Stay Off My Operating Table

Dr. Vyvyane Loh: Normal Weight Obesity is the Hidden Epidemic #153

• Dr. Philip Ovadia • Episode 153

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Have you ever contemplated the profound interplay between your mind, body, and the daily choices you make? This episode features Dr. Vyvyanne Loh, a physician with a holistic approach to wellness, who shares her personal transformation from burnout to a revitalized healer. Vivian's story is a beacon of hope for anyone feeling overwhelmed by the rigors of their profession, demonstrating the power of self-care and a mindful return to one's calling.

Embarking on a thought-provoking voyage through the intricacies of human health, we navigate beyond traditional metrics and delve into the essence of wellbeing with Dr. Loh. From the nuanced art of patient communication to the unexpected connection between metabolism and brain health, our conversation uncovers the delicate balance required to maintain both physical and mental vigor. Vivian's insights challenge us to reconsider what it truly means to be healthy, urging a shift towards a more compassionate and comprehensive view of care.

This episode is an invitation to explore the unexpected, such as the concept of normal weight obesity and its impact on metabolic health, and to embrace movement and creativity as vital components of cognitive function. Dr. Loh's expertise shines as she tackles the role of storytelling in stress management and the importance of a well-rounded knowledge base for any physician. Tune in for a session that promises to enlighten, educate, and inspire a deeper understanding of the symbiotic relationship between our health and the stories we live by.
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Key Takeaways:
• Normal weight obesity affects up to 90% of the population, even those with a "healthy" BMI
• Body composition, not just weight, is crucial for assessing metabolic health
• Stress management and neuroplasticity play significant roles in overall wellness
• Simple daily activities can enhance cognitive function and brain health

Resources and Links:
• Dr. Vyvyane Loh's website: https://www.vyvyanelohmd.com/
• Book: "Breaking the Vicious Cycle" by Elaine Gottschall (mentioned as influential in Dr. Loh's journey)

Timestamps:
00:00:00 - Introduction and Dr. Loh

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Theme Song : Rage Against
Written & Performed by Logan Gritton & Colin Gailey
(c) 2016 Mercury Retro Recordings

Any use of this intellectual property for text and data mining or computational analysis including as training material for artificial intelligence systems is strictly prohibited without express written consent from Dr. Philip Ovadia.

Speaker 1:

Welcome back, folks. It's the Stay Off my Operating Table podcast with Dr Philip Ovedia. Phil, I'm going to do something a little different. I want to read something. The cartography of the known world is defined by lines where certainty and dogma drop into void seas. Certainty and dogma drop into void seas where I am, is it once the everywhere that has marked me, the nowhere that has mocked me, the anywhere that has shunned me, the somewhere that has summoned me ether vacuum which, as you know, is not but the sum of zero point fields. This is taken from the biography of our guest today. It just, it touched me. I'm pretty sure we've never had a Guggenheim fellow on the show, but apparently we do today.

Speaker 2:

Yes, we do.

Speaker 1:

Take it away.

Speaker 2:

Yeah, I think there'll be a number of firsts. I'm very excited to have Dr Vivian Lowe on today. Vivian, I'm going to say, is one of the smartest physicians I know and that's probably one of the least interesting things about her, ultimately. So I've been fortunate to meet Vivian a few years ago and work with her kind of in the metabolic health space and really learn a lot from her and really enjoy listening to her on podcasts and all of that. So excited to jump right in. So, vivian, why don't you start by just giving a little bit of your background and you can focus on the medical part of that, or you can wrap in some of the more interesting parts of that as well.

Speaker 3:

Okay, wow, I never quite know where to start.

Speaker 1:

Well, your local word nerd is going to want to know word stuff too.

Speaker 3:

Well, maybe I'll just start by telling you that I actually never wanted to be a doctor, but I knew very young that I wanted to be a healer. I don't know where that word came from, but I did say that to my mother. I said I want to be a healer and she suggested doctor and I thought I don't know, I don't know if that fits. I ultimately ended up in med school here in Boston, which is where I've stayed. Okay, I'm not that smart, Philip. I'm still in Boston. I'm trying to get out. I've sworn. This is my last winter.

Speaker 3:

I need to get away. So, yeah, I think that I don't have the street smarts there, but I've been in Boston for undergrad, for med school, for residency. Oh my God. It's sounding more depressing as I keep going on, but what I've done here was, you know, I needed to think about what I wanted to do in medicine and I had the gift of burning out very early in my career, two years out from residency, and I found myself completely burned out.

Speaker 1:

It's really important that people understand what you just said the gift of burning out two years into your residency.

Speaker 3:

Right after yeah, two years after my residency. Two years after your residency Right after yeah, two years after my residency, two years after your residency.

Speaker 1:

Yeah, unpack that.

Speaker 3:

As a new attending. Well, you know, I was sort of the lowest person to join a very large and prestigious primary care practice, so that meant that I took on everybody's work while the partners went golfing right. That's really the hierarchy and I ended up not only covering their patients, my own patient load, so that in a day my outpatient load was in the range of 27 patients. And then I also covered, you know, nursing home patients. I covered the inpatient, before we had hospitalists, I covered the inpatients, and so I just found myself working around the clock and I had gotten to a point where I was so burnt out I didn't even know it at first, you know. So I remember just being so dissociated from my body that at one point I found myself it was my one week vacation that I was on and I found myself tearing at, tears running down my face and I thought to myself I must have allergies. And I sat there it was on the beach, probably somewhere in Florida with tears running down my eyes for a week and wondering about this strange allergy that I had. I had no idea what it was. I was so disconnected from my body and then, several weeks later, I found myself in a place where I didn't recognize myself and I knew I had to stop. And at that point I actually to make a very long story short I handed in my resignation. And this was no small decision at that point in time, because, you know, I had bills to pay, I had no way of knowing how I was going to support myself and there were a lot of other things on the line. I made that decision because I realized that I couldn't really, in good conscience, take care of anyone else when I was so sick myself, when I was so tired, when my mind was foggy, and I didn't care when I went in, I just didn't care because I was so burnt out. Right.

