantage of that.

They're the masters of of fat burning.

Um and then it's so so with cardio, the problem with cardio, long-form cardio.

So things like you know, long-form you know, jogging, bicycling, spinning, um, uh, running, etc.

The problem with that is that it's a stress to the body, and your body's trying to figure out the best way to manage that.

It's trying to figure out the most efficient way to perform that activity.

You keep stressing it by making it run mile after mile, kilometer after kilometer, and uh, and your body's gonna figure out like, hey, we gotta conserve energy, we gotta, we gotta figure out how to how to make this less painful, less stressful.

And so your body adapts, and you uh you know you're running 10 times longer just to get the same effect eventually.

And so you have to introduce inefficiencies in your in your movement, and that's where uh there's great power in resistance training.

You can increase the inefficiency um infinitely, there's no limit there.

Uh, and uh the high-intensity intervals or sprint intervals, sprint interval training, uh which is the new term that replaced hit because hit's been watered down big time.

That you know, the modern day HIT workout now looks just like circuit training, and and it's also very stressful.

You know, so like I have these I have these female patients who bust their tails in the in the gym, and they're they're sometimes doing two workouts a day.

And you know, they'll tell me like, oh, I am totally gassed after this workout.

I'm sweating buckets, and I just don't lose weight.

I'm like, well, listen to yourself.

That is a that is a horrible stress that you're describing.

Your body's stressed.

Um, you probably have a crazy high cortisol level uh at the end of that workout, and uh and that's it's just not facilitating fat loss as they expect it to.

And so the sprint intervals is much better in terms of condensing the workout, um condensing the effort into a very short period, maximal effort, followed by a period of of uh recovery and uh and then repeating.

And so uh so so that's been shown to be much more beneficial in terms of uh efficiency of your time and effort, but achieving significant amounts of fat loss.

Um the reality is uh, as many other people, I don't have time to sit in the gym an hour a day.

It doesn't happen.

Um, but I can pound out a 10 to 20 minute um sprint interval workout and it's gold uh and throw some weights in there, it doesn't have to be a lot of time.

Uh so that that's really the uh the big picture of my approach to to activity.

Yeah, yeah, I like that.

And really thinking sometimes I like to you know use a real primal uh perspective.

And if you look at the the line, I mean he's he's going hard for a very short amount of time when he's grabbing that that zebra and ripping it apart.

And then he's lying under a tree for like three days, you know, smiling his literally smunning his balls.

So so and and and as you say, you see these poor people, you know, even you know, overweight people on a Sunday morning, just covered in sweat, doing these chronic, what's these uh extended workout uh sessions, and they'll they'll go to their you know, low-fat, you know, barely enough protein diets and and wonder why they're you know not losing any weight.

But uh yeah, the intermittent stress of it, I think, and and the the recovery from that is is is key.

And you know, part of part of what I'm also interested in in the light part of the story is the same thing is is uh in play with with the circadian rhythm and this idea that you we're supposed to have this full spectrum daytime light, which is probably giving the cell and giving the mitochondria a whole bunch of energy.

And then ideally we'd have this inactive phase where we've there's no light, no stimulation, and the the anabolic pathways, uh sorry, the catabolic pathways and anabolic pathways in terms of muscle growth can happen appropriately.

But uh, you know, if everyone's completely in this twilight zone of light at night and an inappropriate and inadequate sunlight, then they're absolutely going to be helping their metabolism uh turn out of the door.

Right, right.

And those light cues are so vital for quality sleep.

You know, the I mean even the I mean you know, by nature's design, you get the the orange and red hues in the evening, which actually actually protects you from the the harmful effects of artificial light in the evening, uh, which is which is wildly cool.

Yeah, yeah.

It's uh it's it's very elegant the way the the body's response to an adaptation to light.

And and yeah, like I said, if if I can get people sprinting outside on natural grass or or on the beach, I think that's that's uh the added benefit to cloud getting the full spectrum light, then we get more bang fat.

The only thing that um that's helped I had a patient recently who's just done tremendous work getting rid of his visual fat.

And we've we've put in a a couple of key strategies, but he's been doing a 48-hour fast a week and doing a really intense exercise on that day, um, and and isn't going to sleep fasted.

And and that that seems to be working really well for him.

And have you have do you have advice or you have um benefit in a similar protocol?

Yeah, so my usual strategy.

Well, let me clarify that real quick.

