Best Tools for Gut Health & Weight Loss | Dr. Chris Thompson transcript

There's all sorts of evidence that if you don't have a lot of fiber, your microbiome is not healthy. Feed your microbes. You know, they need to be fed. And what they eat is fiber. Okay? That's what you want to eating. You want them eating fiber. >> And if you're not feeding them fiber, they'll eat your mucous layer. Okay? And we already talked about how thin that barrier is. And all of a sudden, they start eating your mucous layer.

They're they're not producing the butyrate you need. And the butyrates needed to maintain the tight junctions, right? So, there's layers to this. It's like a snowball effect that if you're not feeding those micro the microbiome and keeping it healthy, you're going to run into all sorts of all sorts of trouble. >> Welcome to the Hubberman Lab podcast where we discuss science and science-based [music] tools for everyday life.

[music] >> I'm Andrew Huberman and I'm a professor of neurobiology and opthalmology at Stanford School of Medicine. My guest today is Dr. Chris Thompson. Dr. Dr. Chris Thompson is a professor of medicine at Harvard Medical School. He is also the chief of interventional gastroenterenterology at Mass General Bighgam in Boston. He is a renowned expert on the intersection of gastroenterenterology, metabolism, nutrition, and obesity medicine.

And in today's episode, Dr. Dr. Thompson explains how to improve your gut health, including the roles of your diet, gut microbiome, and gastrointestinal motility, as well as how your gut communicates with the rest of your body, which of course includes the gut microbiome, but as you'll learn today, much more. Dr. Chris Thompson is a guest on this podcast because he's not just a GI tract and obesity medicine expert. He's also credited with having created an entire new field of treatments and perspectives on GI and metabolic health.

So the knowledge he shares today is truly at the cutting edge and applicable. Which is why by the end of today's episode, you will have a clear understanding of how your gastrointestinal system works, and you will have a set of new modern evidence-based tools for improving and maintaining your gut health. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford.

It is, however, part of my desire and effort to bring zero cost to consumer information about science and science related tools to the general public. In keeping with that theme, today's episode does include sponsors. And now for my discussion with Dr. Chris Thompson. Dr. Chris Thompson, welcome. >> Thanks so much. Good to be here. >> A lot of us hear these days about the gut microbiome, the gut brain axis. We hear about GLP drugs that help people lose immense amounts of weight and stop feeling this food noise thing and on and on.

But could we start by just having a conversation about this tube that is the digestive tract and get real basic and just educate people a bit on what happens that stimulates them to want to eat, why perhaps for certain periods of day or night they don't want to eat and then what the passage of food through us looks like as a series of steps. This is such a critical part of our biology and our lives. It's becoming more and more complex all the time, right? the gut and it does a lot of things.

So, it's obviously involved in digestion, but it's also an endocrine organ. You can hear it called the second brain, right? There's a lot of different ways we we think about about the gut and it is compartmentalized and each each area has a different job. So, you first you have, you know, the esophagus and its job is to just kind of move the food into the stomach safely and it's thick, right? has different lining so it can handle things that might be a little rougher and uh it pushes sequentially, you know, down into the stomach.

So, it's taking that food bolus and driving it into the stomach and you can have all sorts of problems in your esophagus, right? So, each one of these organs has, you know, things it's supposed to do and then things that it doesn't do well. Sometimes people don't swallow well. It gets too tight at the bottom. There's a condition called acalasia where it's just the bottom of the esophagus doesn't relax, right? And so we have procedures we can do in my line of work where you can tunnel down in between the layers of that esophagus.

It's very thin, you know, a few millimeters you can tunnel down into there and cut that muscle to relieve the obstruction. So >> what are the symptoms of that? >> So inability to swallow. >> So what do they do? They choke. >> Yeah. They'd feel like they're choking. So they'll they'll swallow food, it'll get down and stop and then they'll feel pressure. They'll feel really uncomfortable. If they drank some fluid with it, it might start coming back up.

It'll just stay there. And then sometimes they'll have to, you know, induce vomiting to remove it. >> It's very uncomfortable for them. And it's not a terribly common condition, but it's coming more and more frequent. I see it every week, right? So that inability to swallow and you can get that inability to swallow for other reasons actually that are far more common. Chronic heartburn. If someone has reflux, you know, that burning sensation, uh that can damage the line of the esophagus and it can lead to precancerous conditions called Barrett's esophagus, which is something that, you know, needs to be treated, looked at, and and and uh kind of followed.

But with time, it can actually cause scarring. So you get a stricture. So it's kind of very firodic tissue there. That's another reason why people might have difficulty swallowing. There's other reasons as well that are more obscure, but so that's the job of that esophagus just to move the the food down safely and a lot of times it it doesn't work. Then you have the stomach next, right? First, what the stomach does is is it stretches to accommodate and accept a meal, right?

So it stretches. Normally it's like a tube in your, you know, in in your abdomen. But then when you start to smell food, it starts stretching and becoming more like a bag. >> Really just the the odor of food. >> Yeah. It can it can stretch, relax to accept that meal. And if it doesn't do that properly, it's it causes symptoms like nausea, right? So uh so then it accepts the meal and uh it has to do its job which is to break it down and pass it on.

So that the stomach now isn't just transporting, it's breaking it down. And it does that mechanically. So and the the fundus the top of the stomach is holding that meal. That's what kind of stretched up to hold it. And then the rest of the stomach is working on it. So the body of the stomach next segment is breaking it down. It's grinding the food into smaller bits. Acid is part of this as well. The stomach secretes acid and then the bottom of the stomach called the anstrum will push the food out slowly into the dudenum, right?

That's the first part of the small bowel. Satiety, satiation all becomes part of this because the stomach is what secretes grein. We'll talk about that probably more later, but the stomach secretes ghrein. And so this is part of your satiety signaling. All sorts of problems with the stomach, right? So similar to the esophagus, food might not leave uh you know as it should in the right in the right timing. So it can happen due to ulceration in the stomach, scarring or something called gastroparesis where for a variety of reasons it might be postviral, it might be due to diabetes, uh neural hormonal um kind of origins of this, the stomach just doesn't empty as it should.

People have nausea and vomiting with that and other problems. So then you get into the small bowel and the small bowel's job now typically you do a little digestion so early on cuz you have pancreatic and bilary secretions going in there but its main job is going to be to absorb calories right so that's absorbing calories and moving it down it's very thin it's one cell thick has about the surface area of like a pickle ball court right >> one cell thick >> yeah one cell thick the lining is one cell thick that's where the cell type just to >> interosytes yeah must be some really sturdy cells >> columnar epithel ium.

Yeah. So, they're pretty sturdy. Uh they they rely on more than just the cell itself to to to maintain that barrier. Um there's certain cells called goblet cells that produce mucin and that creates a nice thick layer there uh that help as as as another part of the barrier. They have something called tight junctions right between the cells which are complex little structures that are part of that barrier as well. And there's immune cells in there.

There's other elements to that barrier but it is one cell layer thick. So that's why the stomach's the esophagus and stomach got a good job of processing that processing that food so that it's it's safe to go down through the small bowel and be absorbed. All sorts of issues with the small bowel. Similarly you can have different diseases that affect that you know celiac disease uh Crohn's disease etc. different inflammatory conditions.

Um, and uh, what we're learning now and hopefully get get into is it plays a central role we think in metabolic disease. And that's kind of what's very exciting is is its role in obesity, diabetes, and other similar conditions. And then eventually you have the colon and that's where your microbiome is the star, right? The colon uh, its job is to usually just absorb water. Most of the nutrients are gone by then. But it does play an important role um as well and it is working handinhand with your microbiome to uh you know to to make sure that um you producing it really it's it's it's mostly butyrate I think that's mostly involved there where the microbiome is producing short chain fatty acids and one of them the most important probably is butyrate that has a lot to say about your metabolism as well that's involved in satiety signaling and you have a lot of GLP1 produced in the colon again so you're you're getting these kind of endocrine function function of your colon that's very involved and then it passes.

So and again diseases in the colon colon cancer is a big one right so colon cancer screening is important people typically now I think they moved the age back to 45 everyone should start getting screened uh to make sure you know they don't have uh cancer you can do it different ways there are genetic tests you can do like colig guard and if you do that you have to do it every every few years but you can do that uh you can do screening colonoscopy every 10 years if it's normal and there's other things you can do as well CT colonography is not as common and other tests but those are the two most common.

It's important important to do that. >> How common is um colon cancer >> in our line of work? Is the is the most frequent cause of of cancer? Unfortunately, >> are more people being diagnosed because of more diagnostic procedures and are more people surviving colon cancer. >> The survival rates are definitely improving due to screening programs, right? So that's that's important. So it is definitely important to get screened.

Also screening earlier helps. So for instance, starting at 45 is better than many people who started at 50 and they wouldn't get till 55 or 60, right? But also if you have a family member that has had cancer, you want to start at 40 or if they were younger, you want to start 10 years younger than when they were diagnosed, right? So you want to start that screening process really. It's very effective. Um, you know, and uh it's important to do it.

And I think that things like colag guard and other genetic tests are going to keep getting better and help because you don't have to have that kind of very uncomfortable screening procedure. colonoscopy is not it's not a great way to do screening, right? You shouldn't have to have a relatively invasive procedure to be screened for something, you know? It should be something you just do a blood test or a stool study or something like that.

And I think we're getting there with technology and that will definitely show dividends cuz you can have the colonoscopy to remove the lesion, which is something that we can do. It's it's a newer technique where we can actually go in and remove these very early cancers endoscopically. So, we call it organ sparing surgery. So, you don't have to actually remove a piece of the colon anymore. you can just kind of, you know, take take the lining where that precancer is residing.

It's a complicated procedure, but it's easy for the patient. You know, they keep their colon, they go home the same day. And these tests, you know, are are easy ways to to diagnose those patients and and get them in for proper care. So, very important. So, that's pretty much the quick overview of of the gut. And uh it plays one thing we haven't touched on too much yet is its role in in really uh you know satiety and and kind of how it's involved in processing of food uh in detail and the kind of endoendocrine system that's involved.

