Doing your own research (1 Viewer)

[DA RAIDERS]

Looking around a little at some other information on Means.

I like Dr. Andrew Huberman and think he usually does thoughtful interviews with people.

He interviews Dr. Means and said he loves her work and her book and talks to her here if people are looking to understand more.

- YouTube

Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube.

youtu.be

In this episode, my guest is Dr. Casey Means, MD, a physician trained at Stanford University School of Medicine, an expert on metabolic health and the author of the book, "Good Energy." We discuss how to leverage nutrition, exercise and environmental factors to enhance your metabolic health by improving mitochondrial function, hormone and blood sugar regulation.

We also explore how fasting, deliberate cold exposure and spending time in nature can impact metabolic health, how to control food cravings and how to assess your metabolic health using blood testing, continuous glucose monitors and other tools.

Metabolic dysfunction is a leading cause of chronic disease, obesity and reduced lifespan around the world. Conversely, improving your mitochondrial and metabolic health can positively affect your health span and longevity.

Listeners of this episode will learn low- and zero-cost tools to improve their metabolic health, physical and mental well-being, body composition and target the root cause of various common diseases.

Read the full show notes, including referenced articles and additional resources: https://go.hubermanlab.com/nFNXu30

On Huberman:

"His promotion of unregulated health supplements has been particularly controversial, as these products often have little scientific evidence supporting their effectiveness.[19] According to immunologist, microbiologist, and science communicator Andrea Love, Huberman's podcast content is characteristic of pseudoscience.[2]"

Not surprising he loves her work.

On a scale of 0 (none) to 10 (most) how much authority would you say Huberman has when talking about general health and wellness related issues?

Don't know, don't really care.

When people push things that aren't backed by good evidence, it calls everything into question. Some of his message is likely good. Same goes with Means. But, it then becomes difficult to distinguish good info from bad info and isn't worth the trouble when there are plenty of worthwhile sources that provide credible info.

Seems like you care enough to agree with a person who call his work pseudoscience. And infer Means is as well.

Do you think Dr. Huberman provides credible information?

That's from his Wikipedia page. A quick Google search shows others that say the same thing. He promotes pseudoscience.

You seem to want to ignore that. I don't.

Again, some of what he may say is almost certainly credible. But when you tout things or give credence to ideas that aren't backed by evidence, especially on such a large platform, it invalidates your work. It's time consuming and fruitless to fact check what's accurate and what's not. Especially when there are others that provide similar guidance without the pseudoscience/quackery/grifting.

You clearly like to look at the message and not consider the source. I don't.

But when you post about someone here and give them credit for something, I'm going to call it out, every time I see it, when there's a red flag about it.

When people hear a message they already agree with, they are far less likely to dig deep into the validity of it. They get that dopamine hit of having their pre-conceived beliefs confirmed and that's enough for a lot of people.

This times a BILLION. And then they get upset when their champion is challenged or they themselves are challenged directly.

that’s what this thread is all about.

 

[Terminalxylem]

Looking around a little at some other information on Means.

I like Dr. Andrew Huberman and think he usually does thoughtful interviews with people.

He interviews Dr. Means and said he loves her work and her book and talks to her here if people are looking to understand more.

- YouTube

Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube.

youtu.be

In this episode, my guest is Dr. Casey Means, MD, a physician trained at Stanford University School of Medicine, an expert on metabolic health and the author of the book, "Good Energy." We discuss how to leverage nutrition, exercise and environmental factors to enhance your metabolic health by improving mitochondrial function, hormone and blood sugar regulation.

We also explore how fasting, deliberate cold exposure and spending time in nature can impact metabolic health, how to control food cravings and how to assess your metabolic health using blood testing, continuous glucose monitors and other tools.

Metabolic dysfunction is a leading cause of chronic disease, obesity and reduced lifespan around the world. Conversely, improving your mitochondrial and metabolic health can positively affect your health span and longevity.

Listeners of this episode will learn low- and zero-cost tools to improve their metabolic health, physical and mental well-being, body composition and target the root cause of various common diseases.

Read the full show notes, including referenced articles and additional resources: https://go.hubermanlab.com/nFNXu30

Regarding the bolded, it’s a stretch to say Means is an expert on metabolic health.

She’s got an undergrad degree in biology, almost completed ENT residency, and has no relevant scientific publications. But she did write a best selling book on “good energy”, so there’s that.

This is what we’ve come to accept as experts - intelligent people, usually with an unrelated degree from an elite school (Stanford seems over represented, for whatever reason), who empower their audience to improve health outside conventional medicine. They do this by making grandiose, unsubstantiated claims, sprinkling in some “sciencey”, but meaningless jargon, then direct their freshly minted acolytes to buy stuff. Conveniently enough, they often sell it on their websites.

Again, I know our system is broken, particularly preventative care, but I’m not sure this brand of expertise will fix it.

 

[Terminalxylem]

Which goes back to the original premise of this thread. It is not easy to discern the good info from the bad. The good research from the bad.

A guy like Huberman looks and sounds great, has all kinds of degrees, and is seemingly very trustworthy. Except that doesn't seem to be the case at all. And think of the literally tens of thousands (if not more) that listen and start to believe what he's promoting. And they bring that "research" and ask about it and use that.

That's this thread in a nutshell.

It’s way more than thousands:

As of July 2025, Andrew Huberman has approximately 6.9 million subscribers on YouTube and over 6.3 million followers on Instagram

 

[Terminalxylem]

I’ve seen some Hubermann tweets. He definitely talks a lot about things that are largely not rigorously proven, yet.

I consider that an opportunity to investigate more, which depending on the significance of what I’m considering and what I learn, may or may not include consulting a physician.

It doesn’t have to be Huberman is a fraud or Huberman is truth and exactness personified. I consider him food for more thought. Hard to see the objection.

He provides some good information, I’m sure.

The problem is, people indulging in his “food for thought” aren’t consuming a balanced diet, seeking out manscience “red meat” without critical appraisal, or considering alternative, evidence-based viewpoints.

 

[djmich]

I’ve seen some Hubermann tweets. He definitely talks a lot about things that are largely not rigorously proven, yet.

I consider that an opportunity to investigate more, which depending on the significance of what I’m considering and what I learn, may or may not include consulting a physician.

It doesn’t have to be Huberman is a fraud or Huberman is truth and exactness personified. I consider him food for more thought. Hard to see the objection.

He provides some good information, I’m sure.

The problem is, people consuming his “food for thought” aren’t consuming a balanced diet, seeking out the manscience “red meat” without critical appraisal, or considering alternative, evidence-based viewpoints.

I’m sure that when you say people aren’t doing that you mean some subset of people? Ok, sure, we can say that about everything…that doesn’t mean the net benefit of information shared isn’t positive…

 

[Terminalxylem]

I’ve seen some Hubermann tweets. He definitely talks a lot about things that are largely not rigorously proven, yet.

I consider that an opportunity to investigate more, which depending on the significance of what I’m considering and what I learn, may or may not include consulting a physician.

It doesn’t have to be Huberman is a fraud or Huberman is truth and exactness personified. I consider him food for more thought. Hard to see the objection.

He provides some good information, I’m sure.

The problem is, people consuming his “food for thought” aren’t consuming a balanced diet, seeking out the manscience “red meat” without critical appraisal, or considering alternative, evidence-based viewpoints.

I’m sure that when you say people aren’t doing that you mean some subset of people? Ok, sure, we can say that about everything…that doesn’t mean the net benefit of information shared isn’t positive…

Of course. But it’s a large subset in my experience, so large it’s a challenge to maintain an open mind to putting in the effort to educate otherwise. Some of this stuff has become so dogmatic, it feels about as futile as discussing religious, or political differences.

Medicine shouldn’t be that way, imo.

Is it a net positive? While it’s easy to say more information is better, the calculous becomes more difficult when a big chunk is mis-/disinformation.

 

[Terminalxylem]

And to add - I think it's a given that everyone here is in the top 95% of everything. This is the FFA after all.

I was being facetious, in response to AK’s prior boast. But the sad reality is

I’m increasingly fascinated by how different our experiences are. Are people saying that their experience with doctors is that they don’t want to talk to you about root causes? That’s never been my experience. It’s been the opposite.

Yes. I gave the example with statins earlier in this thread. My doctor wanted me on statins. Full stop. No conversation. I opted for dietary changes and have had it under control for a decade.

IIRC, your doctor recommended HMG CoA reductase inhibitors because your cholesterol was above the level where lifestyle modification alone would be expected to get it in the acceptable range - we know diet/exercise may drop LDL 10-20%, for example.

And I seriously doubt he suggested you only take meds. Lifestyle modification is always part of a multimodal approach to improving cardiovascular risk.