Speaker 3:

And again, the short version, the compressed version, is I went on to have what I call my year of silence. I was just watching the thoughts in my head and I realized that they weren't very helpful and they were very negative and coming from a very dark place. And then I just became so, jack, we were talking a little bit about words and I'm highly sensitive to words. I became very aware of the words that were seeping into my head on a daily basis from listening to songs, conversations around me, and I just decided, okay, I need to clean out my head. And so I imposed a year of silence where I really didn't talk to anyone unless it was absolutely necessary. But the other thing was also I banned all music except instrumental because I didn't want. I listened to some lyrics of popular songs and I thought that is crazy and I'm singing these songs, it's going in my head, right, and I just decided I need to curate the words that are going into my head better. So I stopped that.

Speaker 3:

And if I were standing near someone and I heard conversations that were negative or just weren't very helpful, I had this thing where I would hit delete in my head and so I'd make this little gesture and I'd hear the little trash can sound, you know, like that in my head and my friends would be like what are you doing? And I was always hitting delete whenever it was something that was not productive. So I learned to clean up my mind and delete, delete, delete and just to have this moment of silence and then, as I said, to curate the thoughts and the words that went into my head. So I selected what I wanted to put in.

Speaker 3:

I spent a lot of time reading. They say that you're the average of the five people you spend the most time with. And because I didn't spend a lot of time reading, they say that you're the average of the five people you spend the most time with, and because I didn't spend a lot of time with many, I was just thinking how do I make this work? And I realized, well, it doesn't have to be in the actual presence of someone. It could be someone that I read, someone from another century, you know. So I read a lot of Rilke and you know some of these poets that I really enjoy and that I get so much from.

Speaker 3:

And you know, I selected the five poets and writers that I wanted to spend the most time with, and that's kind of how I spent the year just cleaning out my mind and my soul and my spirit, and then realizing that you know, phil, I know you can relate to this we're supposed to take care of people, but nobody taught us how to take care of ourselves, right. And so you take the brightest people with the best intentions, and then you proceed to like dumb them down and burn them out. That's what our system does. And then you wonder to like dumb them down and burn them out. That's what our system does. And then you wonder why. You know people are leaving the profession and so forth. Right, so I say it was a gift, because two years out from training, I noticed this and I realized if I can't take care of myself, I can't take care of anyone.

Speaker 3:

And then it became this journey to learn what I didn't learn in medical school. Right, they never taught us about nutrition. Right, they never taught us about sleep, except to just not sleep. Right, they never taught us about exercise. And the strange thing is, anytime someone wants to start an exercise program or go on a diet, they're asked to check with their physician, who knows nothing about this. But somehow they're supposed to check with us, right? And I'm like what am I supposed to tell you? I had zero hours in my med school curriculum on any of these topics, right, and that was when I realized, okay, I am going to have to find a way to learn this before I can take care of others, because you know you wouldn't go to a dentist with rotting teeth yes right.

Speaker 3:

So why are we going to doctors who are burnt out and sick and not healthy in their heads, right, who've been, you know, kind of put in a system where they have to suffer moral injury every day and then they're told oh, you burn out as if it's our fault, it's not, as if you're not as if, if anyone say it that way.

Speaker 3:

Yeah, as if we're not tough enough, you're burning out. I'm like no daily we have to face this moral injury of doing things that we know are not right for our patients, and then you wonder why we're in such, you know, decline in terms of our mental health. So it was just the way the system was set up and I realized I needed to change the way I practice. So I know, are you regretting that you asked that question?

Speaker 2:

takes most doctors a very long time, if ever, for them to start to recognize that. You know that sort of moral injury that you talk about. I think most doctors don't recognize that what they're doing for their patients is maybe you know discordant with what their real goals were in becoming a physician.

Speaker 3:

That's right. And then, day after day, we do that knowing better, right, and, as you said, our intention was never that, we were never trained that way. And after a while, you know, you get to this point of you have to dissociate in some way to be able to continue. And many people have families and you know they have responsibilities. So you find yourself in a position where you can't easily back away, right, but at the same time you're doing something that you know isn't necessarily really helping your patient and maybe promotes a different agenda. Because, after all, the entire business model is no one gets paid till you get sick. That's the entire business model. So when people talk to me about changing medicine, I'm like well, you set up the system, the business model's already there. You got to change the business model or else nothing will change, but no one will talk about that. Right, it's all kumbaya, but let's be real.

Speaker 1:

Oh, I love her. Okay, phil, I want to read something else. Every day there is another one, another patient that ends up on my operating table because they have not been properly informed and educated about how to remain healthy. Nearly 700,000 people die each year because of heart disease, and the problem is getting worse instead of better. When we solve the heart disease epidemic and people are in control of their health, we can avoid chronic disease. People will remain vibrant and healthy in their older years. We will be able to keep pace with our grandchildren and our great-grandchildren. The need for heart surgeons like myself will be eliminated. The entire health care system will be revolutionized and downscaled. People will be able to focus on health instead of health care.