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Again, that's drinkelement.com/huberman to claim a free sample pack. Today's episode is also brought to us by Lingo. Lingo is an everyday wearable that tracks your glucose 247. Glucose drives a lot of key processes that support energy, body composition, and long-term health. When glucose is constantly spiking and crashing, that's where we can start to see metabolic dysfunction. And over time, that can even progress to pre-diabetes.

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We'll start at the the top of the the GI tract. People will say sometimes that they eat and some of the food seems to go up their nose. They know this because if they blow their nose, they might get some food particulate. It it sounds like something that's not entirely uncommon based on the number of questions I get about it. What's going on there? Why would you know I get asked a lot of questions some of them truly weird and rare and some of them um weird and less rare and I would put it in the second category >> that could be a variety of different things and this is the area that I do work in right so it can be an oral fingial transfer problem where the the hypoparrenx is transferring food into the esophagus that can be you know ENT thing it can actually be functional medicine as well where you can work with a speech pathologist that teaches people how to swallow better they might have to change the the quality of the food they're eating to thicker food they might have to turn a certain way to swallow and there's ways they can actually train people with with kind of bio feedback to to learn how to swallow better because that part's still under your control a little bit. >> They're not swallowing well. >> Yeah.

And with age that can happen, right? With age that can happen. Now the next thing that can contribute to that is if they have high tension in the first sphincter up above which is the upper esophageal sphincter. That's the the sphincter that separates the top of your esophagus from your mouth basically. And that can be have high tension. And what I see a lot is something called Zanker's diverticula, which we haven't talked much about.

There's a few different little pockets that can form high up on your esophagus near that sphincter. >> There's different names for how they, you know, kind of where they where they exactly occur. [snorts] >> And with time and with age, this this this is like a herniation of mucosa through the muscle and it creates a pocket and that can actually trap food. So when people are eating, the food goes into the pocket and then comes back up on can go out their nose or or sit in there which is very uncomfortable for them, right?

That's another way you can have problems swallowing >> and that can be fixed very easily. We go in through the mouth actually make a tiny incision and just kind of take down the septum that's part of that pocket opening up the pocket so that the food can leave. So it's important to do it early too because people can actually this it looks like an inconvenience initially, right? It's you know you're not swallowing well. foods, you know, is is not where it's supposed to be necessarily.

The problem is when people then aspirate and that food goes in the lung and then it can lead to scarring in the lungs and eventually it can really cause problems. So, it is something that should probably be taken seriously and looked at even though it sounds funny, you know, it is something [clears throat] that can be a real problem. >> There's a weird thing about GI tract and bowel movements in particular, which is the following. with babies, with puppies and to some extent with ourselves, but especially with babies and with uh puppies, we sort of because they can't speak, we have a couple of like key readouts that we intuitively understand reflect their health.

One is the color of their skin, the eyes, like if eyes are looking glassy or tired, you know, um and their and the uh quality or lack thereof of their bowel movements, quality, frequency, etc. But then something happens where speech comes online and we get uh you know uh toilet trained and then everyone's responsible for like understanding like their own bowel movements, right? And then we're never really told like what's healthy bowel movements but we all kind of know what's normal for us or not normal.

I'd be lying if I didn't say like these are important metrics of health. Yeah. Well, there's so much you can tell from bowel movements. Okay. So the rule of thumb is, you know, you don't want to have more than three a day and you don't want to go longer than three days without having a bowel movement. So that's kind of the general rule and you want it to be one formed bowel movement, you know, or a couple. You don't want little tiny pebbles.

That's called scibula stool and that's that's a sign something's going on. But there's a lot you can tell how much are they taking enough fiber, right? the World Health Organization um uh published something in the Lancet years ago on on fiber fiber synthesis I think they called it and they found that you know the vast majority of population really doesn't especially western countries just are not getting enough fiber which is obviously concerning because that that causes a lot of issues long term right which we'll get into.

But if you're having these scibulus stools, if you're if you are constipated, meaning you're having a bowel movement more than once every 3 days and they're hard stools, that's a sign you're not getting enough fiber. So that's one thing you really have to to think about, right? Additionally, there's other things you can tell after procedures. You know, if a if a procedure if a if a bowel movement is very dark, tarry, and shiny, that's sign you have blood in your GI tract, right?

So there's different things you can tell from from from the stool that are important to keep an eye on. But in general, that's kind of the rule of thumb. uh you know uh with with uh with bal having more than three a day is probably leaning towards being too loose, right? And if you're not having one every three days, you're probably bound up and and then you really have to think about fiber. >> As I recall, the recommendations were for adult men 35 grams of fiber per day and for women 25.

And obviously that's not accounting for variations in body weight and height and all the rest. So um does that sound about right? >> Yeah, that's that's about right. And it kind of depends on the quality, too. There's a couple other really interesting studies that came out recently just within the last few years uh looking at the importance of fiber related to certain conditions like one was fatty liver right and fatty liver it was a interesting interesting study they were using resistant starch like level two so basically raw powdered um potatoes something like that right uh >> um and they were supplementing it I think it was at 40 g and they found that when they did that they actually saw a significant improvement in fatty liver which is phenomenal right and it was you know relatively weight stable.

So it has important treatment effects. Another group actually um studied it and looked at insulin uh sensitivity. So they did clamp studies you know where they they would um kind of really be able to detect insulin resistance and kind of try to look at um kind of glucose utilization and clearance. And they found that with this RS2 type, you know, resistant starch too, they were able to improve insulin resistance and insulin sensitivity as well.

So fiber is very important. It's not just about the bowel movements, right? It's also about, you know, really just having, you know, health. >> It probably helps the microbiome. There's there's all sorts of evidence that if you don't have a lot of fiber, your microbiome is not healthy, right? You get less diversity in your microbiome. the different studies that have looked at that. It is important to have that fiber and that constipation is an early window into it, right?

It's an early sign that maybe you're not getting enough enough fiber. >> Yeah, I make it a point to eat fruits and vegetables because I like them. But recently, I started supplementing with a powdered pelium husk that and some of them actually taste pretty good and my expectation is I was going to feel really bloated. It was quite the opposite. It not that I had gut issues before. if it was normally kind of like hypernormalized things actually it made uh postmeal um subjectively the sensation just like feel good feel great um and I didn't expect that I thought okay more fiber I think a perception people have is like more fiber more regularity and more bloat >> and I think that's a that might be true for some people but it certainly wasn't my experience and I think that if I feel like the messaging on fiber to the general public is pretty lousy meaning people are told to take it that's Great.

They're told all the time, but I think people think, "Oh, if I have a lot of fiber, I'm going be really gassy. I'm going to be really bloated." But as you point out, it's not just about regularity and speed of digestion. It's about creating a healthy millu for the gut. I think if more people knew that, they'd probably make a move to consume more fiber. >> Totally. It's like feed your microbes, you know, or they're going to eat you, right?

And it's kind of true, right? Because they need they need to be fed. And what they eat is fiber. Okay? That's what you want them eating. You want them eating fiber. And if you're not feeding them fiber, they'll eat your mucous layer. Okay? And we already talked about how thin that barrier is and all of a sudden they start eating your mucous layer, they're they're not producing the butyrate you need. And the butyrates needed to maintain the tight junctions, right?

So there's layers to this. It's like a snowball effect that if you're not feeding those micro the microbiome and keeping it healthy, you're going to run into all sorts of all sorts of trouble. >> Raises some um interesting questions about uh intermittent fasting. I think very few people are doing long-term fasts of more than a day or so. I mean, it does happen, but most people a lot of people do sort of timerestricted feeding or they they'll skip breakfast.

You know, I'm I'm one of those people most days just by default. I had a a colleague friend at Yale who studied microbiome and I said, "Oh, so does fasting improve the gut microbiome." And he said, "No, actually during the fasting period, your microbiome starts eating up your your digestive tract, which is what you're But then he said, but then the rebound often is puts you at a slightly better place afterward. So it's tricky.

Should people avoid intermittent fasting if they're having gut issues? I know we don't want to make any broad recommendations. It's highly contextual, but based on what you said, it it seems that it stands to reason that you might want to avoid having your stomach empty for very long periods of time outside of sleep. >> I don't see it as being a major issue. I think the benefits of intermittent or timerestricted eating, intermittent fasting probably would outweigh that risk.

You know, you need to give your pancreas time to relax. You know, you need to have insulin come down. If you're eating frequently, your insulin levels are already up, always up, and that that causes problems. So, I do think the benefit of of of the the time restricted eating definitely outweighs that that potential risk. >> Yeah, great to hear. um especially as somebody who just by default doesn't eat breakfast or and just don't get hungry till 11. >> I skip breakfast as well, but there's studies because initially they actually used to say, well, you have a cordal sauce spike in the morning and you know, you know, you're more likely to star the uh the food you take in if you if you if you eat in the morning.

Turns out maybe that's not so true. It might be better to actually have you know, eat earlier and then have your fasting window start in the afternoon, right? I think doing is better than not doing it. I still I still skip the breakfast. The topic of fermented foods, low sugar fermented foods as a possible benefit for gut health has come up um since Justin Sonnenberg and colleagues have published that the study. It there's a small number of people in that study admittedly, but um that taking in some low sugar fermented foods really helped lower the inflamm.

They didn't look specifically at as I recall uh symptoms of gut irritabil irritation or things of that sort, but what are your thoughts on fer low sugar fermented foods? So, we're not talking beer. We're talking kimchi, sauerkraut, brine. >> I [clears throat] think they're they're important. Um, and they're missing in the western diet, which is an issue. And I think there's the study you referred to actually, I think they compared it to to fiber, right?

It was it was fermented foods to fiber. >> And with the fermented foods, you had uh reclaimed some diversity in in the microbiome, which was great, as well as the reduced inflammatory markers where the fiber didn't seem to do that. And you saw all these benefits in these other other fiber trials that we're we're talking about with the resistant starches, right? So, it stands to reason that we'd probably see that as well as we do more research into the fermented foods.

They're beneficial for a variety of reasons. You know, one, they're prebiotic, right? So, you're feeding your microbiome things they want, which is phenomenal. And it's already kind of started. It's a little partially digested, which is really helpful. And um and they're also a little bit of a probiotic as well because you do have some, you know, some live cultures in there, right? And um they usually have bifidto bacterias for lactobles or something like that in in them and a variety of other things as well.