But if he refused to discuss diet/exercise, while insisting meds were the only answer, you were right to seek another physician.

Yes, you're likely right that he was following guidelines and he was doing what was expected. I can't fault that. He was very firm in his counsel that statins were my only viable option and anything less was just going to prolong the damage. Perhaps i was an outlier that i could correct this with diet compared to what he's seen previously with people in similar situations. I probably sound more difficult than i really am. I'll defer to those that know more than me in most instances, but sometimes if there's a second option i might want to try that first if it's not dangerous or reckless.

I shouldn't say he refused to discuss lifestyle. He was just making it clear he thought it would only prolong the inevitable, and was insistent statins were going to be only solution. As my doctor we discussed lifestyle previously aswell, so maybe he didn't think there was enough room for improvement based on our conversations over the years.

I enjoy your input on medical topics. It's helped a lot to get a medical professionals take on things like this. It's easy for me to make assumptions based on my one sided perspective so it's nice to get an understanding about what's happening behind the curtain.

It sounds like his advice was good, but delivery left something to be desired. Realistically, it takes years-decades for high cholesterol to do significant damage, so a few months off meds probably wouldn’t be the end of the world anyway.

Doctors shouldn’t be so paternalistic, as shared decision making is an important part of establishing rapport. Ultimately, it’s your choice, of course.

Still, I’d confirm with your new doctor that your current LDL is acceptable, realizing “ideal” levels haven’t been firmly established.

The PREVENT risk calculator is a good place to start: 10 year risk > 7.5% is where pharmacologic intervention is traditionally recommended, with a goal 30% reduction in LDL. Moreover, there are some “risk-enhancing” factors that should be considered, which may make your LDL target even lower.

Lastly, as I mentioned before, there’s data to suggest driving LDL to very low levels is associated with improved cardiovascular risk, with near linear benefit in mortality reduction all the way down to 45 mg/dL. Newer guidelines have shifted LDL targets lower to reflect this finding, particularly in high risk patients.

Term, interested in what you think about the ApoB test as an additional datapoint for people concerned about cholesterol levels and heart health?

High ApoB is a “risk enhancer” that correlates strongly with atherogenic (blood vessel narrowing) risk.

European guidelines recommend checking it, along with lipoprotein a, once as an adult. US guidelines are more vague.

If either are elevated, your doctor may pursue additional diagnostic testing, like coronary calcium scoring or CT angiography, versus just starting cholesterol lowering medication.

The other test that may be lumped in with these two is C reactive protein, though its utility is less clear imo. @Pip's Invitation may have additional thoughts on this subject.

FWIW, I paid out of pocket to have both Apo B and lp(a) checked, as insurance wouldn’t cover it. Although both were low, my primary care provider offered follow up coronary calcium scan for “more information”, largely because insurance would pay, which I declined.

 

[Joe Bryant]

FWIW, I paid out of pocket to have both Apo B and lp(a) checked, as insurance wouldn’t cover it. Although both were low, my primary care provider offered follow up coronary calcium scan for “more information”, largely because insurance would pay, which I declined.

Do you mind if I ask why you declined?

 

[Terminalxylem]

FWIW, I paid out of pocket to have both Apo B and lp(a) checked, as insurance wouldn’t cover it. Although both were low, my primary care provider offered follow up coronary calcium scan for “more information”, largely because insurance would pay, which I declined.

Do you mind if I ask why you declined?

The test wasn’t indicated. My primary gamed the system, saddling me with a diagnosis of elevated cholesterol*, after a single LDL of 101.

That label was enough to fool the insurers into paying for an unnecessary test. As I’ve explained many times, more testing/information isn’t always a good thing.

*The breakpoint for elevated LDL is 100, and that single test was the highest I’ve ever had. My usual LDL is in the 80s. I suspect the 101 was a lab error, but even if it were legit, my overall CV risk does not meet the threshold for coronary calcium scoring.

 

[djmich]

And to add - I think it's a given that everyone here is in the top 95% of everything. This is the FFA after all.

I was being facetious, in response to AK’s prior boast. But the sad reality is

I’m increasingly fascinated by how different our experiences are. Are people saying that their experience with doctors is that they don’t want to talk to you about root causes? That’s never been my experience. It’s been the opposite.

Yes. I gave the example with statins earlier in this thread. My doctor wanted me on statins. Full stop. No conversation. I opted for dietary changes and have had it under control for a decade.

IIRC, your doctor recommended HMG CoA reductase inhibitors because your cholesterol was above the level where lifestyle modification alone would be expected to get it in the acceptable range - we know diet/exercise may drop LDL 10-20%, for example.

And I seriously doubt he suggested you only take meds. Lifestyle modification is always part of a multimodal approach to improving cardiovascular risk.

But if he refused to discuss diet/exercise, while insisting meds were the only answer, you were right to seek another physician.

Yes, you're likely right that he was following guidelines and he was doing what was expected. I can't fault that. He was very firm in his counsel that statins were my only viable option and anything less was just going to prolong the damage. Perhaps i was an outlier that i could correct this with diet compared to what he's seen previously with people in similar situations. I probably sound more difficult than i really am. I'll defer to those that know more than me in most instances, but sometimes if there's a second option i might want to try that first if it's not dangerous or reckless.

I shouldn't say he refused to discuss lifestyle. He was just making it clear he thought it would only prolong the inevitable, and was insistent statins were going to be only solution. As my doctor we discussed lifestyle previously aswell, so maybe he didn't think there was enough room for improvement based on our conversations over the years.

I enjoy your input on medical topics. It's helped a lot to get a medical professionals take on things like this. It's easy for me to make assumptions based on my one sided perspective so it's nice to get an understanding about what's happening behind the curtain.

It sounds like his advice was good, but delivery left something to be desired. Realistically, it takes years-decades for high cholesterol to do significant damage, so a few months off meds probably wouldn’t be the end of the world anyway.

Doctors shouldn’t be so paternalistic, as shared decision making is an important part of establishing rapport. Ultimately, it’s your choice, of course.

Still, I’d confirm with your new doctor that your current LDL is acceptable, realizing “ideal” levels haven’t been firmly established.

The PREVENT risk calculator is a good place to start: 10 year risk > 7.5% is where pharmacologic intervention is traditionally recommended, with a goal 30% reduction in LDL. Moreover, there are some “risk-enhancing” factors that should be considered, which may make your LDL target even lower.

Lastly, as I mentioned before, there’s data to suggest driving LDL to very low levels is associated with improved cardiovascular risk, with near linear benefit in mortality reduction all the way down to 45 mg/dL. Newer guidelines have shifted LDL targets lower to reflect this finding, particularly in high risk patients.

Term, interested in what you think about the ApoB test as an additional datapoint for people concerned about cholesterol levels and heart health?

High ApoB is a “risk enhancer” that correlates strongly with atherogenic (blood vessel narrowing) risk.

European guidelines recommend checking it, along with lipoprotein a, once as an adult. US guidelines are more vague.

If either are elevated, your doctor may pursue additional diagnostic testing, like coronary calcium scoring or CT angiography, versus just starting cholesterol lowering medication.

The other test that may be lumped in with these two is C reactive protein, though its utility is less clear imo. @Pip's Invitation may have additional thoughts on this subject.

FWIW, I paid out of pocket to have both Apo B and lp(a) checked, as insurance wouldn’t cover it. Although both were low, my primary care provider offered follow up coronary calcium scan for “more information”, largely because insurance would pay, which I declined.

I paid for mine also.

I read about ApoB in some longevity book. Sounded interesting so I asked my Dr. about it. He said "oh yah, Apolipoprotein B-100, that's a pretty good test, do you want to do it?". And that's an example of one time I thought, I guess I'm glad I did my own research.

Now, my cholesterol is low so maybe he thought I didn't fit the risk profile where it was worth considering. But it was higher in the past and he's never mentioned it, not even as a one-time check it out option. I'm 53. And he offered no indication that he thought I shouldn't do it when I mentioned it. Maybe he sucks, but the experience is not atypical for me.

Along the same vein, I've never really been recommended by my primary care physician things that were good things to check out that I might be interested in that could help my health and wellbeing. One time I told him I was having some anxiety and trouble sleeping, and I got a prescription. I've been reading about cold plunges and infrared saunas recently as having some health benefits. When I think about it, I've never been provided a list of non-prescription ideas for what my primary care Dr thinks are great health hacks. Is it that none exist? Maybe cold plunges and infrared saunas don't do anything, but is there nothing that the Dr's I've seen have accumulated over decades of experience to tell their patients hey here are some great health hacks I've learned over time that are backed by science also. There's a huge missing gap...that guys like Hubermann will gladly fill.

 

[Terminalxylem]

And to add - I think it's a given that everyone here is in the top 95% of everything. This is the FFA after all.