Speaker 1:

That was written by our own host, dr Philip Ovadia. I had to pull that in here after reading your bio, vivian um. We so often talk science, biology, neurology, chemistry on this show and it's and it's wildly important, but what we have happening right now is we have two people who've devoted their lives to healing talking to one another, and I just think it's extraordinary, mary. You two have both gone deeper and have have gotten down to the roots of the problem, and I just I'd love to hear more from both of being a healer instead of whatever the medical system tries to turn you into.

Speaker 3:

Yeah Well, I think, Bill, I mean you know what you have done and just promoting the awareness that you don't necessarily need to have. You know the progression and the end course of being on you know an operating theater, right with your heart and with your health, and I think having a surgeon speak out against that is very powerful because, again, no one makes money till you get sick and in that model, that's how you survive, that's how you make a living, and and yet you speaking out and you know letting people know that that's really not where we should be going. That's a powerful message.

Speaker 2:

Yeah, Thank you for that, Vivian. And you know, in the same way, that you were able to recover from your burnout. I mean, you know most people two years into a career, whether it be medicine or something else, and they, you know, they burn out from it. They're not coming back.

Speaker 2:

And yet you know you've found a way to come back, and I would say, come back much better and stronger. And it's now many more than two years since that and you're still. You know, you're still doing it and really getting better. So talk a little bit about, maybe, what that recovery was like to get back into medicine, to change the way that you're approaching things and to really, you know, as Jack said, get back to the healing that we all intended to do.

Speaker 3:

Yeah, it was a very long journey. The first step was trying to take care of myself and sort of learn about what was important in self-care. Right At the same time, phil, I had gotten a scholarship to get my MFA in fiction right at that time. So that was when I sort of had a split life because I was doing this program at Warren Wilson College, getting my MFA in fiction, and at the same time I was practicing but I was doing mostly inpatient hospitalist work because that would allow me sort of shift time right. So it was really one of the loveliest times of my life because I was able to now spend time with my writing. And that was also when I did a lot more of my dance and choreography and so forth, really kind of exploring the side of me that had not had that much freedom to blossom because I was just always doing the sciences and school and so forth for med school. So I was doing that and then at the same time seeing patients, you know. But I also realized that there was a lot of overlap, right, because as a writer you know what you do is observe, you listen, right, you are deeply interested in motivations and human nature, right, and just kind of connecting with characters. So what I did with patients was not very dissimilar.

Speaker 3:

And the other thing was that I realized that most of what we do, phil, are full-time jobs. I wish they'd tell students in med school this your full-time job, your full-time job is telling people things they don't want to hear. That's your full-time job, mrs Smith. You know, I'm afraid it's cancer. We have to amputate. Your son's not coming back. He's in a coma, right Every day. That's our full-time job. Telling people things they don't want to hear. Your kidney's failing Now. How do we then A get them to hear what we're saying? Right, that's our job. Is to make it safe for them to hear. It's to make it clear so that they can hear this. And none of this is taught in medical school, right, the communication aspects, and that's your full time. Every day you go in and you're gonna have to tell people things they don't want to hear. Okay, and I think as a writer, it really helped me think about the character's point of view and therefore the patient's point of view, their motivations, what's important to them, and then that communication to them takes that into account, and I think that really helped me in communicating with patients and understanding where they were coming from, right. So I think that was that was really a big part of of my own learning to be a doctor.

Speaker 3:

But it didn't come from med school, it just came from life and doing something else right being a writer. So I got my book out and, you know, I was at a crossroads, thinking about whether I just wanted to keep going on the writing route or, you know, what should I do about medicine? Now, I never considered stopping medicine because I felt that it was. You know, I had a medical degree, I'd gone to med school, I had taken a place. Someone I mean so many people were trying to get into med school and get that degree and I had this. I felt it was unconscionable to just drop it and not practice, to just drop it and not practice that at some level I still needed to practice, because if I went and did that, then I still need to honor, you know, the fact that I can practice and that I had a duty to help people. So I always, you know, but in what capacity. So I was struggling with this and I remember I was at Bread Loaf as a fellow.

Speaker 3:

So this is a writer's conference. It's in Vermont. I had gone as a scholar and then they invited me back as a fellow and I was working with a writer and so as a fellow, you help out in the workshops. You do the critique of manuscripts, together with the main faculty. One day we went out for a walk during the conference and she was just telling me and she had had I don't know about eight books out. So she was just telling me how she'd just gotten to this point where she felt like what's the point? I write all these books, and yeah, but she said I envy you and I said maybe why you only have one book. You have eight books. And she said I envy you and I said maybe why she said you only have one book. You have eight books. And she said because I don't know what I'm doing with these books. I don't know if anyone really reads them, it makes a difference but you, you get to go in and help people. At the end of the day you can go home and feel like you've done something to help someone. And that sank really deep and I was thinking about that and she said because you know, I can write another book, a 10th book, a 12th book. But at the end of the day, you get to say that you know you helped someone.

Speaker 3:

And I thought about that and that was when I really kind of, you know, re-evaluated my relationship with medicine and that's when I decided okay, if you're going to go back, then you know you could do so many other things in your life. If you're going to go back, you're going to have to do something to change the system. Otherwise, why bother? Right, because there are many ways to make a living, many ways to make a living, many ways to make money, many ways to be successful. So if you want to choose this route, it better be. You know that you're going to do something more than just make a living. And that's when I thought okay, you know, then maybe I'll try to change this in some way. So that was how I went back to medicine.