Um when you say he's doing the uh the the sprint workout, is that on the second fasted day or the or the at the finishing the fast, breaking the fast with a sprint workout?

No, it would be it would be buff.

It would be so finishing food on Friday, fasting Saturday, sprinting Saturday afternoon, going to sleep Saturday night, and then breaking fast on uh I see.

Yeah, yeah.

Okay, okay, got it.

Yeah.

Um my strategy with with fasting uh or workouts related to fasting is um to do the sprint work, the high intensity workout, whether it's sprinting, whether it's weight training, do that at the beginning of a fast.

And so so let's say, yeah, Friday night's my last meal, Saturday morning, I'm hitting it hard.

And the idea being I want to burn off the glucose, burn off the glycogen, force myself into fat burning mode as soon as possible.

Because when I do that, I'm in ketosis by that evening.

And I go to bed not hungry at all.

I wake up not hungry.

I'm gonna fast another day, no problem.

I'm not gonna get any discomfort from from hunger.

Uh so I'll also do uh so last time I did I fasted, I did um just last week.

I did four days.

So I I started the sprint on day two.

I also did another uh sprint workout.

And um and then and then I took it easy the rest of the time.

Uh did some weight trading, but not no more sprint workouts.

Uh but I really like that strategy because it it puts me into ketosis very quickly.

That's it.

That's a very good um advice and and clinical pro.

Thank you.

Because uh if people people have trouble with complying or persisting with fasts, and it's if it's if their hunger cues are kicked in.

Um but if you if you if you as you said burnt all off those those glycogen stores and they're already in ketosis, then they get the the appetite suppressing effects of of the nutritional ketosis that will can keep them there.

So yeah, absolutely.

That's great, fantastic.

And then I also like to take uh take advantage of that, uh, the fact that uh you know growth hormone increases after a 24-hour fast, for example.

And um, and that's a great time to do a resistance training workout.

You know, it's our body's way of protecting our muscle mass.

Um, it's I mean certain uh uh social media personalities, let's say uh shall remain anonymous.

Uh you know, they're they're famous for all these these little clips online about oh well 12 hours into a fast, your your body's liquefying your muscle.

That's BS.

That's not happening.

Um there is there's no way that your body would sacrifice muscle that soon.

Um our species would not survive.

Uh, but rather your body's starting to maintain uh uh mount that growth hormone response because it's protecting the muscle mass.

Uh that's that's why I like to uh you know continue doing resistance training during a fast, you know, sending that signal that hey, this muscle's important, let's let's support it.

Absolutely.

Do you do you have any like clinical experience about fasting in pre-menopausal women, or do you make any allowances for like menstrual timing at all?

Or um, yeah, what's your position on that?

Yeah, I yeah, I have people always brune up.

There's that book, uh uh fast like a woman uh or whatever that's called, and so they'll ask about it.

Uh I don't I I I don't make any any modifications there.

I think if there's any differences, it is so incredibly subtle that that it doesn't really make a huge difference, uh a clinical significantly different uh difference.

Uh you know, one thing about research and um and all these claims that you see online is nobody ever talks about the the degree of of impact.

You know, you you see like oh well well X substance X is bad for your health.

Um like okay, but why aren't we talking about how bad?

Um is that going to shorten your life by a couple milliseconds, or or are we talking years?

And uh, so so people get hung up on on all these all these things on social media about oh, I heard this is good and this is good and this is bad and this is bad, and and and they want to go go uh head over heels over all of these little interventions.

Um, but I have to have to bring them back to reality and say, no, no, no, no, no.

You're focusing on a bunch of a bunch of little little changes.

You need to focus on the big things.

Um the diet, the sleep, the exercise, mental health.

Those are the things that are gonna make differences in terms of years, um, not just minutes.

You know, it's like the big study about statins that says, well, lifetime of of taking statins um extends your life by four days.

Like, well, you spend that much time in the line at the pharmacy uh at that point.

It doesn't make sense.

Yeah, that's not a good return.

Yeah, yeah, you're right.

There's no one to I mean, and there's no training.

People haven't had epidemiological training to understand effect size, like absolute risk reduction and and all these key concepts that that we get taught to uh you know properly analyze clinical data.

So I mean I think I think you gave a pretty good summary of visual fat.

Is there is there anything else that you want to share that I haven't asked you about with respect to like identifying or or treating visceral fat or any like advice for patients?