I was being facetious, in response to AK’s prior boast. But the sad reality is

I’m increasingly fascinated by how different our experiences are. Are people saying that their experience with doctors is that they don’t want to talk to you about root causes? That’s never been my experience. It’s been the opposite.

Yes. I gave the example with statins earlier in this thread. My doctor wanted me on statins. Full stop. No conversation. I opted for dietary changes and have had it under control for a decade.

IIRC, your doctor recommended HMG CoA reductase inhibitors because your cholesterol was above the level where lifestyle modification alone would be expected to get it in the acceptable range - we know diet/exercise may drop LDL 10-20%, for example.

And I seriously doubt he suggested you only take meds. Lifestyle modification is always part of a multimodal approach to improving cardiovascular risk.

But if he refused to discuss diet/exercise, while insisting meds were the only answer, you were right to seek another physician.

Yes, you're likely right that he was following guidelines and he was doing what was expected. I can't fault that. He was very firm in his counsel that statins were my only viable option and anything less was just going to prolong the damage. Perhaps i was an outlier that i could correct this with diet compared to what he's seen previously with people in similar situations. I probably sound more difficult than i really am. I'll defer to those that know more than me in most instances, but sometimes if there's a second option i might want to try that first if it's not dangerous or reckless.

I shouldn't say he refused to discuss lifestyle. He was just making it clear he thought it would only prolong the inevitable, and was insistent statins were going to be only solution. As my doctor we discussed lifestyle previously aswell, so maybe he didn't think there was enough room for improvement based on our conversations over the years.

I enjoy your input on medical topics. It's helped a lot to get a medical professionals take on things like this. It's easy for me to make assumptions based on my one sided perspective so it's nice to get an understanding about what's happening behind the curtain.

It sounds like his advice was good, but delivery left something to be desired. Realistically, it takes years-decades for high cholesterol to do significant damage, so a few months off meds probably wouldn’t be the end of the world anyway.

Doctors shouldn’t be so paternalistic, as shared decision making is an important part of establishing rapport. Ultimately, it’s your choice, of course.

Still, I’d confirm with your new doctor that your current LDL is acceptable, realizing “ideal” levels haven’t been firmly established.

The PREVENT risk calculator is a good place to start: 10 year risk > 7.5% is where pharmacologic intervention is traditionally recommended, with a goal 30% reduction in LDL. Moreover, there are some “risk-enhancing” factors that should be considered, which may make your LDL target even lower.

Lastly, as I mentioned before, there’s data to suggest driving LDL to very low levels is associated with improved cardiovascular risk, with near linear benefit in mortality reduction all the way down to 45 mg/dL. Newer guidelines have shifted LDL targets lower to reflect this finding, particularly in high risk patients.

Term, interested in what you think about the ApoB test as an additional datapoint for people concerned about cholesterol levels and heart health?

High ApoB is a “risk enhancer” that correlates strongly with atherogenic (blood vessel narrowing) risk.

European guidelines recommend checking it, along with lipoprotein a, once as an adult. US guidelines are more vague.

If either are elevated, your doctor may pursue additional diagnostic testing, like coronary calcium scoring or CT angiography, versus just starting cholesterol lowering medication.

The other test that may be lumped in with these two is C reactive protein, though its utility is less clear imo. @Pip's Invitation may have additional thoughts on this subject.

FWIW, I paid out of pocket to have both Apo B and lp(a) checked, as insurance wouldn’t cover it. Although both were low, my primary care provider offered follow up coronary calcium scan for “more information”, largely because insurance would pay, which I declined.

I paid for mine also.

I read about ApoB in some longevity book. Sounded interesting so I asked my Dr. about it. He said "oh yah, Apolipoprotein B-100, that's a pretty good test, do you want to do it?". And that's an example of one time I thought, I guess I'm glad I did my own research.

Now, my cholesterol is low so maybe he thought I didn't fit the risk profile where it was worth considering. But it was higher in the past and he's never mentioned it, not even as a one-time check it out option. I'm 53. And he offered no indication that he thought I shouldn't do it when I mentioned it. Maybe he sucks, but the experience is not atypical for me.

Along the same vein, I've never really been recommended by my primary care physician things that were good things to check out that I might be interested in that could help my health and wellbeing. One time I told him I was having some anxiety and trouble sleeping, and I got a prescription. I've been reading about cold plunges and infrared saunas recently as having some health benefits. When I think about it, I've never been provided a list of non-prescription ideas for what my primary care Dr thinks are great health hacks. Is it that none exist? Maybe cold plunges and infrared saunas don't do anything, but is there nothing that the Dr's I've seen have accumulated over decades of experience to tell their patients hey here are some great health hacks I've learned over time that are backed by science also. There's a huge missing gap...that guys like Hubermann will gladly fill.

Data on cold plunges is inconclusive, and infrared therapy is even more out there (on the spectrum of evidence-based medicine, not wavelength). It’s not a reasonable expectation for your doctor to recommend them, imo. I’ll argue anyone who does so without a lot of disclaimers is doing their patients a disservice.

ApoB testing is more scientifically grounded, but still not explicitly included in American cardiology guidelines, so his ambivalence isn’t surprising either.

From the sound of it, your doctor possibly could have done a better job addressing your sleep and anxiety issues. Did he discuss optimal sleep hygiene, and the possibility of sleep apnea? What did he prescribe?

 

[Terminalxylem]

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

 

[djmich]

And to add - I think it's a given that everyone here is in the top 95% of everything. This is the FFA after all.

I was being facetious, in response to AK’s prior boast. But the sad reality is

I’m increasingly fascinated by how different our experiences are. Are people saying that their experience with doctors is that they don’t want to talk to you about root causes? That’s never been my experience. It’s been the opposite.

Yes. I gave the example with statins earlier in this thread. My doctor wanted me on statins. Full stop. No conversation. I opted for dietary changes and have had it under control for a decade.

IIRC, your doctor recommended HMG CoA reductase inhibitors because your cholesterol was above the level where lifestyle modification alone would be expected to get it in the acceptable range - we know diet/exercise may drop LDL 10-20%, for example.

And I seriously doubt he suggested you only take meds. Lifestyle modification is always part of a multimodal approach to improving cardiovascular risk.

But if he refused to discuss diet/exercise, while insisting meds were the only answer, you were right to seek another physician.

Yes, you're likely right that he was following guidelines and he was doing what was expected. I can't fault that. He was very firm in his counsel that statins were my only viable option and anything less was just going to prolong the damage. Perhaps i was an outlier that i could correct this with diet compared to what he's seen previously with people in similar situations. I probably sound more difficult than i really am. I'll defer to those that know more than me in most instances, but sometimes if there's a second option i might want to try that first if it's not dangerous or reckless.

I shouldn't say he refused to discuss lifestyle. He was just making it clear he thought it would only prolong the inevitable, and was insistent statins were going to be only solution. As my doctor we discussed lifestyle previously aswell, so maybe he didn't think there was enough room for improvement based on our conversations over the years.

I enjoy your input on medical topics. It's helped a lot to get a medical professionals take on things like this. It's easy for me to make assumptions based on my one sided perspective so it's nice to get an understanding about what's happening behind the curtain.

It sounds like his advice was good, but delivery left something to be desired. Realistically, it takes years-decades for high cholesterol to do significant damage, so a few months off meds probably wouldn’t be the end of the world anyway.

Doctors shouldn’t be so paternalistic, as shared decision making is an important part of establishing rapport. Ultimately, it’s your choice, of course.

Still, I’d confirm with your new doctor that your current LDL is acceptable, realizing “ideal” levels haven’t been firmly established.

The PREVENT risk calculator is a good place to start: 10 year risk > 7.5% is where pharmacologic intervention is traditionally recommended, with a goal 30% reduction in LDL. Moreover, there are some “risk-enhancing” factors that should be considered, which may make your LDL target even lower.

Lastly, as I mentioned before, there’s data to suggest driving LDL to very low levels is associated with improved cardiovascular risk, with near linear benefit in mortality reduction all the way down to 45 mg/dL. Newer guidelines have shifted LDL targets lower to reflect this finding, particularly in high risk patients.

Term, interested in what you think about the ApoB test as an additional datapoint for people concerned about cholesterol levels and heart health?

High ApoB is a “risk enhancer” that correlates strongly with atherogenic (blood vessel narrowing) risk.

European guidelines recommend checking it, along with lipoprotein a, once as an adult. US guidelines are more vague.

If either are elevated, your doctor may pursue additional diagnostic testing, like coronary calcium scoring or CT angiography, versus just starting cholesterol lowering medication.

The other test that may be lumped in with these two is C reactive protein, though its utility is less clear imo. @Pip's Invitation may have additional thoughts on this subject.