Speaker 3:

And then I did work for a few years, you know, with other clinics and I was a consultant in a hospital. But then I decided that to take this further, you can't build something new from within a broken system. You just can't, because you're always going to be shackled, some manager is going to be over you, five committees, the budget, la, la, la, la la. And I realized, listen, I want to spend my life energy doing the work that I came here to do. I don't want to spend my life energy convincing you to let me do the work that I can. It's just like that's too much of a waste of my time. So, you know, just cut loose and I went out on my own.

Speaker 3:

And that's really when I spent the last 10 years, philip, just delving into all the things they didn't teach us in med school the medical school curriculum, and I mentor some med students. I'm quite aware even today, the medical school curriculum is about 50 years old, right, and you know it's they. They make it a little flashier and stuff, but you're not really learning anything new. Now the biological sciences have moved so far ahead and this huge gap no one is bridging this gap, right? And that was when I felt like you know, a lot of the stuff we learned just served the system. It was algorithmic.

Speaker 3:

If you see X, do Y, you know again, you take the brightest people and then you know this is what you give them and there's no thinking, no challenge and no real kind of approach to the patient from an organic point of view and from the point of view of health, which comes from the word hail, which means whole, right, seeing the patient. Instead we have these silos pulmonary and cardiology and we just throw them into little buckets as if we were just different organ systems. But we forget that it just works together as a whole. So I had to spend the last 10 years piecing together this wholeness and how things interact, and also trying to move away from the simplistic approach, right, that a lot of times I see people going after that oh, you just do this one thing, you just take this one supplement, and I mean homo sapiens would not have survived if we didn't have all these backup mechanisms. You know you, you stop one route or pathway, we divert, we'll go around it, right, because otherwise, you know, somewhere in year two it would have been like ka-dunk and you're gone. Okay, right, the Neanderthals would have taken over or something.

Speaker 3:

But for us to have survived so long, we had this flexibility and we were able to reroute in many of the molecular pathways and the metabolic pathways and so forth.

Speaker 3:

So just understanding that and realizing that there's a lot of complexity because it's a systems approach and not a simplistic one switch approach, that's the other thing I was really interested in, and trying to bring that into clinical relevance. Because you have the biological sciences, you have medicine which is far behind and dictated by algorithms, but somewhere in there we have to bridge it and find, you know, a way to practice clinically, practically that you know is more up to date in terms of science but also takes into account that you know we don up to date in terms of science, but also takes into account that you know we don't know all the different roots and molecular pathways yet there's so many missing pieces. But what is most relevant now? Where can you get the biggest bang for your buck nutritionally, in terms of activity, in terms of sleep, in terms of, you know, our daily practices, our lifestyle practices? So that's kind of the approach I took.

Speaker 1:

I think it's fascinating how you just described that, because when I tell people about what we do on this podcast, I've heard the message enough that I think I've started to absorb it that health is composed of what we eat, how we move, how we sleep and how we manage stress those four things. It's always been astonishing to me how little those four things are actually addressed by the air quotes healthcare system. I know we want to talk about your obesity medicine work, so let's say for sure we want to talk about that. But I'd love to hear you kind of expand a little bit on how those things all play into health, particularly the stress management, which sounds to me like something you figured out on your own.

Speaker 3:

Well, you know, so many things come to mind. But let's just go back to what you said about health, and you know this doesn't come from me entirely, it's from a model that a very famous immunologist put out. His name is Ruslan Metchitov. Follow him Kind of a little groupie here, because I love the work he does. But you know I was listening to him talk about health in terms of robustness and resilience, right so? Robustness where we don't get sick easily, and resilience, if you get sick, you can come back easily and regain health. And then I thought about also just one other R in my own mind this idea of being not reactive but responsive to our environment, right so, especially with human beings, because we have our minds, and so there's this robustness and resilience that we see in organisms when we talk about health. But I think, adding to that another R, the idea of responsiveness to our environment and to whatever, whatever is around us is how I envision health, because the health care system or the sick care system, has a very low bar right now. It's just absence of disease, which is the lowest of the low in terms of defining health. So I like to think of robustness, resilience and responsiveness to the world around us and think of those R's in terms of health. And, of course, we are made to build and to also break down tissue. We're built in cycles and so learning to respond to those cycles, those circadian cycles, to feedback cycles, right, that's one huge component. Like you said, jack, that's not taught. And so if we look at feeding, if we look at nutrition, sleep, exercise, repair, recovery, these are all in cycles. And so, you know, do we understand those cycles, do we understand the different components involved?

Speaker 3:

A lot of times I hear doctors talk about inflammation and needing to get rid of inflammation. But again, if we think in terms of cycle, the immune system is inflammation and anti-inflammation. If you have too much inflammation then you get, for example, breakdown of tissue and so forth, a lot of destruction in the body. But too much anti-inflammation is what happens in cancer, for example. You lose your immunosurveillance, example, you lose your immunosurveillance, right, and you know, maybe the wound healing aspects get out of control. Now you have fibrosis. So this is all part of the immune system. It does both. It doesn't just do inflammation and then we try to, you know, put on the anti-inflammatory aspects. No, the immune system modulates all of it. And understanding the cycles that we go through inflammation and anti-inflammation. So we have, you know, destruction and then healing, destruction and healing in all our tissues when we engage the immune system right of cycles. That's a very big component for me.