So it gets the ball rolling, right? So it's sort of like when you're you're trying to grow something, you want to plant the seeds but also have the fertilizer and whatnot. And this this is what um fermented foods do for you. So I think you know that that's that's very helpful. And it's all about maintaining this this kind of healthy microbiome that can produce things like butyrate which have a lot of a lot of benefits we can talk about.

You can't just take butyrate and then it's not going to make it to the colon, right? It needs to be in the colon to have its to have to have its effect. And so what these bacteria do is they kind of they they will um kind of crossfeed in a sense, right? So you have those first layer of bacteria that will take the fiber and break it down and they create acetate and lactate and whatnot. And then that can then be used by other bacteria.

So you're feeding the other the other bacteria that can then turn that into butyrate, you know, and things like that. The butyrate is magical, right? So that will feed your colon cells. Your colon cells live on that with butyrates needed for those tight junctions. Butyrate, you know, does all sorts of things via GLP-1 pathways and satiety pathways. So it has a lot of different uh a lot of different roles that it's playing.

Additionally, it keeps your bowel acidic, right? So like these short- chain fatty acids and you know acetate and whatnot and that's great to to make sure you are protected from certain pathologic organisms might want to take take root, right? So the aerobic organisms and the the other organisms that you don't want don't survive as well in an acidic environment. really important to to to take these fermented foods in addition to fiber. >> Do you make it a point to consume them? >> I do.

Yeah. I I Yeah, I like keer or kefir and everyone say that, right? I like I like that. I think it's phenomenal. Yeah, it's good. >> Kimchi is good, you know, sauerkraut. >> Um there's all different types. Yogurt, you know, um there there different types I think that everyone should be able to find. Kombucha, you know, >> um and it's certainly missing in our diets. So I think it's it's important to to to to recommend that the folks do >> cankera sores and ulcers u my understanding for a long time is they were caused by stress or wounds to the mouth and then you know couple folks won a Nobel prize for identifying a soilbased bacterium that causes ulcers and I loved that Nobel Prize year you know as a scientist like some people watch the Super Bowl like you know like who you know who won the Nobel Prize and it's never surprising who wins it's at least for the scientists right um it's often surprising who doesn't but let's leave aside that uh that component but that was a very surprising set of findings right like a gut bacterium is causing ulcers and I I love the findings but at the same time I think many many millions of people hundreds of millions billions across history would say stress gives people ulcers so there's something going on there that's more than soilbased bacterium right >> yeah definitely you know and that that's the problem with these you know the way the media covers these findings like it's not all that you ingested the wrong soil.

Stress can give you ulcers, right? Or am I am I missing something? >> Stress can play a role. Um, you know, it is it is certainly complicated. So Barry Marshall was phenomenal in Australia and he found H. pylori could cause gastric ulcers, right? And he had to consume, no one believed him. He had to consume himself consume it and and then he had gastric ulcers. >> I love it when scientists do self experimentation. >> That's crazy, right?

So, but that was phenomenal, right? And he he proved H pylori and we need to treat that, right? >> And uh and that that actually H pylori was actually found even in AI the iceman. I don't if you remember AI the ice man. He was this uh >> 5,000y old, you know, homo sapien in the in the Italian Alps. He was found frozen, right? So you could actually get into his stomach and see what's in there. [clears throat] >> He died stressed.

He had h pylori in his stomach. That thing's been around a long time. It's kind of interesting. There's other lessons there like like a loss of of of diversity of the microbiome, right? with industrialization, we have far fewer species and less genetic diversity in our microbiome. But regarding ulcers, so I I actually did study this in gastric bypass patients a good bit, right? And uh it was not a bacterium that was causing it, right?

Sometimes it was a relative eskeeia. Type two diabetes causes uh kind of microvascular eskeemia. Smoking can cause microvascular eskeeia. In gastric bypass patients, the small bowel doesn't uh it's it's a distal part of the small bowel from lower down that's connected to the stomach and it doesn't have bicarbonate uh that's being secreted from the pancreas in in the area. So there's no way of neutralizing acid. So if the pouch which you know we can get into the anatomy here, but if the pouch of of the gastric bypass is too large and makes acid the douadinum now has no the junum actually has no natural defense against that.

So acid clearly plays a role and if you're stressed it can produce more acid, right? So generally there's probably multiple hits. We don't fully understand things, but clearly it's not just an infectious organism and it kind of depends on individual circumstances um and susceptibilities, but ulcers are certainly something that can occur short of a bacteria. >> So important for people to hear that, you know, because one thing can cause something, it doesn't mean it's the always the case that >> Yeah.

So, let's talk about metabolic health, hunger, obesity, weight loss. These are areas that went, you know, square in your wheelhouse. Can't have this conversation without talking about the GLPS. Um, most everyone has heard of these things nowadays. Millions and millions of people I've heard, I don't know if this is true, as many as 20% of of uh people 18 and older have taken or are currently taking a GLP or either, you know, Zen Picjaro soon, Red True Tide will be out to market.

What's your thought on these compounds? are they the perfect solution to weight loss? >> Well, I'm grateful we have them, right? Um, obesity is is a serious problem and all the all the metabolic issues that that are kind of there with obesity uh need to be addressed and we weren't doing much with it unfortunately until the GLP1s came around. So, GLP1s are fantastic from that standpoint. They're not perfect, you know, there's limitations, but they're it's much better to have them than not have GLP ones, for sure.

There's issues with with certainly um adherence, unfortunately. Right. So, there's a there's a number over a million people a month are coming off GLP-1s, right? And that's for a variety of reasons. About 30% come off GLP-1s in the first month and then 50% or so by by the end of the year, right? So, and it's not specific to GLP1s. You see that with any medicine. You see that with with blood pressure medicines? You see that with cholesterol medicine? >> What's the Can we say what the primary driving force is in the case of GLP1?

Is it the side effects? Is it they don't like having to pin themselves? >> I I think because the numbers so curiously similar to all the other medicines, maybe there's some underlying thing where people just don't like taking medicines frequently. >> That might be part of it. I think that, >> you know, sticking yourself is is a is probably for some people they don't want to jab themsel once a week. That might be something.

They needle fatigue. That's probably there. I think when you take a medicine orally every day, it gets hard to remember to take it. And then I think there are issues with with how you ramp them up to the effective dose and side effects. I think there's ways you can do that, you know, safely going step by step. But nausea is an issue with some of these. You know, muscle loss is an issue. There's different features there.

And then additionally, you know, long-term this this is, you know, you're taking a super physiologic dose of something and we don't know what the long-term ramifications could be. So even though I believe the benefits outweigh the costs, right? You're treating obesity. We know obesity is a problem. We don't know you GP1 to be a problem long term. That does weigh heavy on some people's minds and that might be why they stop as well.

So in my practice where we do endoscopic therapies, uh over 85% of people have already been on a GLP-1 and either they're struggling on it or they've come off. >> 80 85%. >> Wow. Yeah. Um we again we don't want to get too far into the sociology and psychology of of uh uh medication adherence but it is interesting that so many people come off meds but then there are meds like SSRIs and things like that which I think can benefit certain people like people with like full-blown clinical OCD extreme they save lives right but but then they're overprescribed I feel like especially in the United States people like their prescription drugs so if they're stopping I feel like there's got to be a reason.

I mean, aren't we the biggest consumer of prescription drugs in the whole world? [laughter] Like, people love their drugs. Like, I you know, I've heard about the nausea. I I don't >> There are a number of people now who are quote unquote micro doing the GLPS and finding that they're getting some benefits without taking the the the prescribed amount. I'm not recommending people do that. Uh, you know, I guess talk to or don't talk to your doctor.

They probably won't approve. But I know people are doing that. I think initially it was because of cost and actually pen sharing. Um but also people feeling like oh I get the same effect. So is your sense that when because the way clinical trials are done there aren't often there aren't like really nice dose responses that you're just kind of comparing they're so expensive to do these trials that they're going you know two doses you know moderate high versus placebo and then the that's what the doctors have to work from.

Do you have any knowledge of whether or not the lower dosing brings takes people away from side effects and then you're seeing fewer of them? >> I think it's actually very useful. So that's you know the approved dosages are kind of just an effect of our regulatory system as as you've alluded to, right? And it's too expensive to do different different doses. Plus it takes it takes away personalization. You know we're all trying to get to precision medicine and personalized medicine and that's what micro dosing allows you to do.

The first time I I heard about micro dosing was one of my patients and he was a physician and he came in and he he said, you know, I it's a it's too expensive, you know, b I don't feel great on it and c I'm doing this thing where I take the pen and I inject it into a sterile vial and they use a an insulin syringe and I'll take a small amount out and I'll give it to myself. And he said, I'm doing great. You know, I don't feel nauseous.

My weight is staying off. and you know he was a physician so he's he was familiar with with you know the the equipment if you will and that was the first time I came across it I was like wow that's actually that's a great idea so a lot of my patients actually do micro dose these things uh and you know generally you get up to the the point where you want to lose weight you get to that dose you're losing weight you're losing weight and then for maintenance rather than just stopping it because if you stop the jp1's there's problems right this is not meant to to be stopped these are kind of lifelong medicines instead of stopping it just go to micro dosing and you'll find a spot hopefully you know, not everyone does, but you'll find a spot where uh you keep the weight off, you feel good, and you're not you're not taking as much of the med.

Now, the problem with coming off of them is especially with the the the original drugs, you know, like simaglletide's an example, right? Where when you lose weight, about a third of the weight you lose would be lean mass, right? So, most muscle, right? Maybe some bone, etc. And the problem is when you cycle on and off, right? So, say you come off of it and you put your weight back on. You're not putting the lean mass back on, okay?

You're putting the fat back on. So, now you've shifted your body composition to be less favorable than before you run the GLP1. And then you go on it again and you lose weight again and you lose a little more muscle. And then you go off and you put more fat on, not more muscle. So now, basically, you're taking your your your body composition and shifting it, you know, worse every every cycle. So, there has to be a game plan.