FWIW, I paid out of pocket to have both Apo B and lp(a) checked, as insurance wouldn’t cover it. Although both were low, my primary care provider offered follow up coronary calcium scan for “more information”, largely because insurance would pay, which I declined.

I paid for mine also.

I read about ApoB in some longevity book. Sounded interesting so I asked my Dr. about it. He said "oh yah, Apolipoprotein B-100, that's a pretty good test, do you want to do it?". And that's an example of one time I thought, I guess I'm glad I did my own research.

Now, my cholesterol is low so maybe he thought I didn't fit the risk profile where it was worth considering. But it was higher in the past and he's never mentioned it, not even as a one-time check it out option. I'm 53. And he offered no indication that he thought I shouldn't do it when I mentioned it. Maybe he sucks, but the experience is not atypical for me.

Along the same vein, I've never really been recommended by my primary care physician things that were good things to check out that I might be interested in that could help my health and wellbeing. One time I told him I was having some anxiety and trouble sleeping, and I got a prescription. I've been reading about cold plunges and infrared saunas recently as having some health benefits. When I think about it, I've never been provided a list of non-prescription ideas for what my primary care Dr thinks are great health hacks. Is it that none exist? Maybe cold plunges and infrared saunas don't do anything, but is there nothing that the Dr's I've seen have accumulated over decades of experience to tell their patients hey here are some great health hacks I've learned over time that are backed by science also. There's a huge missing gap...that guys like Hubermann will gladly fill.

Data on cold plunges is inconclusive, and infrared therapy is even more out there (on the spectrum of evidence-based medicine, not wavelength). It’s not a reasonable expectation for your doctor to recommend them, imo. I’ll argue anyone who does so without a lot of disclaimers is doing their patients a disservice.

ApoB testing is more scientifically grounded, but still not explicitly included in American cardiology guidelines, so his ambivalence isn’t surprising either.

From the sound of it, your doctor possibly could have done a better job addressing your sleep and anxiety issues. Did he discuss optimal sleep hygiene, and the possibility of sleep apnea? What did he prescribe?

Thats interesting you say that about infrared saunas as I thought it was more about the heat itself than the mechanism that generates the heat (and therefore would have similar benefits as traditional saunas). Do you think in general that sauna's don't have much science-based evidence that they deliver health benefits (or just not substantial enough to warrant meaningful consideration)?

The sleep anxiety part was a few years ago so don't recall the entire discussion, I'd be surprised if he didn't mention some overall hygiene things related to either work, screen time etc. I don't have sleep apnea, did some snoring tests, which I think were less related to his recommendation and more to my kids making fun of me.

He prescribed trazadone, which I found to kick *** lol. I don't use it any longer unless I know I'm going to have a sleep issue, international travel, etc. I did my own reserach on it when he prescribed it, seems pretty good overall risk profile...I always chuckle when thinking about it because it seemed like he was a raving fan of it lol.

But my point overall is less about plunges or saunas...but that is there nothing besides eating veggies, sleeping good, and exercising that would be recommended as "healthy habits". That stuff is like 2,000 years old knowledge lol.

 

[Sparky Polastri]

Looking around a little at some other information on Means.

I like Dr. Andrew Huberman and think he usually does thoughtful interviews with people.

He interviews Dr. Means and said he loves her work and her book and talks to her here if people are looking to understand more.

- YouTube

Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube.

youtu.be

In this episode, my guest is Dr. Casey Means, MD, a physician trained at Stanford University School of Medicine, an expert on metabolic health and the author of the book, "Good Energy." We discuss how to leverage nutrition, exercise and environmental factors to enhance your metabolic health by improving mitochondrial function, hormone and blood sugar regulation.

We also explore how fasting, deliberate cold exposure and spending time in nature can impact metabolic health, how to control food cravings and how to assess your metabolic health using blood testing, continuous glucose monitors and other tools.

Metabolic dysfunction is a leading cause of chronic disease, obesity and reduced lifespan around the world. Conversely, improving your mitochondrial and metabolic health can positively affect your health span and longevity.

Listeners of this episode will learn low- and zero-cost tools to improve their metabolic health, physical and mental well-being, body composition and target the root cause of various common diseases.

Read the full show notes, including referenced articles and additional resources: https://go.hubermanlab.com/nFNXu30

Regarding the bolded, it’s a stretch to say Means is an expert on metabolic health.

She’s got an undergrad degree in biology, almost completed ENT residency, and has no relevant scientific publications. But she did write a best selling book on “good energy”, so there’s that.

This is what we’ve come to accept as experts - intelligent people, usually with an unrelated degree from an elite school (Stanford seems over represented, for whatever reason), who empower their audience to improve health outside conventional medicine. They do this by making grandiose, unsubstantiated claims, sprinkling in some “sciencey”, but meaningless jargon, then direct their freshly minted acolytes to buy stuff. Conveniently enough, they often sell it on their websites.

Again, I know our system is broken, particularly preventative care, but I’m not sure this brand of expertise will fix it.

Another way to approach this is to ask for the body of peer reviewed and published work these people have produced in well known medical periodicals that they are basing their claims on.

 

[Nipsey]

Doing some research last week saw the American College of Cardiology now says Ozempic before lifestyle modifications.

https://archive.ph/6prpJ

Lilly and Novo "welcome" and "applaud" the change in guidance.

 

[Terminalxylem]

And to add - I think it's a given that everyone here is in the top 95% of everything. This is the FFA after all.

I was being facetious, in response to AK’s prior boast. But the sad reality is

I’m increasingly fascinated by how different our experiences are. Are people saying that their experience with doctors is that they don’t want to talk to you about root causes? That’s never been my experience. It’s been the opposite.

Yes. I gave the example with statins earlier in this thread. My doctor wanted me on statins. Full stop. No conversation. I opted for dietary changes and have had it under control for a decade.

IIRC, your doctor recommended HMG CoA reductase inhibitors because your cholesterol was above the level where lifestyle modification alone would be expected to get it in the acceptable range - we know diet/exercise may drop LDL 10-20%, for example.

And I seriously doubt he suggested you only take meds. Lifestyle modification is always part of a multimodal approach to improving cardiovascular risk.

But if he refused to discuss diet/exercise, while insisting meds were the only answer, you were right to seek another physician.

Yes, you're likely right that he was following guidelines and he was doing what was expected. I can't fault that. He was very firm in his counsel that statins were my only viable option and anything less was just going to prolong the damage. Perhaps i was an outlier that i could correct this with diet compared to what he's seen previously with people in similar situations. I probably sound more difficult than i really am. I'll defer to those that know more than me in most instances, but sometimes if there's a second option i might want to try that first if it's not dangerous or reckless.

I shouldn't say he refused to discuss lifestyle. He was just making it clear he thought it would only prolong the inevitable, and was insistent statins were going to be only solution. As my doctor we discussed lifestyle previously aswell, so maybe he didn't think there was enough room for improvement based on our conversations over the years.

I enjoy your input on medical topics. It's helped a lot to get a medical professionals take on things like this. It's easy for me to make assumptions based on my one sided perspective so it's nice to get an understanding about what's happening behind the curtain.

It sounds like his advice was good, but delivery left something to be desired. Realistically, it takes years-decades for high cholesterol to do significant damage, so a few months off meds probably wouldn’t be the end of the world anyway.

Doctors shouldn’t be so paternalistic, as shared decision making is an important part of establishing rapport. Ultimately, it’s your choice, of course.

Still, I’d confirm with your new doctor that your current LDL is acceptable, realizing “ideal” levels haven’t been firmly established.

The PREVENT risk calculator is a good place to start: 10 year risk > 7.5% is where pharmacologic intervention is traditionally recommended, with a goal 30% reduction in LDL. Moreover, there are some “risk-enhancing” factors that should be considered, which may make your LDL target even lower.

Lastly, as I mentioned before, there’s data to suggest driving LDL to very low levels is associated with improved cardiovascular risk, with near linear benefit in mortality reduction all the way down to 45 mg/dL. Newer guidelines have shifted LDL targets lower to reflect this finding, particularly in high risk patients.

Term, interested in what you think about the ApoB test as an additional datapoint for people concerned about cholesterol levels and heart health?

High ApoB is a “risk enhancer” that correlates strongly with atherogenic (blood vessel narrowing) risk.

European guidelines recommend checking it, along with lipoprotein a, once as an adult. US guidelines are more vague.

If either are elevated, your doctor may pursue additional diagnostic testing, like coronary calcium scoring or CT angiography, versus just starting cholesterol lowering medication.

The other test that may be lumped in with these two is C reactive protein, though its utility is less clear imo. @Pip's Invitation may have additional thoughts on this subject.