Um let's see.

Well, you know, there's uh the uh interesting thing about uh uh men versus women.

Uh uh a very cool difference here is that men with low visceral fat uh tend to have um I'm sorry, backup.

Men with low testosterone tend to have more visceral fat.

Whereas in women, women who have more testosterone, and the classic condition we know this is PCOS, they tend to have more visceral fat.

Uh and so so it's a little different.

There's a there's a cool uh uh sex difference in terms of the effect of low versus high testosterone, which I think is a really uh really interesting um feature about about our physiologies.

Um that was just something I was I was thinking as we were talking about sex differences.

Yeah, I I think Dr.

Sean has noticed that in patients who are like androgenic um anabolic steroid users, they can look cut, but they seem to obviously be very well muscled, but still have persistence of on visual fat.

So right.

So it's maybe a U-shaped curve, right?

Like uh there's an optimal range, and once you get past that, you're in trouble again.

I think that's probably the case.

Another reason for people to get a scan, ideally, and no matter what stage you are, and and and have a look and see what's going on in your abdomen, because yeah, like don't wait for the blood tests of the range.

It could take you seen years, it could you take you decades.

Um and often people at I at the page in a in a vascular path who's in like not near diabetic um criteria, fract-for-frec diabetes, but he's been dwelling in in a prediabetic state, parked with visceral fat for you know how many knows how many decades.

Um suffering some pretty bad end organ complications.

And you know, luckily he's doing a tremendous job uh you know putting together a whole bunch of lifestyle strategies, uh, you know, of which spending time outside and and kick kicking the biscuits is uh doing wonders for him.

But uh you know, it's it it takes a lot.

Um so yeah.

Can you maybe we'll quickly finish with uh a bit about the direct primary camera because uh it's something that I've noticed in medical my experience with medical practice, which is when you have a a third-party payout um in Australia, that's the government in terms of Medicare, and in the US it's private insurers, it's almost like there's a third person at the at the date table.

You know, you're always you're you're trying to you're trying to like get get along with someone, and then someone was like, what about me?

And inevitably that that draws the I don't know, it draws the the focus of the center of the console basically away from what you would have otherwise said if it were a direct transaction.

You and that's been my personal experience, um, but I'm I'm really keen to hear yours.

Yeah, yeah, I mean it's a it's a universal sentiment uh uh around here in the US that that health insurance is a racket.

And and it's uh it's it's resulted in outrageous costs of healthcare, uh outrageous restrictions in terms of um what you can uh how you can use your your health coverage to improve your health.

I mean, let's face it, it's a it's a sick care system, it's not healthcare.

We don't we're not promoting health.

We're just we're waiting for for disease to strike, and then okay, now it's the it's the band-aid approach, uh reactive rather than proactive.

And uh I mean and the thing is, if you if you want your insurance to pay for it, whatever it might be, you're not gonna like what you get.

Uh, because they're following their algorithms, they're financial organizations, right?

Uh they just use healthcare as a front for their for their business.

And um and so so healthcare is always uh uh getting between the patient and physician, as you mentioned.

And uh, but but it's it's far more than than just the insurance company, it's it's the pharmacy benefit managers and and just an infinite complex comp complex of bureaucracy.

And uh it's so so direct primary care is a membership model of healthcare.

And basically a monthly fee gets you full access to your physician.

And there's there's no third party providing influence on what we do.

Now, people can people are free to use their health insurance any way they want outside of my office.

Uh they can use it for labs, medications, imaging specialists, hot procedures, etc.

And that's fine.

However, we have negotiated discounts on labs, medications, and imaging uh with local preferred vendors.

And uh those negotiated rates are are profound, um, way better than anything people will get using their insurance card.

You know, so people think that that when they use their insurance, they're getting the best deal.

Couldn't be further from the truth.

Um I mean, for example, I mean take a uh take a comprehensive metabolic profile, a lab, right?

It's they're gonna bill you like 60 to 80 dollars.

Um, we've seen the bills, we know what it is.

Um, what do we charge?

Five dollars.

Uh just a profound benefit.

Uh MRI scan.

You have to jump through so many hoops to get an MRI.

You know, oh, you gotta do uh six weeks of physical therapy, you need an X-ray, an XYZ, all to get uh an MRI, and you end up paying$2,500.

Uh, pretty typical.

Uh we charge$462.