If you're coming off the JLP1, you need either to micro dose it or have a bridging plan to a procedure or something else which uh you know will keep the weight off for you. >> Are there any good studies um showing that resistance training can offset the muscle loss um from a standard or micro dose of of one of these GOP drugs? >> Yeah, resistance training definitely I I'm not familiar with that where that was the primary outcome of the focus, right?

But you can actually see that that does play a major role in maintaining muscle and that's with anything. It's not just GLP-1 medications. It's with the first generation medications. It's with any surgical procedure or endoscopic weight loss procedure. You know, you if you're doing resistance training, you tend to maintain your muscle because the body realizes, hey, I need this muscle. I'm not going to I'm not going to get rid of it as the person's losing weight, right?

So, when there's a caloric deficit, the body is looking for what it can do to, you know, uh, you know, to to to uh maintain, you know, energy levels, if you will. And you don't want it chewing up the the muscle to do that. The side effects that I see getting the most coverage are um increased feelings of apathy. Um general, you know, food noise is down, al alcohol appetite is down, appetite for life is down. You hear this, but I don't know that how accurate that is, right?

Social media is a weird place cuz certain things get amplified it um out of proportion to the the real data often. The other one is that GOPs um can cause blindness. these GLP drugs, but turns out that's in a very very rare set of individuals that have this uh optic nerve head kind of eskeemic opportunity. So like so yes, the GLPS can make certain people blind, but yes, also it's a very small number of people. So you want to get screened for this um structural thing in the eye, but it's not true that like GLPs are making people go blind all over the place.

So what I'd like to ask is like when patients come to you and they say like, "I didn't like the GLP or it wasn't working for me." Are they telling you why? Are they saying, "Look, it made me feel nauseous." Certainly, you know, if it they lost their vision because of it, but is there some resounding themes there? There are. I think that muscle loss honestly is is one of the bigger ones, right? Um and it might just be subtle like ompic face, ompic butt, right?

You're losing some muscle in places where it's noticeable. Other people actually truly develop sarcopenia, I think, right? Where you have significant loss of muscle. It's rare, but those are people that they're not really exercising a whole lot when they take it and they might have had a predisposition to it in the beginning, right, to start with. >> So, in people that I'm concerned about that, it's good to get a DEXA scan beforehand, right?

Make sure you have adequate muscle mass. And if you don't, you really have to think twice about if you want to do the GLP1, right? Or if you want another another avenue to try to lose the weight and you definitely have to start hitting the gym. I think that's the most common thing is is muscle loss in obvious places or sarcopenia developing. The other one's nausea. A lot of folks do get nausea on the higher doses and they will not lose weight on the low dose, right?

And if they go on the high dose, they feel nauseous. So that's another issue. Some people say it stops working and that might be because you know of of that of that similar issue. They don't tolerate the higher doses. Those are the primary reasons that I that I hear. U maybe we can move a bit towards some of the surgical procedures. And um I always uh like to remind people there's basically two ways you can affect your your brain and body.

You've got chemical methods and mechanical methods. So uh you know um and when I think of quote unquote stomach stapling, I think of that purely as a mechanical thing. You're making the stomach smaller. Make people feel full earlier in the meal is my naive view of this, right? But of course it stands to reason that you're also removing tissue and so you're going to change the chemical millu of the environment. I'm sure that you'll tell us that the you know both things are involved and what we had this thing called stomach stapling for a long time.

Why did we need the GLPS? Now, some people say, well, that's a surgery. But I think in today's conversation, hopefully we'll convince people that uh surgeries can be done less and less invasively now and can be done with tools that make it seem a lot more like a a dental cleaning, maybe a bit more than the idea that, you know, you're cutting open the body and taking things out, laying them out on a table, putting back in this kind of thing.

Cuz people's minds go all sorts of crazy places, trust me, including mine. When we hear surgery, why did we ever need the GLPS? We had stomach stay. >> So surgery, it really started back in the 50s. University of Minnesota, I think, was the first place they did it. And the first procedures were focusing on malabsorption, right? So the idea was they're going to bypass a portion of the small bowel so that you don't absorb your calories.

Okay? And it was called a juno ilial bypass. But this procedure was awful, right? So the people did lose weight, but the problem was they created a long blind limb. So there was there was no actual food going through the limb. Okay. So you connected the junum which is the kind of early small bowel to the very bottom small bowel and the rest of the small bowel was still in there but it wasn't no food was going into it. >> So you had bacterial overgrowth in there. >> You had all sorts of problems.

You had the fat that was being malabsorbed was binding calcium. And so calcium you didn't have calcium in the bowel. So what happens is the oxalate which normally binds calcium gets absorbed and then it binds calcium in the body in the kidneys. So you're having all sorts of renal failure issues and it was a disaster went on for years right because you know people were desperate but it was a very bad procedure and it was replaced by something called gastric bypass and I think that came about probably in the in the mid to late60s and Mason I think was the was the surgeon that came up with this.

So his goal was to avoid the problems with the ji bypass and um you know still get a treatment effect and he did right so he thought of this as restriction. So when you eat stomach stapling the stomach is smaller so you'd have some element of restriction and then also an element of bypass where you're not absorbing all your calories. Turns out that's not really how this thing works really but that's what he thought was going on. >> And then from there you keep moving forward you have all these other procedures. lap bands, adjustable gastric bands that was just purely restrictive.

It it worked. True stomach stapling which was I think the VBG and now the sleeve gasterectomy. So these are the real surgeries and you know they were created at the time just conceptually thinking about either restriction or thinking about malabsorption but they work entirely different than what they thought. >> I have a question about your profession generally. I'm guessing there are not large-scale clinical trials of each of these surgeries like they're doing you know 5,000 of these surgeries comparing to the existing surgery.

So, how much license do physic do surgeons have? Say, you know what? I'm very familiar with this tissue. Maybe I just like graft these two, cut out the middle. That's the part that absorbs stuff. Oops. Okay. Actually, big problems and modify. And then cuz I mean there's >> there are other things, but there are few things greater in terms of trophies for a physician knowing some physicians aside from the great feelings they get from healing patients and saving lives.

Let's let's be fair. having a procedure named after you that saves lives like that seems to me like that's like the ultimate thing. So there's got to be a huge incentive for um physicians to do it on that basis which might sound all like ego but there's another facet to this which is no and we know this from science too like you can read about the brain but if you get your hands on brains record from them slice them up look at them under a microscope you just like a familiarity with the tissue of interest especially in the context of the whole person who's coming back and saying I don't know I'm still hungry less hungry but I got this pain on my left side you know what that pain could Are there any procedures that you would love to be able to do?

Cuz you have the sense that it could really help people, but the red tape is just too thick that it doesn't even make sense to try and develop that procedure. >> I don't think so. I think the proper channels are workable. I do think that there are compassionate use cases where you need to make exceptions and then they have expedited protocols for that. I remember one time I had a person that was bleeding and it was was bleeding that was chronically going on and couldn't be stopped and we needed something that was not yet approved in the United States. was approved in Canada and the person they had no other option right and so we were actually able to get within you know 12 hours approval to use it as compassionate use and it worked for the patient so there's even pathways for that right so I think there's always you know there's always a way to use that it slows it down yeah you're excited to do something right and it does slow things down but um but I think it's always workable now there are other examples of where you have a device that's approved for one thing that the company doesn't want to get it approved for everything.

So, it would have no money to do that. So, you use it off label. That happens every day in every hospital. >> Just like drugs are used off label. >> Yeah. Right. Same thing, right? So, so um like we use wires when we're when we're accessing a bile duct to remove a stone, right? That wire has not been approved for that. It was approved for some vascular indication, right? And we've been using it that way forever because no company ever went through and did it.

So, the whole field is based on this, but it was never approved for that. So, so there are examples where you use your clinical knowledge and use a device that's approved. it's approved but just not approved for that indication necessarily. And so there's there's that. Um and that does require medical judgment happens on a daily basis. Um but if you're developing something truly new, generally the proper channels are very workable.

And actually a lot of times they give you even better ideas like oh why don't you think about checking these studies like if you're doing this check this gut hormone, right? So they have uh you know a lot of times they they give good feedback that helps the study um you know improves the study. >> I'd like to take a quick break and acknowledge our sponsor AG1. AG1 just launched their newest formulation called AG1 Pro.

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For a limited time, you can get an extra 20% off your first subscription to AG1 Pro by going to drinkag1.com/huberman and using the code backtoine. So that's with the numeral 2 back numeral 2 routine. Just go to drinkag1.com/huberman. When it comes to the chemicals associated with hunger and satiety, we could just kind of like list out the the big players. So we're talking about the GLPS, which obviously play a role in satiety and other things, hence the side effects.

So what are some of the big ones that we don't hear about so so much anymore because of the GLPS? >> Yeah. >> Well, it starts grein's a big one. That's the hunger hormone, right? So that goes up and it is produced in the fundus of your stomach. And uh when that >> the fundus is the uh >> the very top of the stomach, the top thin part of the stomach, right? The the kind of where the esophagus comes in and a lot of the ghre is produced there.

And when that's how you feeling hungry, >> so it leaves the gut, travels to the brain. >> Yeah. and stimulates hunger. What a beautiful mechanism. You're the top of the gut. You're like, I haven't seen food in a while. I'm still, you know, I I have to say I'm proceverating in the background about this this thing that the gut expands in anticipation of food and that that's odorbased. So, does that mean that the alactory neurons are communicating with the gut directly?

Are they talking to insulin goes up and then the gut expands? Does >> insulin actually does go up, too. So, insulin is before you eat, you'll have a little spike in insulin, too, right? So I don't I don't know if they ever figured out exactly that mechanism by which uh smell you know tasting food early on um uh triggers or seeing food potentially right triggers this whole process to start but before you swallow any food right you already have insulin coming up a little your stomach's already starting to stretch to accommodate the meal so maybe some of it's learned as well I don't know but I'm not sure those mechanisms but it's very interesting how it's a critical role right it certainly is involved >> when Was it grein discovered?

I I should know this. It was this is like over 30 years ago. >> Yeah, it was it was it was a while ago. Yeah. So after grein that's your hunger hormone, right? When you eat it drops and then you know it comes back again sometime after the meal. So grein is one to watch cuz we actually we actually use ghrein. We work with ghrein. It's one of the mechanisms we we use to to um get our treatment effects with endoscopic procedures and with surgical procedures too.