FWIW, I paid out of pocket to have both Apo B and lp(a) checked, as insurance wouldn’t cover it. Although both were low, my primary care provider offered follow up coronary calcium scan for “more information”, largely because insurance would pay, which I declined.

I paid for mine also.

I read about ApoB in some longevity book. Sounded interesting so I asked my Dr. about it. He said "oh yah, Apolipoprotein B-100, that's a pretty good test, do you want to do it?". And that's an example of one time I thought, I guess I'm glad I did my own research.

Now, my cholesterol is low so maybe he thought I didn't fit the risk profile where it was worth considering. But it was higher in the past and he's never mentioned it, not even as a one-time check it out option. I'm 53. And he offered no indication that he thought I shouldn't do it when I mentioned it. Maybe he sucks, but the experience is not atypical for me.

Along the same vein, I've never really been recommended by my primary care physician things that were good things to check out that I might be interested in that could help my health and wellbeing. One time I told him I was having some anxiety and trouble sleeping, and I got a prescription. I've been reading about cold plunges and infrared saunas recently as having some health benefits. When I think about it, I've never been provided a list of non-prescription ideas for what my primary care Dr thinks are great health hacks. Is it that none exist? Maybe cold plunges and infrared saunas don't do anything, but is there nothing that the Dr's I've seen have accumulated over decades of experience to tell their patients hey here are some great health hacks I've learned over time that are backed by science also. There's a huge missing gap...that guys like Hubermann will gladly fill.

Data on cold plunges is inconclusive, and infrared therapy is even more out there (on the spectrum of evidence-based medicine, not wavelength). It’s not a reasonable expectation for your doctor to recommend them, imo. I’ll argue anyone who does so without a lot of disclaimers is doing their patients a disservice.

ApoB testing is more scientifically grounded, but still not explicitly included in American cardiology guidelines, so his ambivalence isn’t surprising either.

From the sound of it, your doctor possibly could have done a better job addressing your sleep and anxiety issues. Did he discuss optimal sleep hygiene, and the possibility of sleep apnea? What did he prescribe?

Thats interesting you say that about infrared saunas as I thought it was more about the heat itself than the mechanism that generates the heat (and therefore would have similar benefits as traditional saunas). Do you think in general that sauna's don't have much science-based evidence that they deliver health benefits (or just not substantial enough to warrant meaningful consideration)?

The sleep anxiety part was a few years ago so don't recall the entire discussion, I'd be surprised if he didn't mention some overall hygiene things related to either work, screen time etc. I don't have sleep apnea, did some snoring tests, which I think were less related to his recommendation and more to my kids making fun of me.

He prescribed trazadone, which I found to kick *** lol. I don't use it any longer unless I know I'm going to have a sleep issue, international travel, etc. I did my own reserach on it when he prescribed it, seems pretty good overall risk profile...I always chuckle when thinking about it because it seemed like he was a raving fan of it lol.

Saunas and cold plunges are two sides of the same coin, but the infrared takes another step into the alt med universe, with a bunch of dubious “detox”, “immune-enhancing”, “anti-inflammatory”, etc. benefits.

And FWIW, trazodone is not recommended in the most recent version of the American Academy of Sleep Medicine guidelines, though they pertain to pharmacologic treatment of chronic insomnia. Trazodone can be used off-label to treat anxiety, however.

 

[Nipsey]

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging why people turn to these things in the first place?

 

[Terminalxylem]

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging why people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

 

[Terminalxylem]

But my point overall is less about plunges or saunas...but that is there nothing besides eating veggies, sleeping good, and exercising that would be recommended as "healthy habits". That stuff is like 2,000 years old knowledge lol.

What percentage of people are doing all these things? I bet it’s 10%, or less. And they probably wouldn’t agree on the specific diet, nor exercise regimen for optimal health.

So the high yield intervention is working to improve the fundamentals first, rather than entertaining every health hack du jour.

 

[Terminalxylem]

Doing some research last week saw the American College of Cardiology now says Ozempic before lifestyle modifications.

https://archive.ph/6prpJ

Lilly and Novo "welcome" and "applaud" the change in guidance.

That’s not what they said, and may reflect your bias against pharmaceutical management of obesity.

Read the article again. Better yet, read the primary reference. If you’re gonna do your own research, it’s important to do it right.

 

[Nipsey]

Doing some research last week saw the American College of Cardiology now says Ozempic before lifestyle modifications.

https://archive.ph/6prpJ

Lilly and Novo "welcome" and "applaud" the change in guidance.

That’s not what they said, and may reflect your bias against pharmaceutical management of obesity.

Read the article again. Better yet, read the primary reference. If you’re gonna do your own research, it’s important to do it right.

My "bias against pharmaceutical management of obesity"? Ok then.

 

[Nipsey]

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging why people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

 

[Nipsey]

Doing some research last week saw the American College of Cardiology now says Ozempic before lifestyle modifications.

https://archive.ph/6prpJ

Lilly and Novo "welcome" and "applaud" the change in guidance.

That’s not what they said, and may reflect your bias against pharmaceutical management of obesity.

Read the article again. Better yet, read the primary reference. If you’re gonna do your own research, it’s important to do it right.

My "bias against pharmaceutical management of obesity"? Ok then.

For the record: 54YO 6'0" 192.

 

[fatness]

Doing some research last week saw the American College of Cardiology now says Ozempic before lifestyle modifications.

https://archive.ph/6prpJ

Lilly and Novo "welcome" and "applaud" the change in guidance.

Can you "explain" what you think that article "says"?
Thanks.

 

[Pip's Invitation]

And to add - I think it's a given that everyone here is in the top 95% of everything. This is the FFA after all.

I was being facetious, in response to AK’s prior boast. But the sad reality is

I’m increasingly fascinated by how different our experiences are. Are people saying that their experience with doctors is that they don’t want to talk to you about root causes? That’s never been my experience. It’s been the opposite.

Yes. I gave the example with statins earlier in this thread. My doctor wanted me on statins. Full stop. No conversation. I opted for dietary changes and have had it under control for a decade.

IIRC, your doctor recommended HMG CoA reductase inhibitors because your cholesterol was above the level where lifestyle modification alone would be expected to get it in the acceptable range - we know diet/exercise may drop LDL 10-20%, for example.

And I seriously doubt he suggested you only take meds. Lifestyle modification is always part of a multimodal approach to improving cardiovascular risk.

But if he refused to discuss diet/exercise, while insisting meds were the only answer, you were right to seek another physician.

Yes, you're likely right that he was following guidelines and he was doing what was expected. I can't fault that. He was very firm in his counsel that statins were my only viable option and anything less was just going to prolong the damage. Perhaps i was an outlier that i could correct this with diet compared to what he's seen previously with people in similar situations. I probably sound more difficult than i really am. I'll defer to those that know more than me in most instances, but sometimes if there's a second option i might want to try that first if it's not dangerous or reckless.

I shouldn't say he refused to discuss lifestyle. He was just making it clear he thought it would only prolong the inevitable, and was insistent statins were going to be only solution. As my doctor we discussed lifestyle previously aswell, so maybe he didn't think there was enough room for improvement based on our conversations over the years.

I enjoy your input on medical topics. It's helped a lot to get a medical professionals take on things like this. It's easy for me to make assumptions based on my one sided perspective so it's nice to get an understanding about what's happening behind the curtain.

It sounds like his advice was good, but delivery left something to be desired. Realistically, it takes years-decades for high cholesterol to do significant damage, so a few months off meds probably wouldn’t be the end of the world anyway.

Doctors shouldn’t be so paternalistic, as shared decision making is an important part of establishing rapport. Ultimately, it’s your choice, of course.

Still, I’d confirm with your new doctor that your current LDL is acceptable, realizing “ideal” levels haven’t been firmly established.

The PREVENT risk calculator is a good place to start: 10 year risk > 7.5% is where pharmacologic intervention is traditionally recommended, with a goal 30% reduction in LDL. Moreover, there are some “risk-enhancing” factors that should be considered, which may make your LDL target even lower.

Lastly, as I mentioned before, there’s data to suggest driving LDL to very low levels is associated with improved cardiovascular risk, with near linear benefit in mortality reduction all the way down to 45 mg/dL. Newer guidelines have shifted LDL targets lower to reflect this finding, particularly in high risk patients.

Term, interested in what you think about the ApoB test as an additional datapoint for people concerned about cholesterol levels and heart health?

High ApoB is a “risk enhancer” that correlates strongly with atherogenic (blood vessel narrowing) risk.

European guidelines recommend checking it, along with lipoprotein a, once as an adult. US guidelines are more vague.

If either are elevated, your doctor may pursue additional diagnostic testing, like coronary calcium scoring or CT angiography, versus just starting cholesterol lowering medication.

The other test that may be lumped in with these two is C reactive protein, though its utility is less clear imo. @Pip's Invitation may have additional thoughts on this subject.