Speaker 3:

The other thing is stress. When you're talking to me about stress, I'm thinking, okay, generally this is not how we're taught, but if you think of it, we think about stress and everybody's thinking about their own particular stress. It's really hard to define, but if we bring it back to the body which is my favorite way to start it is a state of arousal, simply a state of arousal. So how do we detect the arousal? Your heart rate goes up, your blood pressure goes up, your breathing goes up, right, and we have these sensations Heart rate up, blood pressure up, breathing is up, and Jack, I'm so angry, stressed out, because so-and-so said something to me, and I'm so angry. Your blood pressure goes up, your heart rate goes up, your breathing goes up and, jack, I'm terrified. I have this exam tomorrow and I don't know if I'm ready. Your heart rate goes up, your blood pressure goes up, your respiratory rate goes up and, jack, I'm in love, I met the man of my life, or whatever. So you can see, the body's response is the same and that is a state of arousal.

Speaker 3:

It's the stories, there's the writer in me. It's the stories that are creating the stress experience that you're having. Right, so that that experience is based on the story that's going on in your head. Remember, I started by telling you that I needed to wipe my head clean and just be very careful about how I curated what went in my head. So when we talk about stress, you know it's like I don't know if I'm going to be able to pay these bills and so forth. And that is, you know, anxiety. Right, we call it financial stress. You know why? She always like picking a fight with me. She never sees the. You know the work that I do and, again, the body experiences it as increased heart rate, increased blood pressure, increased breathing rate and so forth.

Speaker 3:

There's one physiologic response. There are a million stories, wow. So managing stress for me is managing the stories right In the end, because I could be in love, excited, or I could be in fear, I could be sad, I could be angry, and it's all depend. There's only one physiologic response, but there are a million stories, so I need to pick the right story. Yeah, that's kind of how I see it. So my approach to stress management maybe because I'm a writer, I'm very interested in the story. Right, because I know as a doctor there's only one physiologic response. So tell me the story and then to manage stress, we're going to have to tweak that story. Right, little editing, right back to writing.

Speaker 1:

Delete right.

Speaker 3:

Yeah, delete, you know, cut out certain paragraphs, rearrange, reframe, right, change the point of view. There's so many things that you can change right, but we're going from the point of view of the story because that is the experience, that is the experience of the stress that we have to address.

Speaker 2:

And to kind of maybe take that a bit deeper and build on it. You know, when we look at all these diseases that we talk about, you know, heart disease, cancer, alzheimer's, whatever diabetes, cancer, alzheimer's, whatever diabetes, you know, and in a similar way, you know we've gotten so deep in the woods about the end of the story, like the heart disease, the diabetes, the cancer, and we miss that, you know again, these all come from a common physiologic response.

Speaker 2:

Basically our body has or physiologic derangement, and I think that really ties into a lot of the work that you've now been doing, you know, focusing on obesity, but really again getting back to this root cause of of our diseases.

Speaker 3:

Absolutely. I mean, almost all chronic diseases are, to my mind, metabolic diseases, right? So I had a conversation with someone a couple of weeks ago and he was like no heart diseases cardiovascular. I'm like, no, it's a metabolic disease. Even the drug companies call it cardiometabolic, right, at this point they realized that and in the end and I started with this in my bio on my website, jack, about the life force, but essentially, in the end, everything is about energy, right, and metabolism is the regulation and management of energy in your body.

Speaker 3:

And when that is kind of when that is off, when we're not regulating and managing the energy correctly, then different systems basically become dysfunctional. But we can also look at it the other way, that if we were to exploit metabolism, were to exploit metabolism, if we were to exploit energy management, then that will also change. You know how your body functions. So in the latter case, take cancer right, and cancer cells are notorious for exploiting and rewiring the metabolism, the regulation of energy in your body, right, and that's why we're looking now at immunometabolism and a lot of the cancer research is looking at how cancer cells rewire our metabolism and how do we unplug that rewiring and reassert a different wiring, right? So in the end, it's all about energy. War, war, gentlemen, right, because it's about resources. Yes, right. And whether it's a pathogen, it's a bacteria, it's a virus, it wants resources from you and your body is about protecting those resources, defending those resources. Cancer cells want resources and you're defending against them as well. So everybody is battling for energy, because energy is life.

Speaker 1:

I would just like to I know you get most of this, phil, but I just want to sit and just bask in these ideas. This is, this is this is beautiful. It's literally the first time I've ever heard anyone connect the, the metabolism, the you know what you eat and how your body burns it with the stress situation. Granted, I'm not the brightest bulb on the shelf, but all of a sudden it makes sense. Oh, of course, it's all about energy. It's all about energy.

Speaker 3:

Yeah it's all about energy and also partitioning of energy within the body, and different organ systems are going to be fighting for those resources as well.

Speaker 3:

Right, so just to go back to obesity, one of the things that I've been trying to get across to people who actually are practicing obesity medicine is the one thing I want to say over and over and over again, because I don't think it's there's the one thing I want to say over and over and over again, because I don't think it's getting. You know, the message is getting out there enough. That is that we know we know this because we have seen it and there are studies that show this that when you have increased fat content in your body okay, you have increased percent body fat there is a concurrent decrease in blood flow to the brain. Okay, and this occurs even at bmis of 26 I hate using bmis, but the studies were done and this occurs in 20 year olds and 30 year olds. So please don't tell me about oh, when we get old, and blah, blah, blah. Okay, so we have decreased blood flow to the brain decreased cerebral blood flow.