So that's ghrein. So then after it kind of the food leaves the stomach, right? Then you have your CCK which goes up, right? Which um CCK will cause the the gallbladder to dump bile, but it actually also will be a satiety signal as well. And um it that that's secreted from the the first part of the the dueum there. And you also have peptide Y and GLP1. Of course, they're big ones. Before you get there, I guess G GIP from the K cells approximately too.

GIP is like GLP-1. It's kind of similar. It's not it's not quite as potent. um people think of as Batman and Robin with JLP1 and GIP, right? >> People might um be curious to know that this drug retorew tide that the more cavalier peptide curious folks are already getting off from compounding and gray market, black market reat, as I understand promotes GLP, GIP and glucagon um to I think the clinical trial Lily ran showed a 30% reduction in body weight, which is really striking.

So, it's kind of curious that this GIP never really took off as a drug, a druggable thing, but you know, GLP seems to be like the heavy gun, but now by combining with other things, maybe you actually get some synergistic effects. >> It does help. I think it helps with nausea. So, it allows you to have higher doses potentially of GLP-1 with less nausea. So, CIP, I think, plays that role. It has a role in insulin sensitivity as well.

And it does some of the same stuff JLP1 does, and it's synergistic, I think. But what's interesting about the glucagon is potential muscle sparing there, right? So glucagon among other things. So, you know, glucagon is usually up when your insulin is down and vice versa, right? And its job is is is to say burn fat, right? That's it main job. It also causes you to to dump your your um glycogen out of your liver a little bit, but the main job with glucagon being up, it says burn fat, right?

It's kind of nice that uh they're adding that as a muscle preservation as well as as a way of helping to burn some of the fat potentially. >> Yeah, these uh pharmaceutical companies, however a bunch of people might hate quote unquote big pharma, I mean they're putting hundreds of millions of dollars into the the research. There's kind of an amazing case of the of like 20 years ago there was nothing for for druggable for for obesity as I understand and what was there was mainly stimulant based >> like the finine and like the valve issues but you had well you had fentamine right which was a sympathomimedic really um and >> speed >> yeah basically >> mother's little helper kind of thing right I mean and nicotine you know there's a whole set [laughter] of conversations there some people think that when we you know basically abolished smoking.

Um, people started eating more and then America got fat. Then snack foods and highly palatable and there are a lot of things, right? Moving more, eating more, highly palatable foods and less fiber. But um, now nicotine's back in oral forms is back big time, mostly with men, but also with women. And um, a lot of people like it because it's an appetite suppressant. I'm not a fan for a bunch of reasons. Raises blood pressure, highly addictive, and so on.

But it's interesting, right? Like people have struggled for forever to like how can I eat enjoy food but not eat too much whether it's a compound that we norm you know a drug that increases a compound we already make like gip or we're taking something to make us move around more and like you said sympathy medics it's like stimulants it's like a human obsession why can't we just eat enough and not too much >> I think it's uh obviously metabolic dysregulation and there are of it.

The processed foods which you touched on certainly is an element to it, right? There was a study done I believe it was in Bethesda NH study when they had they had like 20 subjects and they randomized and crossed it over and they could either have whole foods or they could have processed foods and the people that were eating the processed foods they could eat at will. They were eating like 500 calories more a day. So it is something that you do in in your normal environment if you're eating stuff in a wrapper and you're eating it you're inclined to eat more of it.

And not only are you eating more of it, right? It's easier to digest, right? You're getting bigger glucose spikes and you have a lower thermogenic effect of food, right? So, it really is it's probably also not doing great for your microbiome because there's less fiber in it. And so, that is playing a big role. It starts starting the ball rolling for sure. >> And then there's different there's different layers to it. Then you have your your PY and your and your GLP-1 which the GLP1 um you know it's triggered by anything but glucose tends to trigger more of it, right?

And then the PY, um, that's more, you know, your proteins and your fat. And it does something similar. You stay full longer, I think, and with a with a big heavy fat and protein meal, probably because of the the PY. Um, uh, that's something that's been very hard to drug, right? They didn't have a Hila monster to solve the problem that the GLP1 did, but uh, it's it's also very potent. And they both come from the L cells in the distal small bowel and the colon.

And, uh, those are those are kind of all the the major players. You also have leptin in the background. Now, that's more of a thermostat, if you will. It gets involved in it set point and things like that. And it's that's secreted from your fat cells. Uh, and if it's in almost proportionate to fat. So, if it's high, you know, generally you're going to probably eat less. If it's low, you're going to eat more. But there's all sorts of problems with leptin resistance and other things like that, too, that complicate it.

I remember coming up through science like leptin was all the rage. um it's discovery, it's cloning, and everyone thought, okay, there drugs gonna are going to come along to mimic or stimulate leptin and we're going to solve the obesity or overweight issue, but it didn't really pan out. Why was that? I think leptin never panned out in large part because of leptin resistance, right? I think the hypothalamus and the uh the brain itself is is just becoming resistant to it because it's so high in people with obesity for so long, right?

And >> there's just saturated. They got a lot of fat, a lot of leptin receptors are are clogged. >> There's low rate inflammation we know in in in those tissues and and you eventually just yep you don't respond to it anymore. And so >> so the the drugs just didn't pan out. I think that um with with the GLP1s it's another story, right? I think you know incrretins in general we've talked about incrretins we've been talking about these these hormones that are produced in the gut they go into the blood and they do something.

So the concept first came about in the 1930s and it was in it was in London and they basically were um grinding up animal um douadinums. Okay. And they're emulsifying it and injecting it back into the animal in the vascular system. >> Science in its not crudest [laughter] form history. This is 1930s folks said science is not that old you know [clears throat] real science >> right nittygritty right and the idea for that was secretin.

So someone had found secretrretin right and that is that that's a hormone produced in the dueadium that goes to the pancreas and says secrete fluids for digestion. So extorine function of the pancreas. So this person thought well wow if the dueium secretes secretrretin maybe it secretes something else. So he they did this study and in the animal the blood glucose fell and like holy cow right this something in the dudenum is causing glucose to fall phenomenal.

I'll call it Inkrretton because you have Sacretton I'll call it Incretton. So [snorts] that was that was where it started 1930s, right? And then there's another lab uh Sheila Sherlock's lab in in London and she was famous for being one of the kind of you know founding physicians that that that started the field of hepatology and she was trained in some medicine and some some internal medicine some surgery and they had this concept but what they had access to was this new tool which is where you see innovation right they had access to this way of actually detecting and measuring insulin and so they did a very interesting study where they gave subjects a set amount of glucose introvenously and then they measured the amount of insulin that was produced.

Then they gave them the exact same amount of glucose orally and they found they produced much more insulin. All right, so this was something they they they coined the incrretin effect. But is that based on taste? So they had no idea, right? But they knew the insulin was going up and they thought it probably because the only other research that was out there was from this this old 1930s study where it was coming from the dudenim. was probably due to that inkerton.

Then there's other studies that come after that that get get closer and closer to it. Right. So eventually what ends up happening is uh in in the uh um Lily Labs I believe it was there was there's a physician named Bell who actually he he the pre-p pro glucagon he ends up you know cloning that and then from that you get GLP1 and GLP GLP2 right and so he now he now we now have GLP1 we've identified it and then there was this a physician um uh Blossom I believe was the name in in London again this guy did some phenomenal work.

So what he ended up doing is now we had GLP-1 so he could actually study it. He found GLPM1 was in the bowel where we thought it was. He also um found out that when you actually gave glucose GLP1 increased in the blood and then he actually infused GLP-1 and found that when he infuses it insulin goes up, glucose goes down. So now all of a sudden we had a real sign that what what what this incretin was and it was GLP-1.

Very exciting work. The problem was you had to infuse it, right, for it to work because it gets chewed up really quickly by dipepadil peptidase. It chews it up. There's something on the end terminus of it that is susceptible to that. And uh that's the part that binds the receptor so you can't really get rid of it. [gasps] Uh and then it was in the Bronx in the '9s when there's a Dr. Ang and he's studying Hila Monsters and in Hila Monster he finds this thing in the Hila Monsters Venom that looks very much like GLP-1. has one uh substitution like second second uh yeah amino acid in from the inside otherwise looks just like it'll bind a receptor.

The C is a little longer and different but this is um you know uh extending 4 uh and basically this is the the molecule he he discovers and this is what ends up becoming all the GLP ones. >> These healer monsters don't have to eat very often so it makes a good candidate to to [laughter] stay. >> So you do surgeries of various kinds. um the people are coming to you, they have they all tried GLPs and they don't like them or they're not working for whatever reason or they'll micro dose it but it's not solving the problem and um what sorts of surgeries were you trained to do and then at what point did you become the doctor I referred to earlier uh who seeks out IRB approval to build something better like like I'm a I guess if there are multiple themes in today's discussion but one of them is if the really great physicians look at a problem they look at the tools they've got to solve that problem and if they're not working for any number of patients, they build something better or different or they they increase the array of of tools.

So tell us that story. How does that where where did that start and where are we at? Where are you at now with that? >> Really for me it started in in um fellowship. So I moved to Boston to to learn interventional gastronurology, right? So this is not you know colonoscopy and whatnot. It's doing procedures mostly focusing on pancreatobilary. So pancreas and bilary conditions and the big problem at the time was really pancreatic cancer diagnosis.

And so I was moving there to learn a new procedure uh that they called endoscopic ultrasound. So you'd be able to put a scope in the mouth into the stomach and small bowel and then use the ultrasound probe that's embedded in its tip to see the structures just outside the lumen and you could gain access to them. You could put a needle in them and that held a lot of promise. You could maybe ablate lesions with it. You >> So you're feeding a needle through a tube.

You're watching it on a screen, right? So you're not you're not using the you're you're not opening up the the abdominal cavity. >> Yeah. So you can do it through this through the mouth. So it's a natural orifice. You're going through the mouth rather than opening up which for pancreatic cancer a lot of times that's how they would do it. They would go to surgery, open the belly up, and get the biopsy, right? To see what it was.