FWIW, I paid out of pocket to have both Apo B and lp(a) checked, as insurance wouldn’t cover it. Although both were low, my primary care provider offered follow up coronary calcium scan for “more information”, largely because insurance would pay, which I declined.

C-reactive protein flags people who are at elevated cardiovascular risk due to inflammation as opposed to cholesterol/lipids or blood pressure. People who have heart attacks or strokes despite having their cholesterol/lipids or blood pressure under control may have "residual inflammatory risk". If a CRP test confirms that, the patient may be put on colchicine, an anti-inflammatory drug traditionally used for gout that is approved at a lower dose for reduction of heart attack/stroke risk.

I expect new US cholesterol guidelines in the next year or two. They should be more clear about ApoB and Lp(a) than the previous version, which came out in 2018.

 

[Nipsey]

Doing some research last week saw the American College of Cardiology now says Ozempic before lifestyle modifications.

https://archive.ph/6prpJ

Lilly and Novo "welcome" and "applaud" the change in guidance.

Can you "explain" what you think that article "says"?
Thanks.

No. Love you Fatness.

 

[Pip's Invitation]

Doing some research last week saw the American College of Cardiology now says Ozempic before lifestyle modifications.

https://archive.ph/6prpJ

Lilly and Novo "welcome" and "applaud" the change in guidance.

Can you "explain" what you think that article "says"?
Thanks.

This is an expert consensus statement, which does not have the same force as a guideline.

It also says Ozempic/Wegovy/Rybelsus and Mounjaro/Zepbound AT THE SAME TIME AS lifestyle modifications. The bottom line is that the panel believes that patients should not have to wait for lifestyle modifications to "fail" before getting access to these drugs. The data are pretty clear that for most people, these drugs produce more weight loss and more cardio-kidney-metabolic benefits than lifestyle modifications alone. This statement is designed to get insurance companies to realize that and to broaden their coverage for them. It does not, however, advocate for ignoring lifestyle modifications.

 

[Terminalxylem]

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging why people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

The difference is, I realize my bias exists, and work to mitigate it.

But your post is a great example how people with good intentions can perform faulty “research”, and when called on it, they become defensive.

 

[Nipsey]

"Patients should not be required to 'try and fail' lifestyle changes prior to initiating pharmacotherapy; nonetheless, lifestyle interventions should always be offered in conjunction with NuSH therapies," wrote Olivia Gilbert, MD, MSc, of Atrium Health Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, and colleagues.

The recommendations were published in the Journal of the American College of Cardiologyopens in a new tab or window.

"Weight management by the cardiovascular community needs to be embraced, given both the prevalence of obesity and the impact it has on many forms of CVD [cardiovascular disease]," Gilbert said in a press release.

Her group cited evidence that average weight loss can approach 10% with lifestyle modification (e.g., diet and exercise), whereas it more typically reaches 15% with semaglutide and 20% with tirzepatideopens in a new tab or window.

"Disappointingly, weight loss achieved with lifestyle interventions has not been associated with a reduction in adverse cardiovascular outcomes. Although bariatric surgery is able to achieve substantial weight loss and reduced CVD events, it may be less desirable for some patients," the ACC committee wrote.

 

[Terminalxylem]

Doing some research last week saw the American College of Cardiology now says Ozempic before lifestyle modifications.

https://archive.ph/6prpJ

Lilly and Novo "welcome" and "applaud" the change in guidance.

That’s not what they said, and may reflect your bias against pharmaceutical management of obesity.

Read the article again. Better yet, read the primary reference. If you’re gonna do your own research, it’s important to do it right.

My "bias against pharmaceutical management of obesity"? Ok then.

For the record: 54YO 6'0" 192.

You don’t need to be obese to be biased against obesity drugs.

 

[Terminalxylem]

Doing some research last week saw the American College of Cardiology now says Ozempic before lifestyle modifications.

https://archive.ph/6prpJ

Lilly and Novo "welcome" and "applaud" the change in guidance.

Can you "explain" what you think that article "says"?
Thanks.

I can tell you what it didn’t say, if that helps?

 

[Nipsey]

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging wh

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging why people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

The difference is, I realize my bias exists, and work to mitigate it.

But your post is a great example how people with good intentions can perform faulty “research”, and when called on it, they become defensive.

y people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

The difference is, I realize my bias exists, and work to mitigate it.

But your post is a great example how people with good intentions can perform faulty “research”, and when called on it, they become defensive.

imho you’re less about self-awareness and more about self-importance. It’s all right there in post 1 (and everything since). Take care.

 

[Terminalxylem]

Doing some research last week saw the American College of Cardiology now says Ozempic before lifestyle modifications.

https://archive.ph/6prpJ

Lilly and Novo "welcome" and "applaud" the change in guidance.

Can you "explain" what you think that article "says"?
Thanks.

This is an expert consensus statement, which does not have the same force as a guideline.

It also says Ozempic/Wegovy/Rybelsus and Mounjaro/Zepbound AT THE SAME TIME AS lifestyle modifications. The bottom line is that the panel believes that patients should not have to wait for lifestyle modifications to "fail" before getting access to these drugs. The data are pretty clear that for most people, these drugs produce more weight loss and more cardio-kidney-metabolic benefits than lifestyle modifications alone. This statement is designed to get insurance companies to realize that and to broaden their coverage for them. It does not, however, advocate for ignoring lifestyle modifications.

Excellent summary.

 

[Terminalxylem]

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging wh

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging why people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

The difference is, I realize my bias exists, and work to mitigate it.

But your post is a great example how people with good intentions can perform faulty “research”, and when called on it, they become defensive.

y people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

The difference is, I realize my bias exists, and work to mitigate it.

But your post is a great example how people with good intentions can perform faulty “research”, and when called on it, they become defensive.

imho you’re less about self-awareness and more about self-importance. It’s all right there in post 1 (and everything since). Take care.

I’m sorry you feel that way. AFAIK, we’ve never had bad interactions before this, but I agree, my wording in the OP poisoned the well.

 

[DA RAIDERS]

And to add - I think it's a given that everyone here is in the top 95% of everything. This is the FFA after all.

I was being facetious, in response to AK’s prior boast. But the sad reality is

I’m increasingly fascinated by how different our experiences are. Are people saying that their experience with doctors is that they don’t want to talk to you about root causes? That’s never been my experience. It’s been the opposite.

Yes. I gave the example with statins earlier in this thread. My doctor wanted me on statins. Full stop. No conversation. I opted for dietary changes and have had it under control for a decade.

IIRC, your doctor recommended HMG CoA reductase inhibitors because your cholesterol was above the level where lifestyle modification alone would be expected to get it in the acceptable range - we know diet/exercise may drop LDL 10-20%, for example.

And I seriously doubt he suggested you only take meds. Lifestyle modification is always part of a multimodal approach to improving cardiovascular risk.

But if he refused to discuss diet/exercise, while insisting meds were the only answer, you were right to seek another physician.

Yes, you're likely right that he was following guidelines and he was doing what was expected. I can't fault that. He was very firm in his counsel that statins were my only viable option and anything less was just going to prolong the damage. Perhaps i was an outlier that i could correct this with diet compared to what he's seen previously with people in similar situations. I probably sound more difficult than i really am. I'll defer to those that know more than me in most instances, but sometimes if there's a second option i might want to try that first if it's not dangerous or reckless.

I shouldn't say he refused to discuss lifestyle. He was just making it clear he thought it would only prolong the inevitable, and was insistent statins were going to be only solution. As my doctor we discussed lifestyle previously aswell, so maybe he didn't think there was enough room for improvement based on our conversations over the years.

I enjoy your input on medical topics. It's helped a lot to get a medical professionals take on things like this. It's easy for me to make assumptions based on my one sided perspective so it's nice to get an understanding about what's happening behind the curtain.

It sounds like his advice was good, but delivery left something to be desired. Realistically, it takes years-decades for high cholesterol to do significant damage, so a few months off meds probably wouldn’t be the end of the world anyway.

Doctors shouldn’t be so paternalistic, as shared decision making is an important part of establishing rapport. Ultimately, it’s your choice, of course.

Still, I’d confirm with your new doctor that your current LDL is acceptable, realizing “ideal” levels haven’t been firmly established.

The PREVENT risk calculator is a good place to start: 10 year risk > 7.5% is where pharmacologic intervention is traditionally recommended, with a goal 30% reduction in LDL. Moreover, there are some “risk-enhancing” factors that should be considered, which may make your LDL target even lower.

Lastly, as I mentioned before, there’s data to suggest driving LDL to very low levels is associated with improved cardiovascular risk, with near linear benefit in mortality reduction all the way down to 45 mg/dL. Newer guidelines have shifted LDL targets lower to reflect this finding, particularly in high risk patients.