Speaker 3:

This is well known, well documented. I can't tell you how many times I have to say that. Now, at the same time, we worry, we go wow, why is there young onset dementia? Why is everybody so anxious these days? Why is is everybody, you know, so distractible? Why are we having a lot of mental health issues?

Speaker 3:

Well, think about this. Your brain is about two pounds, two and a half pounds, and it consumes 20% of your energy intake. Wow, when you're stressed, it goes up to 25%. It says I need more because you're juggling more, so I need more energy. Now I just told you, if you have increased fat content percent, body fat, even at overweight, bmi 26, you have decreased blood flow to all areas of the brain and it's almost like a linear the higher the weight goes, the lower the blood flow to the brain, which means that there is a condition of hypoxia not enough oxygen to the brain cells and not enough nutrients, not enough glucose to the brain cells. So your brain cells are dying every day. Okay, yeah, I don't know why we don't talk about this. Okay, so your brain cells are dying every day. All right, great. Now just think about this Whenever they say oh, patients are not compliant and things.

Speaker 3:

Just think about this Okay, you're, you have a brain, it's struggling and at the end of the day, you know, you've been busy all day, you got the kids to pick up, finish your project, blah, blah, blah, and there's increased demand. You know, in terms of cognitive functioning, right, but you can't increase the blood flow, right, your blood flow is fixed, it's decreased, so. But what can you manipulate? You could manipulate the concentration of nutrients, for example. Yo buddy, go get that donut. Example Yo buddy, go get that donut, because per unit flow to your brain. If we have a higher concentration of glucose, brain says that works for me, right. And so we go oh, I am, I don't have enough willpower, I don't have enough, I'm like it has nothing. Your brain is saying go get something because we are starving and dying, Right. And then, not to put anybody down, but honestly, sometimes I hear this, you know, I don't know where this comes from, because there's no research. But then we have this intuitive eating. Well, let me tell you, intuitively, your brain is like I want to stay alive. Tell you, intuitively, your brain is like I want to stay alive, so go get that donut, right. So, and then we blame the patient. I'm like, uh, did anyone like look at the physiology? Right? This is the kind of stuff that gets me frustrated, because we talk about obesity but we don't understand what is actually going on, basic physiology in the body, and then we treat it like some big mystery, patient's non-compliant, don't know why they don't have enough willpower. I'm like, yo, you know, just understand what's going on in the body. But again, we're just trained in a paradigm of when you see A, do B. When you see this, you know, and that kind of thing.

Speaker 3:

Ai deserves to take over, deserves to take over. Because why the heck right? Why do I need that? I didn't look anything up. You know I don't want to have to memorize an algorithm. Please, AI, take that Right. Memorize an algorithm, please, ai, take that. What they can't replace, I think, is just the humanity of practicing as a physician, the thinking, the looking at the big picture and assessing. That is still going to be hard for AI at this point, maybe in the future. But what I'm saying is the easy part is the algorithm.

Speaker 2:

They're welcome to have it, I don't care. Yeah, I think we certainly probably share that opinion about the algorithms and what worth they are, and I've said the same thing to many of my colleagues If all you're doing is following some algorithm, then what are you doing is following some algorithm. Then you know what are you doing. What do you need it for?

Speaker 3:

And it's all guidelines, phil. It's guidelines not based on outcomes guidelines. It's just somebody's guidelines, right, you know, but not on actual outcomes and benefit to the patient. This is what they don't point out. Well, the guidelines say, well, the guideline means shit, which, by the way, jack, is a medical word, you know, I say it frequently.

Speaker 1:

Oh my gosh.

Speaker 2:

It's a loud yeah, so, um, so I guess you know, uh, there might be some people thinking, okay, well, that all sounds really good and you know, vivian's obviously very smart and she thinks deeply about this. But you know, like you said, outcomes, we got to help the patient ultimately in front of us. So how does that help us? You know what do we do with that. If we come to that recognition, what do we do with it to then help that patient in front of us who is battling with obesity?

Speaker 3:

I think, and that's a great question. So, Phil, this is the first thing I want to do is explain to the patient what's going on, because they're already blaming themselves. They think they don't have enough willpower. I don't know why. I know what to do and they're really harder on themselves than anybody else. Right, I treat a lot of my patients and I just my heart goes out to them because they're really kind of blaming themselves there. And the first thing I want them to understand is this is your physiology, and it's a huge relief when they can actually understand that. Right, and remember what I said our full-time job is to tell people things they don't want to hear. But now, if they understand it, they're open to hearing what they could do.

Speaker 3:

And I'm like, at this point, we need to prioritize keeping as many brain cells alive as possible. All right, so the nutritional aspects, the sleep all you people thinking that, oh, I don't like the CPAP, I'll use my you know CPAP for my sleep apnea, you know, once in a while, yeah, I don't get that. With my patients, I have a lot of compliance because their understanding I'm like well, those brain cells, yeah, they're dying already and if we have sleep apnea on top of it, we're making it worse. So that understanding is no small feat, because we can make all. I said this, you know, I was at a conference two weeks ago. I said this we can make all the treatment plans we want. The only person who can carry out the plan is the patient. And at this point we give no guidance, no tools, no support, and then we say non-compliant, right. So if you can really explain it and say this is what we're going for, that person is more likely to carry out the plan. That's the only person that can carry out the plan, right?