Uh cuz it's really hard to make the diagnosis. And so I wanted to learn this new technique where you just the patient goes home the same day. They don't feel anything, right? So I thought it was phenomenal. When I got there, I I'd done a masters in health evaluation science at Penn State before before going and I thought that I would be doing epidemiologic research. And when I got there, the my my my uh mentor, Bill Buggy at the time was a pioneer in this ultrasound.

And um he he he gave me a needle and said, "Hey, this thing doesn't work to make the diagnosis of pancreatic cancer. I need you to try to fix this. Right. And he was right. The thing didn't work. Unfortunately, like we had about a 50/50 chance of getting a diagnosis with the needle. And it's because it was it was designed like a hypodermic needle. Like you get an IV placed, right? The IV is not taking chunks of tissue out of you.

It's designed to atroatically split the tissue. And that's needles we were using, right? So for >> to deliver stuff, not take stuff. >> Yeah. Yeah. So I kind of figured out what the problem was. They didn't know the solution honestly, but I gave him my report and the company thought it'd be too expensive to fix and we didn't really do much with it. But it still went on. when I was a couple years into practice on faculty there and you know we still had the problem of you know you you take these FNAS final aspirations of it and you wouldn't have an answer and you know you'd have people that wouldn't want to have a major surgery having their pancreas taken out without an answer and then they'd have worsening cancer and then by the time you'd be able to make the diagnosis it'd be too late to treat them and help them.

So that's where I started kind of uh you know entrepreneurial stuff right and so my first um my first company I guess you'd say was based on that and uh I needed a team you know and one of the engineers had the brilliant idea of how to change that bevel design helped raise the money I knew what the clinical problem was and and and that and whatnot but you needed a team to fix it. So we hired engineers and we got together and we came up with a needle that could bind to the pancreas without causing pancreatitis or any problems and it has been wonderful because that that really became very instrumental in helping a lot of people to get the diagnosis earlier.

So we're saving lives with that. But now we look forward to the the fact we have preserved cell cellular architecture. So you could do you know precision medicine. You can actually uh test different drugs on the tissue and see what it's going to respond to. you can do immuno staining and uh it's a lot better than just having a few shaved cells. So that was the first time I really get involved in in trying to solve a problem like you say and that was before I started diving into metabolic disease where I've spent really a large part of my time but that was what started it off.

So just like earlier I you know I was saying the mechanical influences and chemical influences over our health and biology for what I call like reading from the body like people get a sleep score or your heart rate or blood pressure that's reading obviously you're not writing to the body but you have a structure and you have functional readout so like if you know someone goes I have a pain in my side and you go okay well you you uh give them an ultrasound there's a massive thing there like you got a structure there that doesn't belong there then then you can decide to cut open right What I hear biopsy, people hear biopsy, they go, "Oh boy, you're getting poked with a needle." this kind of thing.

But I might shock a few people, but if you told me that I could come into the clinic and spend one long day under anesthesia and get completely non-damaging biopsies of every single one of my major organs to grab a few cells here and there through the mouth or heck, even if they have to make a small incision one place and then zip me back up and send me home and I can just say, "Okay, like I'm let's just look at all the cells.

Let's see what's you know, let's see if I have any issues." A lot of people be like, "Why would you do that?" Well, I'd rather do that than walk into the clinic at 72 and go, "I've got this pain or I'm not sleeping well or I'm sweating or I have this bump here." I mean, in the end, we end up diagnosing ourselves. Well, we either drop dead, diagnose ourselves, or someone else diagnoses us, right? And so, with a procedure like yours, I'm kind of inclined to say like, would you just get it?

You seem healthy. Have you done it to yourself? Can I come in and get it just for uh checking things out? We take blood tests now. People go, "What's my testosterone, my estrogen, my uh luteinizing hormone, my lipids, my, you know, small uh, you know, LDL, APOB." 20 years ago, if you wanted to get a blood test 15 years ago and you didn't have a problem to motivate that, it was thousands of thousands of dollars at best.

It was very hard to find people that give you these. Now, it's triv trivially inexpensive for most people. Um, so I feel like we're kind of going that way with biopsy. So how soon are we um going to just be doing biopsies with non-damaging procedures? >> So I think a lot of times with biopsies, you have to be very targeted to get the tissue of interest, right? So even in the pancreas like like we said earlier, you know, you could be even in the area that looks like a lesion like a tumor and not getting cancer cells out.

So I think that you have to be very very targeted, but then once you do get the tissue, you can do all these stains and you can really figure out what's going on. Is there a gen genetic predisposition to it? Is there some way it'll respond to one drug over another? I think that's phenomenal. But I would like to see the diagnostic studies become less and less invasive so they can scale easily. So the the one problem with uh procedure-based diagnosis, I like procedure- based treatment.

I love it. It's better than surgery. Um you know going through the mouth and rather than making an incision in the abdomen I think has has benefits for the most part. But when you get diagnostic studies similar to colonoscopy, there's a scaling problem, >> right? So when when a patient has to come in and spend an hour with a doctor or two hours, that doctor is taking care of one patient for two hours and he's outnumbered, right?

Everyone needs screening and it becomes very complicated. So, I would love to see innovation in technology go where we have minimally invasive ways of diagnosing things, whether it's via your smartphone and AI or it's via minimally invasive scans and and uh um blood tests are great because it it's quick and easy to do. And we're not even doing talk about metabolic health. You know, there's several things we could be doing non-invasively at home right now that we're not doing that catch it much earlier.

So, >> well, so an example is most of the time we're waiting for hemoglobin A1C, right? And that's the the marker of diabetes and that's the going to be the thing that you know once you have an A1C or a high APOB which they're probably not checking maybe you know an LDLC or something right once those are high we know there's a problem however there are signs much much earlier than that and so so metabolic dysregulation follows a a fairly predictable sequence right first it's calorie excess right so it's it's in the western diet it's usually glucose right so you have too much glucose around you have too much saturated fat but too much glucose and then at too much glucose uh you could catch that by doing a CGM right so that's one way you could do it a continuous glucose monitor you could then see if you have particularly glucose spikes to certain foods and if your glucose is shooting up to 200 with certain meals you know you're sensitive to that and maybe you should change how you're eating it try to eat it after having something fatty maybe avoid it right so because we know this is part of a sequence that's going to lead to problems and this goes back to the white hall 2 study which um to to give relevance here so the whiteall two White Hall 2 study was on British civil servants.

It was a prospective kind of longitudinal thing and they found that um they followed all sorts of metrics. One of them was insulin. Fasting insulin was one thing that they followed. They followed other things as well. And they saw that if someone had high fasting insulin, they're more likely to get diabetes long term. So, so and it was a long period of time. It was like a 10 15 year time. They could detect this thing 15 years earlier.

They could do something about it, right? But no one does because no one looks for fasting insulin. And the other thing that's very relevant here is there was another study was the UNCC NHANE study. Okay. And um that's another large database. It's more cross-sectionally looking at at a at a point in time. And what they found was that less than a third of people that are lean are are metabolically healthy. That's crazy. 12% of the whole population, less than a third of lean people are metabolically healthy based on their parameters.

And the parameters looked at waist circumference and glucose and blood pressure and whatnot. Right? So looking at metabolic signals. The word there is start looking early and don't look with the traditional things. Okay, we have to look at other things. Getting back to you know metabolic syndrome ideas. So first you could check for glucose. So glucose spikes a CGM can do that. I wouldn't say wear it all the time. Get one for a month or two.

Learn what spikes your glucose. See if something spikes your glucose and adjust it. Next you have fasting insulin. Okay. So the next thing that happens is first in anybody they have the insult of excess calories. The excess calories comes. That's what happens. Insulin's job is to take that sugar and push it into the cells because glucose is really bad for the body. We know this. If you look at endstage diabetes where they can't control their glucose anymore, they go blind.

You know, they have kidney failure. It's killing the vasculature. It's sticky. Glucose is sticky. It glycates things. It causes problems. So, the insulin's got to get it out of the bloodstream. So, next in the sequence of metabolic dysregulation is high insulin levels. Fasting insulin goes up. So, you can get a fasting insulin level. That's the next thing you check, right? It's not a lot to ask for. It's an inexpensive test and you can see if you've if you've evolved into that problem where now you have chronically high insulin levels.

And part of that honestly is due to eating too frequently and could be eating you know certain things that are uh you know high fructose corn syrups or things that that basically u you know have a high glycemic index or load that's going to cause your sugar to spike. So and the problem is if you're eating every few hours insulin goes up and it spikes. It drives the glucose out of your blood but then the insulin stays high.

Okay, it doesn't go right back down. It stays high for a few hours. So, if you're eating every few hours, you always have this high insulin. That's going to lead to other problems. And the next thing that happens is ectopic fat, right? So, your fat exists in different areas. You have subcutaneous fat. That's where it's supposed to be. That's your depot for energy and uh it's healthy there. Has different ways of growing.

Then you have visceral fat, which is really in your your momentum. You know, it's a it's in the abdomen and uh in your mezzentary in the abdomen that's around the bowel. Okay, so that's that kind of your visceral fat. Then you have your organ associated fat. You have some fat around the heart. You have some fat around the kidneys, etc. It's kind of supposed to be there. They're all adiposicides. They're all fat cells.

Their job is to store fat and release it, right? That's what they do. Then the last bucket is ectopic fat. And ectopic fat is where you have fat in cells that is not their job to store fat, right? Like liver cells or muscle cells or pancreas cells. And that becomes that becomes a problem. >> It's like Wagyu beef. >> Yeah. It's like Wagyu beef. >> Yeah. Those cows are over they're not they don't move. They're overfed.

It's >> Yeah. >> And and that that's you know that's another problem. Right. So that's the next phase of metabolic dysregulation. And they've done all sorts of great studies that have shown exactly from each step what happens and how you get there. Right? And so that's when you get fat in your muscle and you get fat in your liver and that's bad. Fatty liver is very bad. And then that is what goes on to insulin resistance.

Okay. So for the fat, how can you look for that? Well, you can do a waist circumference measurement, waist to height ratio. You can get a DEXA scan that'll tell you if you have visceral fat or you know if you have a lot of subcutaneous fat, a CT scan MRIs, other things will do it too. Um or an ALT, look at a liver test measurement, right? Uh that's amotransferase in your liver. Um and usually, you know, that'll signify some inflammation.