Term, interested in what you think about the ApoB test as an additional datapoint for people concerned about cholesterol levels and heart health?

High ApoB is a “risk enhancer” that correlates strongly with atherogenic (blood vessel narrowing) risk.

European guidelines recommend checking it, along with lipoprotein a, once as an adult. US guidelines are more vague.

If either are elevated, your doctor may pursue additional diagnostic testing, like coronary calcium scoring or CT angiography, versus just starting cholesterol lowering medication.

The other test that may be lumped in with these two is C reactive protein, though its utility is less clear imo. @Pip's Invitation may have additional thoughts on this subject.

FWIW, I paid out of pocket to have both Apo B and lp(a) checked, as insurance wouldn’t cover it. Although both were low, my primary care provider offered follow up coronary calcium scan for “more information”, largely because insurance would pay, which I declined.

C-reactive protein flags people who are at elevated cardiovascular risk due to inflammation as opposed to cholesterol/lipids or blood pressure. People who have heart attacks or strokes despite having their cholesterol/lipids or blood pressure under control may have "residual inflammatory risk". If a CRP test confirms that, the patient may be put on colchicine, an anti-inflammatory drug traditionally used for gout that is approved at a lower dose for reduction of heart attack/stroke risk.

I expect new US cholesterol guidelines in the next year or two. They should be more clear about ApoB and Lp(a) than the previous version, which came out in 2018.

Colchicine gave me the trots. Bad. How do they counter that?

 

[Nipsey]

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging wh

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging why people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

The difference is, I realize my bias exists, and work to mitigate it.

But your post is a great example how people with good intentions can perform faulty “research”, and when called on it, they become defensive.

y people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

The difference is, I realize my bias exists, and work to mitigate it.

But your post is a great example how people with good intentions can perform faulty “research”, and when called on it, they become defensive.

imho you’re less about self-awareness and more about self-importance. It’s all right there in post 1 (and everything since). Take care.

I’m sorry you feel that way. AFAIK, we’ve never had bad interactions before this, but I agree, my wording in the OP poisoned the we

There are many doctors on the forum but you're the only one I know about.

 

[Terminalxylem]

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging wh

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging why people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

The difference is, I realize my bias exists, and work to mitigate it.

But your post is a great example how people with good intentions can perform faulty “research”, and when called on it, they become defensive.

y people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

The difference is, I realize my bias exists, and work to mitigate it.

But your post is a great example how people with good intentions can perform faulty “research”, and when called on it, they become defensive.

imho you’re less about self-awareness and more about self-importance. It’s all right there in post 1 (and everything since). Take care.

I’m sorry you feel that way. AFAIK, we’ve never had bad interactions before this, but I agree, my wording in the OP poisoned the we

There are many doctors on the forum but you're the only one I know about.

That’s funny, because I’ve never disclosed my profession.

 

[The Longtime Lurker]

"Patients should not be required to 'try and fail' lifestyle changes prior to initiating pharmacotherapy; nonetheless, lifestyle interventions should always be offered in conjunction with NuSH therapies," wrote Olivia Gilbert, MD, MSc, of Atrium Health Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, and colleagues.

The recommendations were published in the Journal of the American College of Cardiologyopens in a new tab or window.

"Weight management by the cardiovascular community needs to be embraced, given both the prevalence of obesity and the impact it has on many forms of CVD [cardiovascular disease]," Gilbert said in a press release.

Her group cited evidence that average weight loss can approach 10% with lifestyle modification (e.g., diet and exercise), whereas it more typically reaches 15% with semaglutide and 20% with tirzepatideopens in a new tab or window.

"Disappointingly, weight loss achieved with lifestyle interventions has not been associated with a reduction in adverse cardiovascular outcomes. Although bariatric surgery is able to achieve substantial weight loss and reduced CVD events, it may be less desirable for some patients," the ACC committee wrote.

What's the bolded all about?

Also bariatric surgery is still a thing?

What are the guidelines for pharmaceutical weight-loss? If say someone is 25lbs overweight are drugs prescribed, or are there other metrics looked at when prescribing?

Edit. This thread had a discussion about the over prescribing of opiates and while i realize there's a massive difference is there any concern that these drugs will be over prescribed? Are there downsides to taking these drugs? Can they be abused by people looking to lose 10lbs for beach season?

I see these drugs being discussed like a miracle, but I've found very fee free lunches in this world, so I'm looking for the catch here. Maybe there isn't a lot of downside? I'll admit i don't know a ton about them which is why i ask.

 

[Terminalxylem]

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging wh

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging why people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

The difference is, I realize my bias exists, and work to mitigate it.

But your post is a great example how people with good intentions can perform faulty “research”, and when called on it, they become defensive.

y people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

The difference is, I realize my bias exists, and work to mitigate it.

But your post is a great example how people with good intentions can perform faulty “research”, and when called on it, they become defensive.

imho you’re less about self-awareness and more about self-importance. It’s all right there in post 1 (and everything since). Take care.

I’m sorry you feel that way. AFAIK, we’ve never had bad interactions before this, but I agree, my wording in the OP poisoned the we

There are many doctors on the forum but you're the only one I know about.

That’s funny, because I’ve never disclosed my profession.

I thought you were a GP in Hawaii who bitched about his patients.

You got the Hawaii part right.

 

[Nipsey]

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging wh

Also, I fundamentally object to the idea of “health hacks”. Healthy habits aren’t meme-worthy shortcuts.

Your patients see you for minutes a year. The other 364+ days they are being bombarded on social media, podcasts, YouTube, and in real life. Wanting to feel better and trying things they have seen or heard when they are not in the doctor's office office is not new. It has been happening long before the internet. The difference now is the scale and speed. Instead of dismissing it, maybe start by acknowledging why people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

The difference is, I realize my bias exists, and work to mitigate it.

But your post is a great example how people with good intentions can perform faulty “research”, and when called on it, they become defensive.

y people turn to these things in the first place?

I don’t think I’m communicating effectively. My point was, good health isn’t a secret, or quick fix.

I’ve acknowledged the shortcomings of conventional western medicine, so it’s easy to understand why some people seek out something different. But the scale and speed of mis/disinformation is exactly why this strategy has become a problem, for both patients and healthcare providers.

So no more bias against the patients who do their own research? Hate the game not the player?

The difference is, I realize my bias exists, and work to mitigate it.

But your post is a great example how people with good intentions can perform faulty “research”, and when called on it, they become defensive.

imho you’re less about self-awareness and more about self-importance. It’s all right there in post 1 (and everything since). Take care.

I’m sorry you feel that way. AFAIK, we’ve never had bad interactions before this, but I agree, my wording in the OP poisoned the we

There are many doctors on the forum but you're the only one I know about.

That’s funny, because I’ve never disclosed my profession.

I thought you were a GP in Hawaii who bitched about his patients.

You got the Hawaii part right.

To quote @Joe Bryant : "Interesting."

 

[Terminalxylem]

"Patients should not be required to 'try and fail' lifestyle changes prior to initiating pharmacotherapy; nonetheless, lifestyle interventions should always be offered in conjunction with NuSH therapies," wrote Olivia Gilbert, MD, MSc, of Atrium Health Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, and colleagues.

The recommendations were published in the Journal of the American College of Cardiologyopens in a new tab or window.

"Weight management by the cardiovascular community needs to be embraced, given both the prevalence of obesity and the impact it has on many forms of CVD [cardiovascular disease]," Gilbert said in a press release.

Her group cited evidence that average weight loss can approach 10% with lifestyle modification (e.g., diet and exercise), whereas it more typically reaches 15% with semaglutide and 20% with tirzepatideopens in a new tab or window.

"Disappointingly, weight loss achieved with lifestyle interventions has not been associated with a reduction in adverse cardiovascular outcomes. Although bariatric surgery is able to achieve substantial weight loss and reduced CVD events, it may be less desirable for some patients," the ACC committee wrote.

What's the bolded all about?

Also bariatric surgery is still a thing?

What are the guidelines for pharmaceutical weight-loss? If say someone is 25lbs overweight are drugs prescribed, or are there other metrics looked at when prescribing?

Edit. This thread had a discussion about the over prescribing of opiates and while i realize there's a massive difference is there any concern that these drugs will be over prescribed? Are there downsides to taking these drugs? Can they be abused by people looking to lose 10lbs for beach season?

I see these drugs being discussed like a miracle, but I've found very fee free lunches in this world, so I'm looking for the catch here. Maybe there isn't a lot of downside? I'll admit i don't know a ton about them which is why i ask.

Though I’ve never reviewed that literature, it sounds like no study has ever shown behavioral modification for weight loss to correlate with decreased risk of adverse cardiac outcomes.