Um and that alone, just one MRI pays for uh nearly two months of or sorry, two years of our of our membership.

Uh and so so our patients enjoy uh you know great cost savings, uh as well as uh great accessibility to uh primary care services.

So instead of being told, like, oh, you you need an appointment today, uh sorry, uh we can't get you in for three months.

I've also heard five months recently uh from one of our local uh health systems.

Um or you could go to urgent care and pay three to four times the price and have to wait hours and hours.

Instead of that ridiculous model, our patients get same day or next day visits, and we guarantee that.

And so that's a huge difference.

It's the accessibility.

Uh that's what it really comes down to.

And we're spending more time with patients because we're not we're we're not on the assembly line of healthcare.

We don't have an administrator telling us, yeah, you need to see more patients, generate more revenue, keep going.

Um instead, um uh we can spend a lot of time with our patients.

Uh it's not just five to seven minutes face to face.

We're doing routinely half hour visits, uh sometimes hour long visits, just in follow up uh with our patients, and uh, and that's a huge benefit.

In terms of being more proactive about their healthcare in general.

Yeah, Dr.

Jim Cruz, I don't know if you followed any of his work.

He calls it the sausage grinder of centralized medicine.

And it really sometimes can feel like that.

And yeah, I I I echo all that.

I think it makes so much sense to me.

Because if and in in in Australia, obviously our systems are again a bit different.

And we've we're finding public healthcare or socialized healthcare as being really a politicized football than the political parties kick around and they promise the healthcare healthcare equivalent of bread and circuses in the form of what we call bolt-build appointments, which is if you go to C GP then then it gets all settled without you having to swipe your your your card.

But I I really think that there's in that institutionalization or that centralization of care, the the autonomy of that in and the clinical now sort of um expertise of that doctor in many cases, not always, but sometimes gets dissolved into a into a real guideline-based, formulaic, protocol-based care.

And um I think that that sometimes isn't the best thing for the patient.

Right.

Yeah, so one of the issues that I hear from all doctors, uh whether they're working for health systems or or um you know larger uh clinic groups, um is that they are forced to spend so much of their time and effort on meeting all these ridiculous metrics that have nothing to do with patient care.

You know, I mean they're just just total nonsense metrics.

And and and these health systems, they need metrics, they need something you can put a number to and measure and then compare you to last year and and then determine bonuses based on these ridiculous numbers.

Um, but they're not helping patient care, they're not improving anything about patient care.

Uh, and that and that's a that that just wears on doctors over time.

Uh they can't they can't sustain it.

Um what one of the biggest things about this model that that appealed to me and still does is is looking at what's what's the physician incentive uh in these different models.

And so if you look at the traditional insurance-based model, okay, you you let's say you get sick, you make an appointment, you go pay your your cook your um your coinsurance, your co-pay, uh, then you're you're paying for the visit.

Uh you only got seven minutes.

I mentioned that earlier, and then there may be uh balance billing, uh uh, etc.

Additional fees tacked onto there and so on.

So every visit to the health system is a chance for them to bill you, to generate revenue from you.

So they're incentivized.

So they're incentivized by you being moderately ill for a long period of time.

Because every time you visit, ka ching ka ching.

Okay.

Now, contrast that with direct primary care.

Here's the deal.

I'm getting a monthly fee, no matter how often you visit.

I may not hear from a patient for six months even.

Um, or I might see that person six times in one month.

I'm getting paid the same.

So the the onus is on me to provide high quality care up front so that that person is not beating down my door every week.

I can't afford to do that.

And so it puts the it puts the physician in the in the driver's seat in terms of deliver quality care from day one.

Uh otherwise you're not gonna be able to expand your practice very well.

You're gonna have a ton of people who are incredibly uh demanding because they're because you never adjust their their underlying issues and they're and they're always gonna be come back.

Multiple visits for the same price, why not?

Um, so that's part of the beauty of the model that really attracted me to it in the first place.

Yeah, it's incredible.

And I can't help but think of the underlying similarities to so many other parts of the economy and society.

And uh I I talk a lot about regenerative farming and purchasing meat directly from a farmer and but disintermediating things like you know, cartels of beef producers and avatars and supermarkets that are all incentivized to clip the ticket on the way through.

Um in the same way, but you you're just going straight and and and making an economic transaction between two two parties and cutting out all the the BS and the fluff.