So you know that's the next level, right? And then you have insulin resistance, which that's a little harder to check. That's a combination of there's a formula that you can do to look at that. It's a it's a a fasting blood glucose and a fasting insulin level. And you multiply those and divide it by a constant. And if it's greater than two, you have insulin resistance. So that's the next next phase of it. And then finally, you have metabolic inflexibility.

Your body is supposed to change between calories, right? What is burning? If you're fasting, it's supposed to be burning fat. And if you're eating, it's supposed to be burning some element of carbs depending on what you eat. But if you have carbs in it, it should be burning the carbs, right? And so you can develop metabolic inflexibility as the next phase of this once you have insulin resistance where when you're fasting, you're not really accessing your fat anymore.

Your fat's still there. It's burning more your glycogen stores and god forbid it's chewing up muscle, right? But it's it is no longer accessing the the fat stores is supposed to be accessing. And then when you eat, it doesn't shift over to burn the carbs well either. kind of just it doesn't know what to do. So that's a loss of metabolic flexibility. And by then you're getting near the time when all of a sudden something's going to happen cuz once you have a loss of metabolic flexibility, they've shown in studies that you're more likely to gain weight and develop obesity.

You're more likely to start losing beta cells. You start burning out your beta cells and they became apoptic and you lose beta cell mass and you start having all sorts of other problems. So this is a very kind of typical sequence that you see. It can happen in other ways, but that's a typical sequence that's backed by science and different clinical trials. And each each step of that way, you have a study you could do to find out about it.

The last one, the metabolic flexibility is a little harder because you you have to do kind of go and do a breath study for that where you're looking at gas exchange and it's very accurate actually because we know that there's a respiratory exchange ratio. Um, athletes do this to optimize performance. You can do this where you get a DEXA scan. A lot of places they'll tell you how many calories you're burning or what you're burning.

And basically it's you know first law of thermodynamics and you're burning calories but it's a ratio of a volume of carbon dioxide divided by volume of oxygen. When you eat carbohydrates carbohydrates have an equal number of carbon and oxygen. So it doesn't require much oxygen to to burn the carbohydrates. But when you burn fat it requires more oxygen. So if that ratio is like 7 uh so it's it's carbon dioxide oxygen that means you're using more oxygen.

That means you're burning fats, right? And if it's one, you're burning carbs. And then there's an in between. And so this is a great way to see if you're metabolically flexible. Eat fat, see what happens. Eat carbs, see what happens. Do it fast, see what happens. Right? And you sit in a chair, and you breathe for half an hour. There's companies that are actually developing at home method that's doing this, too. There's a few of them.

And actually, one of them recently, I think, now has one that does both the oxygen and the carbon dioxide. >> I've seen this like a little box that you breathe in, too. >> So, I mean, you can do everything, right? So, and then or you can just wait until you have diabetes and your A1C goes up. And so, yeah, there's a lot of things we should be doing before we do the standard test of looking at your fasting glucose and looking at your hemoglobin A1C. >> I'd like to take a quick break and acknowledge our sponsor, Function.

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Very early, in fact. I mean, I I don't I want to be clear. I'm neither complaining about nor am I um trying to turn you against your colleagues. But I'm going to just be really blunt from and these are my words and my words only. I want people to understand this. Like I mean, I've gone public many times saying, "Hey, like as the cost of blood testing comes down, this is awesome. you get a window into uh lipids, hormones, things that can be very informative whether you have issues or not.

And the push back on that from the medical community, not all cuz I have friends in the medical community who will quietly say, "Yeah, I totally do that test. I take that test, you know, but many of them just say, "Oh, great. Now patients are going to be coming to me saying like, I need to do I need to be worried about this? Do I need to be worried about this?" I said I actually put a post out recently that as the cost of of whole body MRI comes out.

It's going to be interesting to see what happens. I have neurosurgeon friends who tell me about life-saving procedures they they do all the time. The neurosurgery community was super angry. It generated some press this week. Actually, uh this is how the the tables kind of turn. There's a celebrity, I forget their name, who took a one of these types of scans from a company I have no affiliation with, by the way. I took a POVO scan and um identified a a malignant issue that could be cut out and very likely saved their life or at least extended it.

So, I get it on the one hand why a lot of physicians are worried about people walking around with a lot of data. I heard the same about CGMs. Okay, I'm gonna try not to rant here. It was like, "Oh gosh, who needs to know their glucose goes up, glucose comes down in the absence of diabetes or pre-diabetes?" Like, you can have a glucose spike. We don't want people walking around neurotically worried about eating a grape, which I totally understand.

Your body can manage these things. But now that CGMs have been out for a couple of years, I don't hear much push back. Yeah, somebody wants to use a CGM for a couple weeks and see how they react to different foods post exercise, post poor sleep, etc. Cool. So, it's kind of wild to me that physicians don't want patients to have data. But here, I'm hearing something very different. You're saying, "Yeah, it's I think people should pay attention to how they're regulating their blood glucose." The problem with medicine is it moves very slow, right?

So, a lot of people are going to want you randomized control trial, another randomized control trial, maybe a few more, and then a meta analysis, and maybe understandably, but from a patient perspective, people want data now. if they can get it inexpensively. And by the way, these are are they called elective or elected >> procedures? They're elective. If they're elective procedures, so no one's saying you have to get this done. >> It's an option. >> Yeah. >> I don't get it.

Can't wrap my head unfortunate. It's it's it's unfortunate that um there's there's a reason for it. Obviously, do no harm, right? There's a reason for it. But by the same token, it does not necessarily um do the patient any favors by waiting for something that's that that is logical and makes sense, right? And there's enough evidence for this sequence of events, if you will, for metabolic illness all the way back to syndrome max in the 80s, right?

We know there's this constellation of things. And we also know that if you don't act early, you're much less likely to have a good treatment effect. If you start treating someone once they have diabetes, it's much harder to get them back to healthy and normal. They've already lost beta cell mass >> or peripheral nerve. I mean they could have loss of their fingertips and toes or sensation, excuse me, in their fingertips and toes. >> And now before I mean we might not have had access to things.

We had access to fasting insulin, right? But think about this. So say you don't get the CGM and you have fasting insulin, right? And the fasting insulin is normal. You don't know if step before that is a problem and you're going to have problems with fasting insulin or if it's abnormal, you need the CGM to learn how to eat, right? Because that fasting insulin is high for a reason. you're spiking your insulin or you got to figure out why you're spiking it, right?

So, so then you go back to the CGM and you learn and I don't I don't have any stock in the CGM company either. You got to learn how to eat to not spike your insulin in that case. Now, if you're taking a bunch of, you know, saturated fat, that's not great either. You can't be on super high saturated fat with an Ape B through the roof. But, you know, either way, it's not good, right? So, most of the time in Western countries is it's the glucose and insulin that are the problem.

And it's the very beginning of it. So, why not learn about yourself? take some responsibility, right? Learn and and prevent these diseases from from going on. And I do hope physicians are are more open to kind of encourage this as well. Um where we start acting earlier. It's going to it's going to be better for the, you know, for the population in general. >> Yeah. Because I could see why physicians would be very reluctant towards self-directed interventions.

I get it. But here we're just talking about getting data and it's voluntary. The costs are coming down. And as you point out, having data early is better than having data late when it comes to um physician guided interventions. So what I've what I've heard in this regard is um you know I with in conversations is well the problem is a patient's going to then figure out they can eat junk food like like a like something that's really bad for them. you know, some greasy fatty thing that's unhealthy for them, going to, you know, put their, you know, APOB through the roof and they'll think it's okay cuz it's not showing up in their CGM.

I think it's not giving the patients enough credit because generally if you're getting a CGM, you probably are are trying to do the right thing. So, I think it's how will they use the information? Could they accidentally not be informed enough to to use that information appropriately and could they do the wrong thing? But again, I think more information is better almost in all circumstances with diagnostic stuff. Now, I agree with this MRI thing being concerning because you might have a lot of little lumps and bumps there that now you're doing diagnostic studies for that could increase risk, >> right?

So, because diagnostic studies could increase risk and also could be a burden on the health care system, but >> more information I still think more information is better. We just have to find better ways of doing the followup confirmatory diagnosis. there might be other ways we can do it. Looking for metabolic activity of tissue like PET scans or what doing other things rather than a biopsy and and something that would increase risk. >> Okay.

Well, thank you. I wasn't asking you to take my side in the argument, but since you threw out CGMs first, I just kind of took that as an opportunity. I think uh my um I won't name names, but let me put it this way. Whenever I get that sort of push back, I'll go to people I know in the field and I and I'll say I'm not looking for confirmation that I was right and they were wrong. to tell me what what I'm hearing here.

What what's beneath what's the layer beneath what I'm seeing? And almost inevitably they say the same thing. Give it 20 months. This will be standard. And that happened with CGMs. No one bulks at the idea of a CGM. Yeah, you want to put that thing on, you can afford, you want to get some data. Like most people, most physicians I know now are comfy, but at the beginning it was like all the push back in the world. That's really wild how.

So wait 20 months and and this will be a non-issue is what I keep hearing again and again. Well, even when you have procedures that have gone through rigorous, you know, evaluations and they have FDA approval and, you know, they're they're ready. You have so many people that are reluctant to send patients for them, right? >> Why is that? >> Yeah, I think it's it's in the culture. >> Are they afraid they'll do it wrong?

It's like a new skill to learn. >> That could be. So, some of these procedures, you can't learn them in a weekend course. You know, you have to spend a year or or longer learning some of these things. And so for a physician who wants to add something to their practice, that's they're not going to dedicate a year to it. They might do a weekend course and realize it's it's too hard and then they don't they don't adopt it.

The problem is the people that do adopt it and they're not ready. So then doctors that are referring go, "Huh, this procedure's been around for 6 months or a year. It really has great data in the clinical trials, but does the guy down the street know how to do this after doing a weekend course?" And so they were reluctant maybe for that reason. So just give it time. and wait until it's maybe insurance not covering it yet, right?