That doesn’t mean losing weight can’t impact CV risk, rather, the amount of weight loss resulting from behavioral modification alone hasn’t shown benefit. This is probably because most people fail to maintain weight loss with diet and exercise - this is the sad reality.

And yes, bariatric surgery is still a thing. It typically results in sustained weight loss of 20-30%, while behavioral modification is more like 5-10%. More importantly, the vast majority regain the weight they lost within a few years.

The newest weight loss meds approach the efficacy of surgery, with lower risk. Moreover, the GLP drugs (Ozempic, for example) are independently associated with mortality reduction from cardiovascular disease, kidney disease, diabetes, and fatty liver disease. Plus, they have a role in treating other conditions, like sleep apnea and polycystic ovary disease.

The guidelines for use are based on BMI and comorbidities. Anyone with BMI over 30 qualifies, or BMI > 27 in concert with an obesity-associated disease like high blood pressure. But this is always in combination with lifestyle modification.

And of course there are side effects and potential toxicities. Plus they can be abused. The same can be said for virtually any medication. So far, they appear pretty safe, however, and the GLP agonist class has been around for 20+ years.

The question is, does the risk exceed the benefits, particularly considering our abysmal track record managing obesity long term?

 

[The Longtime Lurker]

the vast majority regain the weight they lost within a few years.

I know 3 people that had bariatric surgery and all regained the weight and then some. One was a close friend from high-school who really wasn't all that overweight and suffered pretty bad complications that required hospitalization. A second developed breast cancer (not related) and was unable to take low dose aspirin as a means of lowering recurrence (i don't know how accepted this is, but she was regretful over it).

I hadn't heard much about this surgery lately, especially with the glp-1 drugs readily available. I had assumed they were kind of phased out.

 

[Terminalxylem]

the vast majority regain the weight they lost within a few years.

I know 3 people that had bariatric surgery and all regained the weight and then some. One was a close friend from high-school who really wasn't all that overweight and suffered pretty bad complications that required hospitalization. A second developed breast cancer (not related) and was unable to take low dose aspirin as a means of lowering recurrence (i don't know how accepted this is, but she was regretful over it).

I hadn't heard much about this surgery lately, especially with the glp-1 drugs readily available. I had assumed they were kind of phased out.

Bariatric surgery isn’t perfect, but it’s much better than behavioral modification for sustained weight loss. The drugs are a better option though, imo.

 

[Pip's Invitation]

the vast majority regain the weight they lost within a few years.

I know 3 people that had bariatric surgery and all regained the weight and then some. One was a close friend from high-school who really wasn't all that overweight and suffered pretty bad complications that required hospitalization. A second developed breast cancer (not related) and was unable to take low dose aspirin as a means of lowering recurrence (i don't know how accepted this is, but she was regretful over it).

I hadn't heard much about this surgery lately, especially with the glp-1 drugs readily available. I had assumed they were kind of phased out.

Bariatric surgery isn’t perfect, but it’s much better than behavioral modification for sustained weight loss. The drugs are a better option though, imo.

The doctors I’ve spoken to about this all say that, pretty much universally, their patients would rather go on a drug regimen than have surgery.

Weight-loss surgery still exists, but it’s mainly now reserved for people who were unable to lose weight with one of the new drugs or who are contraindicated for them (pancreatitis, for example).

 

[Pip's Invitation]

"Patients should not be required to 'try and fail' lifestyle changes prior to initiating pharmacotherapy; nonetheless, lifestyle interventions should always be offered in conjunction with NuSH therapies," wrote Olivia Gilbert, MD, MSc, of Atrium Health Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, and colleagues.

The recommendations were published in the Journal of the American College of Cardiologyopens in a new tab or window.

"Weight management by the cardiovascular community needs to be embraced, given both the prevalence of obesity and the impact it has on many forms of CVD [cardiovascular disease]," Gilbert said in a press release.

Her group cited evidence that average weight loss can approach 10% with lifestyle modification (e.g., diet and exercise), whereas it more typically reaches 15% with semaglutide and 20% with tirzepatideopens in a new tab or window.

"Disappointingly, weight loss achieved with lifestyle interventions has not been associated with a reduction in adverse cardiovascular outcomes. Although bariatric surgery is able to achieve substantial weight loss and reduced CVD events, it may be less desirable for some patients," the ACC committee wrote.

What's the bolded all about?

Also bariatric surgery is still a thing?

What are the guidelines for pharmaceutical weight-loss? If say someone is 25lbs overweight are drugs prescribed, or are there other metrics looked at when prescribing?

Edit. This thread had a discussion about the over prescribing of opiates and while i realize there's a massive difference is there any concern that these drugs will be over prescribed? Are there downsides to taking these drugs? Can they be abused by people looking to lose 10lbs for beach season?

I see these drugs being discussed like a miracle, but I've found very fee free lunches in this world, so I'm looking for the catch here. Maybe there isn't a lot of downside? I'll admit i don't know a ton about them which is why i ask.

Reputable doctors aren’t prescribing these drugs to people who want to lose 10 pounds for beach season but are otherwise healthy. The cost and side effects don’t justify it. If these people are getting a GLP-1, it’s probably from a compounder, which was legal when there was a shortage but now is not.

 

[The Longtime Lurker]

Bariatric surgery isn’t perfect, but it’s much better than behavioral modification for sustained weight loss

Not questioning this so much as it makes me sad that this is the case. I know there's people that have conditions that they can't control and that by the time some people are adults and seeking medical care bad habits are already ingrained. I have such different life experience and expectations for my own health. I'm a food and movement as medicine proponent so the fact that that's not effective for so many people feels a little disheartening.

For the record I'm not judging anyone that does what they feel is best for their health and weight-loss. I think it's great people are able to take control of their own health, just that it's a little shocking to me that lifestyle fails enough that it doesn't seem a very popular recommendation on it's own.

 

[The Longtime Lurker]

which was legal when there was a shortage but now is not.

Are you sure about this? I feel like there's still loopholes that allow this. I know locally we have a wellness clinic that offers them and also a compounding pharmacy that is still offering them.

 

[Pip's Invitation]

which was legal when there was a shortage but now is not.

Are you sure about this? I feel like there's still loopholes that allow this. I know locally we have a wellness clinic that offers them and also a compounding pharmacy that is still offering them.

This is a good explanation: https://www.hchlawyers.com/blog/2025/june/glp-1-shortage-ended-can-you-still-legally-presc/

Anything that is “essentially a copy” is illegal. If it’s not “essentially a copy,” is it really a GLP-1?

 

[Max Power]

But my point overall is less about plunges or saunas...but that is there nothing besides eating veggies, sleeping good, and exercising that would be recommended as "healthy habits". That stuff is like 2,000 years old knowledge lol.

What percentage of people are doing all these things? I bet it’s 10%, or less. And they probably wouldn’t agree on the specific diet, nor exercise regimen for optimal health.

So the high yield intervention is working to improve the fundamentals first, rather than entertaining every health hack du jour.

Seeing both perspectives I can see where the cracks are forming. I'm a data guy so solving a problem with the highest probability of success makes the most sense almost all of the time. The example of weight loss is a great one. If a PC has 100 overweight patients and tells all of them to eat better, exercise more and he'll check back with them in 6 months. Maybe 10% (no idea the real number) come back with results. If he prescribes that same 100 weight loss medication and 25% come back with results, it drives the theory to prescribe medicine as option A. I can understand why a PC doc would lean the way they do and spending extra time per patient to facilitate a lower success rate isn't a good use of their time.

That said, there is still the 10% who don't require the extra level of medical intervention that would now be subject to any side effects or complications that come from pharmaceutical treatments. These are most likely the people willing to explore holistic treatment options. I'm a believer that these holistic options do work for a lot of people, but not everyone. This group probably feels alienated by PCs who don't take the time to individualize treatment plans.

Compounding the issue is how poorly the overall US healthcare system is performing. We're not doing well and this "do your own research" really took off once this country tried to implement a once size fits all healthcare formula.

 

[jm192]

which was legal when there was a shortage but now is not.

Are you sure about this? I feel like there's still loopholes that allow this. I know locally we have a wellness clinic that offers them and also a compounding pharmacy that is still offering them.

I think whether or not it's fully legal is a bit of a grey zone, and I wouldn't want to risk being in the business.

The FDA banned it. That's factual.

In an online doctor group, some doctors have expressed that these pharmacies may still be allowed to compound it if the doses are between the standard doses.

I would NOT want to be arguing to any kind of legal authority or fighting a law suit saying "Well, it was a non-standard dose that they don't even make."

I think there's a lot of extra risk in compounded GLP-1's. I would not write a prescription for them prior to the ban. I certainly won't do it after the ban.