Speaker 3:

So for me, the education is huge. That's why I spend a huge amount of time on the education, because we need to know what we're going for together. And then I can tell you nutritionally, these are the benefits if we do X, y or Z. This is why I need you to work on your sleep, right, and you know this is why you need to be using your, let's say, cpap device if you're on that. And then we have to monitor stress, because that's going to be an increased energetic demand on your brain, right? So how do we manage that? So now we have a framework and we can use that framework, it becomes very useful for the patient because they understand what we're going after and they also now have concrete steps in terms of nutrition, in terms of exercise, in terms of sleep whatever Concrete steps for achieving that goal right.

Speaker 1:

I'm, I'm, uh, I, I'm loving this. One of the things that occurs to me is, um, how lucid your explanations are and I I don't have to know a whole lot about science to follow you, and I can't help but wonder, if, wonder, if that year of silence and that pursuing a master's of fine arts in writing and actually creating a novel and actually working in a non-science, completely not rationally driven field has strengthened that part of your brain, your cognition, your perception, and physicians who are forced down this hyper-rational rabbit trail.

Speaker 3:

You know I'm going to disagree, jack, because as an undergraduate I was a double major in classical languages and literature and biology. So I studied Latin and Greek and it was really my classical studies and translation. Where I it was very small department so I only I actually met with my professor one-on-one. A big class was five people, right, but he was so exacting in looking at the text and I had to justify every single translation choice and really kind of dig into the text. So I think a lot of the critical thinking happened when I was a classics student.

Speaker 3:

Thinking happened when I was a classics student. I got a lot more out of that than I did the biology part, because he was the person who taught me how to think. He was very exacting. He'd hand me back my papers if he didn't see that lucidity and that clarity. He was someone who demanded a lot of clarity of thought and it was that that shaped the way and that was why I didn't do that well in med school, because I went in I was like dang, I don't know what's going on here, but there's a lot of memory work in medicine and it just.

Speaker 3:

You know, those first two years were tough for me because I come from an environment where thinking was so prized and then memory is more prized in med school to a large extent. And that's what you know, phil. I mean I'm sure you know you take the. These are really bright people to be able to get into. And then you just dumb everything down and you just kind of dampen everyone's spirits. At that point it's just about passing the damn exam. Who cares? You know, it's not about really seeing the connections, and that was the part that really disappointed me, but it's the connections that I'm.

Speaker 1:

I'm thinking of the, you know, the, the, the, the, the split brain, the bicameral brain. The model is is that that one side is rational, mathematical brain. The model is that one side is rational, mathematical, moral, judgmental, and the other side is a rational, nonverbal, but a pattern recognition machine. And I can't help but think that your dance, your choreography, all the creative work that you're doing, Okay, now that's really interesting because movement and cognition are linked right.

Speaker 3:

And now a lot of you know we used to do these, what you call it, phil, those mini mental status. You know the cognition screens to screen for dementia or cognitive impairment. We used to ask you, you know, remember these three words apple chair table, remember that. And what year is this? Who's the president? And there were a few years in residency I didn't know the president because I never stepped outside right, but the point was that we used to do these screens and ask these dumb questions, and we've actually replaced them with movement screens.

Speaker 3:

We want to look at how fast you walk, how you get out of a chair, for example, how you do what they call timed up and go, stand up from a chair, walk, turn around, come back and sit down. Because the movement, the quality of your movement, the speed of movement, relates to processing speed and you know gray matter volume speed and you know gray matter volume right in your brain, and so movement is actually the the more movement you have, it's actually a higher um sort of activity for the brain. And you know, if you look at it, dance is the only activity that improves dementia symptoms, right. So playing chess doesn't help. Playing the piano it's dance, because of the. I guess, yeah, it makes your brain really. I mean, you're judging what's upright, you're judging distance, you're listening to music, there's rhythmic patterns, you're coordinating. It's much better than a computer puzzle or something like that. And so when you want to build neuroplasticity, you should really be encouraging people.

Speaker 3:

So I have my patients eat with chopsticks if they're not used to it. If you know how to eat with chopsticks, eat with the chopsticks in your non-dominant hand. Walk around the block in the opposite direction. You normally go, brush your teeth with your non-dominant hand. So have them do just simple things to build neuroplasticity. Because again, we have this decreased blood flow, so the brain is shrinking and we actually do have atrophy of the brain, so the brain does shrink over time and this leads to cognitive impairments.

Speaker 3:

Right, so having them build in some neuroplasticity with movement. So I'm really a fan of movement and I just try to move all day. I know I'm standing here doing a Zoom with you. I think, phil, you're standing too right. I rarely sit and I to move and I try to do complex movements right, non-dominant hand, do something unexpected, and of course I dance too, but my point is, I try to make my patients aware of that and guide them towards that right. So these are things that we know in neuroscience helps the brain. But again, why don't we bring it to our patients? This is the kind of thing it's like, not that difficult to brush your teeth with the other hand. Right, it doesn't cost anything extra. No extra toothpaste, even right, except the stuff that drops.

Speaker 2:

So you miss, yeah, the stuff you miss with because you can't do it.

Speaker 3:

That's right.

Speaker 2:

I mean, this has just been a fascinating conversation. So I guess you know, maybe just one practical point we'll hit on, you know, because a lot of what I hear you often pointing out and talking about is maybe, let's say, the inexactness of the measurements that we sometimes use in assessing certain things. And I'd love to. We're not going to get into it today, but we'll probably put a pin for part two of this conversation sometime about the whole lipid discussion. But I know you talk about BMI, body mass index, and how, when it comes to obesity, maybe it's not the right thing to be looking at. Uh and uh, body composition is really what you know we should be interested in. So, uh, talk about a little bit about that in uh, as we kind of start wrapping things up.