Wait to see if the insurance companies think it's it's it's a good idea, then maybe we'll start sending patients. So, it just it's it moves slowly. >> Yeah. Well, I don't want to you hover on this too long, but I have a friend who's really into cars and uh he told me that in the mechanic and automobile community, a similar thing like as things became more and more computerized, there was a lot of push back because it makes it hard for auto shops to do their um their work.

You know it changes the the field changes and you need more tools. Sometimes those tools are expensive. You need training and people like to hold on to the way they were trained. This is absolutely true of most every field. Adapt or die or your patients die there. Um that's my you know if you don't adapt your patients will die. I have to imagine that there are good surgeons there are mediocre surgeons and there are exceptional surgeons.

Are there places where you've brought in devices or machines that could offset the mediocre and um lousy surgeons or surgeons by day sleep a little sleep deprivation? So I'm not just saying like bad surgeon good surgeon but there so what has come into the field that's allowed you to do your work more effectively and others to do the work more effectively. >> Most devices we see are kind of incremental improvements. a little bit of better wire, you know, devices a little more ergonomic.

But what I see kind of happening more recently is AI starting to have an impact where it can actually coach you through procedures, which is kind of work. You have an earbud in or something >> uh on the screen itself, it's like a heads-up display, right? On that heads-up display, uh it will actually give you information so you're not just seeing the images you're working on. It can actually highlight certain structures you want to work on.

It can actually point to something where you want to put your stitch, right? And it can count the stitches as you're placing them and tell you if they're close enough together. It can change the shape of the stomach as you're working on the stomach to let you know if you're having a good treatment effect. This is something that we we never could have have done before in real time. >> Real time. Yeah. Which is phenomenal.

Right now it's not widely available yet. This is in research centers, right? But you actually can see this happening in real time and um it's it's phenomenal. So you see that in more and more it's happening in different surgical procedures where AI is kind of real-time coaching you and in endoscop endoscopic procedures. Additionally there's the hope for robotics to help as well and we've done a lot of research in our lab on robotics and how it can take trainees that are learning a new very complicated procedure and shorten the learning curve dramatically.

And we'll randomize the trainees and have them do the traditional way like this is usually resecting a tumor from the colon leaving the colon in place. That's a very complicated procedure and or from somewhere else in the in the stomach or whatnot. And the fellows will learn they'll spend a couple of weeks training in both modalities and then they will struggle horribly with the original way. That's why it takes two or three years to learn how to do it.

They'll sit down with the robot and be almost good as an expert. So robotics are very interesting and now in the future we haven't done it yet. But when you start layering on AI and automation with the robots, now you might have a big win. And we we've seen this before with different surgeries as well with the with you know intuitive surgicals robots when they first came out years ago. It democratized the field. It took mediocre surgeon it made them excellent and the excellent surgeons were still excellent right but it really helped the ones that were struggling. >> How the excellent surgeons feel about it in keeping with our previous discussion. >> Seriously like are is it is it is part of it's like is it like athletics like it people want to be they want a hierarchy of performance um for themselves. they don't want patients dying at the hands of poor surgeons.

But I would think that um if do no harm is really the the uh the true um central cord of medicine, then every person in a field would want more people being healed independent of their own stature as a physician. Yeah, I think they're um supportive of robots, but I think that a truly exceptional surgeon is probably just going to be better without the robot and just, you know, the robot is just it's going to it's going to make you worse. >> How do I know if I'm getting a truly exceptional surgeon? >> That's a good question. >> Understanding do am I getting the best physician for this thing is really hard to determine. >> Yeah, that's common across all medicine, right?

And even as I'm looking for a doctor for something, it's hard to find the right person. I'm in a massive medical center, you know, and have great connectivity. But knowing who truly is the best is complicated, right? So some things we rely on are volume, case volume, and historic case volume. So how many procedures do they do? That's important. And probably more important, how many have they done over the course of their career.

So if you're having a procedure, you want to know volume because volume is important. It's not the whole story, but volume is important, right? And we need in medicine honestly to move more towards objective metrics. And this is one thing AI can do for us. Right? I'm involved in a um a healthcare delivery platform. It's called Everself. And what it does basically is the doctors that are doing these procedures are held to a certain metric.

Right? So it starts with just collecting the data, you know, finding out what their weight loss outcomes are, finding out how many stitches they place per procedure, looking at their procedure time, looking at their complications. So, you're grading all that, but the next layer is putting this AI on top of it where the AI, not only can it coach you through the procedure, it can give you a grade at the end of the procedure.

It can be very specific and it can tell you you placed this many full thickness sutures versus this many. You want 100% of your stitches to be full thickness. Maybe the doctor's putting in 70. They're full thickness. That's not good. This number of sutures were close enough together. Some were too far apart. It will give you a grade. This is the pattern used. This is the volume of stomach you reduce it by. It'll give you a grade at the end of that procedure.

And that grade is incredibly important. And then the the idea next would be is to share that data so people know kind of what grade you're getting. It'd be great to share that with governing bodies that do credentiing. So people that are truly underperforming, maybe they should get refresher, right? It would be nice for patients to be able to select, you know, who they're going to go to based on objective metrics. And AI can do this probably across the board with other things as well.

So that's part of it. We've seen this a little bit with ADR, edenoma detection rates in colonoscopy where they used to publish that and they stopped doing it. So doctors were expected to have a certain number of polyps they'd see per colonoscopy and they'd report that. That was something that was another way. But then the problem was all the patients wanted to go to the one or two doctors that had the highs and their weight times became enormous, >> right?

And then patients couldn't get access to them. That's a problem as well. But there should be a reasonable cut off where a certain level of expertise is required and um you know I think AI you know hopefully will help us get there. I'm excited by what you told me about how AI can um provide real time data and perspective data about how the stomach will change shape in with the opportunity to make the adjustments as you go as opposed to having the patient heal up and have to have to come back in for another surgery. years ago, I saw something amazing.

A a neuroopthmologist um friend allowed me to sit in on a on something. He said, you know, people forget that surgeons wear microscopes on their eyes, right? They they wear these like um uh optics that allow them to see things bigger obviously, but then there are all these new tools that you know like a little drop of florosine, a little bit of like innocuous uh liquid that creates a contrast for the for the surgeon or for the eye doctor to see what what is what and not cut the wrong tissue.

It seems like a like such an obvious thing, but I was told that for you know a hundred years the same procedure had been done without that. And so eye surgeons had to essentially guess based on their intuition, their training of what was tissue to uh preserve what was healthy, what was unhealthy tissue. I mean these what seem like kind of simple to us now technologies have improved the margins of safety have improved the you know outcomes tremendously.

And so the idea that you would have AI combined with really good microscopes either worn on the eyes or you're looking down a microscope better surgical tools to me it just seems obvious like yes yes and yes >> but a lot of people hear AI they hear robot and they hear surgery and they go oh my goodness like what if the they go to the extreme I think with AI people think it can go rogue has a mind of its own so I don't want you to give false assurance that that's not going to happen but when you sit down to do a procedure and you're getting information from AI where does your trust come from that um it's giving you good information as opposed to faulty information. >> Yeah.

So the AI is is trained on thousands and thousands of procedures, right? So more than I' I've done, right? So >> which is good and so it recognizes patterns. So you have to use your clinical judgment and you're not doing you're not using this AI kind of blindly. You're using your clinical judgment and you might ignore it sometimes. You don't have to follow it. Now, if it becomes the time where you're automating operative robots using AI, >> like suture placement, >> that'd be different.

If it's doing it itself, that's different. But for this, where it's just suggesting where you put a stitch or showing where a blood vessel is, I think it's a huge advantage. So, we do these procedures that are very technical where where you tunnel, you know, you're creating a potential space in the esophagus. So, back to that earlier um person that couldn't swallow, right? They had trouble swallowing because they had acalasia.

So the procedure how we do that is we go in through the mouth. We inject a little fluid under the mucosal layer to to lift it with a with a pocket of fluid. We make an incision in that and we take the endoscope. We slide under in between the mucosal layer and the muscle. We dig all the way down to the bottom of the esophagus and then we cut through the muscle. When you're doing that, there's vessels in there and they're hard to see.

AI can actually see those vessels because it's got pattern recognition and color them for you so you don't hit the vessels as you go, reducing your chances of hitting a blood vessel. Right. Beautiful. So that's just one example of something that's a very complicated procedure and you're certain you're you're you're making certain aspects of it a little easier. We think that >> physicians are looking at the equivalent of a medical textbook with coloring, but it's not.

It's black and white and gray and beige and there are certain structures that look different that are contrasty and look different. So now with with endoscopic ultrasound, it's not even color. It's all gray. So when we're doing endoscopic ultrasound, we talked about looking for a pancreas tumor. It's all gray. It's just different shades of gray. There's no coloring to it. Now, you can you can turn on a button to see if there's blood flow, right?

But it's all gray. So, I years ago in my lab, I was trying to use image registration. So, I could take a CT PET scan and I could link it to the the angle of the probe and you could see a CT scan fluctuating in the probe of the ultrasound and lay the overound the ultrasound over it and then you get an idea of the tumor you're looking for, the leion you want to biopsy or whatever, right? >> It was too hard to do. it would take three hours of preparation to be able to set that up.

You could never scale that. Now with AI, other groups are doing similar work now and it's it's almost automated. So I'm hoping that we'll see image registration with these very advanced imaging tools that are being used help us with diagnosis and hopefully even with therapy too. They're they're doing something now called hyperspectral imaging and they're doing it in surgery as well. There's several groups doing this.

One group in Lond is doing phenomenal work. They're using all these narrow bands of wavelengths, just tons of wavelengths, and they're finding out that each tissue actually has a fingerprint. So, you can actually use this this hyperspectral imaging to fingerprint tissue, and you can actually see margins of tumors with this. And it's very interesting without giving a die anymore. So, you still might want to give it for lymph node testing or whatever.

Sometimes they'll inject something into a tumor and then look to see if it gets into lymph nodes. That's different. But this is for actually looking for margins or for lesions. And it's just with light technology, it's amazing. So that's what LEDs are doing, right? In different kind of cameras, right? So instead of CCD chips, you have CMOS, right? And so with newer technology, even though it seems incremental, with LEDs being able to flu kind of fluctuate the wavelengths of light and your chips being able to read it faster and better, we're able to make better diagnosis.

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