And yeah, it's it's really beautiful how how those incentives are are aligned instead of um yeah being so too just dis discrepit.

And you do you um accept Bitcoin for your payment?

No, no.

Oh man.

Um no, too complicated.

But um, and um finally is there anything else, or I guess maybe there's some doctors listening.

Do you do you have any like messages or if they're thinking about a model like that in the US?

Yeah, what what would your advice be?

Uh so one of the biggest problems for doctors who are who are in their current positions is it's it's we call it the golden handcuffs, right?

They have great salary, great benefits, and it is scary as hell to walk away from that and go into a uh a new business owner situation, uh, and start from scratch, basically.

Um so I I was working as a hospitalist when I when I uh I decided that this was this is what I needed to do.

Um part of it was that my job fundamentally changed big time and I wasn't gonna stick with it.

I I planned on that being my retirement job.

I was gonna work that until I didn't want to work anymore, but uh they changed ownership of the of our of our team, and uh and I knew there was no way I was gonna do it.

And so while I was building this model, I was working as a locum tenant, so a temporary dock, traveler dock, whatever you want to call it, uh still working in the hospital on my my weeks off or or well intermixed, right?

So then um when I had when I was able to dedicate some time, I could work in the hospital, make some money while I was building the the clinic model.

And I initially started just focused on metabolic health, which is why my clinic's name is Revitalized Metabolic Health.

And then several months into it, my patients started demanding that I be their primary doc.

And uh so I jumped through all the hurdles uh for that and and opened up the primary care service, which I'm very glad I did.

So for docs transitioning, um one, it's probably easiest to find an existing DPC clinic that's already doing it uh and and join them.

And and that's they've they're they're doing the marketing already, they're doing the business management.

Uh so that's an easy way to to get into it.

Uh so I have a I have a physician partner who joined me uh in February of this year.

And I manage all of the administrative stuff.

And uh and she's free to just build build her client base, her patient base.

And uh and so it's so it's a it's a great great uh model for her to get started.

And uh so that's probably the easiest way to get into it.

Uh find that existing clinic, one that you meld with um philosophically, and uh and and make that.

Um otherwise you just have to you have to hammer it out, you have to figure out a way to uh to moonlight, make some extra income while you're while you're building your your practice.

And uh it's a lot of work.

Uh you know, they say on average it's about 18 months before you you're able to start paying yourself uh from the time you start your your clinic.

And so it's it was it was a very stressful period of time uh for me.

Um, you know, I got two kids, lots of bills, and uh uh oh not to mention the uh the pandemic was going on at the time, adding stress to everyone, and uh uh but stuck with it, uh worked on a lot of networking and uh and and grew it.

And so now we're uh now we're in a totally different uh position than we were you know four years ago.

Amazing.

Well, uh what maybe yeah, just share share where people can uh like employ your services if they're based in I guess the Pacific North Northwest.

Do you or do you see patients from around the states?

Or what's your policy?

Yeah, yeah.

So uh so I'm in Gig Harbor, Washington, uh, which is Pierce County.

Uh and uh so it's about it's about a 45-minute drive from Seattle.

And uh I can do things virtually uh throughout the state.

I'm also getting licensed in uh multiple other states, actually.

Um so currently licensed in North Carolina, also, complete opposite side of the country.

Long story.

Uh but getting a license in California as well as several of the neighboring states, uh like Montana, Idaho, Wyoming, uh, and then Arizona as well.

So those are all in the works.

Uh, because we have a lot of patients who are who have been moving to these areas, and uh in the US, it's all state by state uh in terms of licensing requirements.

And so uh in order for them to continue as patients, I've decided I'll just get licensed there and continue providing services.

Um but that also opens up to a up opens us up to a lot of telehealth uh capacity, and so we'll see where we go with that.

Um, but I'm a uh my my website's revitalizemetabolichealth.com.

Uh you can also get there by a simpler uh uh domain, rmhgh uh.com.

The gh stands for gig harbor.

Uh and then uh you know I'm Instagram, Facebook, YouTube, LinkedIn, all those all those things uh I have presence on.

Cool.

Well I will include the all the contact details uh for this out here in the show notes.

So yeah, thank you very much, Chris.

It was great conversation.

Thank you for sharing your insights and experience on metabolic cultural visceral fat.

So I think yeah, people get a lot out of these.

Um yeah.

So yeah, thanks again, man.

Yeah, thanks for having me on.