Speaker 3:

Thanks, bill Um, because that's something I really want to get across is that by BMI. If we look at 2018 numbers, 42% of Americans have obesity by BMI. But, honestly, if we go by percent body fat, it's going to be about 90%. So you walk in a room, 10 people in the room, 9%, and nine people in there have obesity, and that's because we're missing normal weight obesity. The people who step on the scale, they're normal BMI, normal weight, and they think they're fine.

Speaker 3:

But if I don't care what weight you are, if you're 100 pounds, soaking wet, but you are 40% body fat, you have obesity. Duh, right, you shouldn't be 40% body fat. You should have more muscle, okay, and this is going to have profound metabolic implications in your body. You know where's that glucose going to go? It usually goes to muscle. The less muscle you have, the more it spills out in the bloodstream. Hello, right.

Speaker 3:

So my point is that when we just look at the number and the scale and this whole ozempic thing and everybody's like, oh, the weight, how much weight did you drop? But understand that every time you lose weight everybody knows this Well, they should You're losing muscle and fat. You're always losing some muscle. All right. Bad news again Every time you gain weight sorry, you're only gaining fat mostly, unless you're really really working towards building some muscle. But as we age, it's very hard to do because of our hormonal status and so forth. So, primarily, you lose weight, you lose muscle and fat, you gain weight, you gain muscle. So over time we are actually changing our body composition and becoming more fat and less muscle. And if you lose five pounds of muscle, gain five pounds of fat, you will be weight neutral. You step on the scale and you're the same weight and you're happy, but you have changed profoundly in terms of metabolic regulation in your body. So when we're not paying attention to this, you know, we don't realize that more people are sick than we thought. Instead of 42% obesity, we have closer to 90% obesity, right, and now you know, yeah, that's a whole different thing to like contend with and that's a whole different approach that we need.

Speaker 3:

So, coming back from this conference that I just gave, a talk on the fat, muscle, bone axis in metabolic health, my main point was all of us are missing the normal weight obesity patients. Okay, and those are the ones he was so healthy, just killed. Oh, I wonder. We all know one or two of those they were jogging every day they seem so, and then they like what happened? Genetic? No, we miss the normal weight obesity. Right, because those people still have impaired blood flow. Right, even though they looked in. They still have fatty liver, they still have metabolic abnormalities, the diabetes and so forth. Look at all the Asians that are skinny, right? I remind you that bariatric surgery in Thailand was, you know, not so much, for it wasn't for weight loss, it was for diabetes. Right, because it was again normal weight obesity that we're seeing. So nobody talks about this, and that's something I'm glad the first time I've ever heard the phrase yeah, and I just want to get it out.

Speaker 3:

So thank you, phil, for for actually bringing that up. It's a big point. I want people to stop thinking about the number on the scale and start thinking about what you're made of and how do we optimize that so we have less fat, we have more muscle and bone.

Speaker 2:

Yeah, yeah. And of course you know all of that correlates, like you said, with the underlying metabolic issues. You know that come with normal weight of obesity.

Speaker 3:

Absolutely.

Speaker 2:

So the consequences Well, this has been an amazing discussion and really enjoyed it. I know people are going to want to connect, find you see how you work with people, so where should they go for that?

Speaker 3:

website, which is simply my name, vivianlomdcom. So I'll spell it, because my name is spelled a little differently it's V-Y-V-Y-A-N-E-L-O-H-M-Dcom, vivianlomdcom. And yeah, I work with people who are interested in improving their metabolic health and also in training. You know physicians and so forth who want to learn how to do this. I do that as well. I have a training program for physicians or PAs and so forth. So if they're interested, they can go to my website, send me a note and I'll get back to you.

Speaker 1:

All right. So if you're Joe Sixpack, like me, and you hear this and you really want to get a hold of things, go to Dr Lowe's website. And if you're a health care practitioner and you're hearing stuff that makes the bells go off and you go I got to learn this go to Dr Lowe's website. We'll make sure that this information shows up in the show notes. Thank you, bill. I realize it sounds like I say this after every single guest, but this one in particular. I'm just. I'm enraptured over this human being who's path and and lays it out so clear. I heard things today that made it all make sense that I think I really didn't get it before, but I got some things today.

Speaker 3:

I'm glad.

Speaker 2:

So, that's why we keep doing this, week after week. I really enjoy it as well and just all these amazing people that I feel blessed to be able to interact with, learn from, have some of these conversations with. It's really what's been fun about doing this podcast and also being in this space of medicine, where I think we're thinking differently about things, I think absolutely. Yeah, when you look at the metabolic health space, what I see is challenging the norms and recognizing where we're failing and how we can go about changing that.

Speaker 3:

So excited for what. I'm glad you're on our team, Phil.

Speaker 1:

I'm glad you're on our team, phil, I'm going to beg you to promise to come back Right here.

Speaker 3:

Oh be my pleasure.

Speaker 1:

Okay, we got it, Phil. We have a commitment from her.

Speaker 3:

Very good, I'd love to.

Speaker 1:

We'll do a chapter two of this conversation. There's so many things I want to ask you about, but it'll have to wait. All right For Dr Vivian Lowe and Dr Philip Ovadia. This has been the stay off my operating table podcast. Thanks for joining us. They're all like this, so you ought to subscribe and get get reminded. We drop it, do it, do it. Subscribe Every Tuesday we drop it, do, it Do it. Subscribe Every Tuesday. We'll talk to y'all next time.

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Dr. Philip Ovadia

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Jack Heald

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