169 | An Obesity Doctor on GLP-1s, Cortisol & Peptides

Because I'm not just trying to hit some number that we pick out of the sky. I want to make sure that you are living a life that you can sustain and that you find meaningful.

Doctors don't learn anything about nutrition in medical school. You've probably heard that on social media or experienced it yourself. And while there's definitely a nutrition gap in medicine, this is what I built my entire platform on, the truth is actually a little more nuanced. Today I'm excited to be talking to Dr. Reese Czechitz. He's an internal medicine physician who actually studied nutrition science before medical school and went on to specialize in metabolic and obesity medicine. He's also deeply passionate about making nutrition advice realistic enough that patients can actually use it. Welcome back to the Exam Room Nutrition Podcast. I'm your host, Colleen Sloan. I'm a PA and dietitian, and today we're talking about what physicians really learn about nutrition during training and where that education still falls short. But we also get very practical. We're going to talk about how to approach weight without immediately jumping to restriction, why Dr. Reese uses an add-in approach with food. And you know, as a dietitian, I love that approach. We also get into compounding GLP1 medications, the impact of cortisol on weight, and one very popular social media wellness trend that Dr. Reese says simply doesn't have the evidence yet. You're gonna love this conversation, so grab your coffee or drive safe and enjoy my conversation with Dr. Reese. Dr. Reese, I am so excited to have you on the podcast. We've connected on social media for a while now, so it's really fun to see you face to face. Thanks for being here and welcome to the show.

Yeah, of course. Thank you for having me. It's great to connect. I love it.

All right. So there are some strong opinions on social media that medical school, PA school doesn't teach nutrition at all. And doctors, quote, know nothing about nutrition. So from your perspective, I would love to hear what exactly does medical training does well, and maybe where do you think that it fell short?

Yeah, it's a great question. Uh it's it's very controversial and provocative to say your doctor knows nothing about nutrition. And it's better than nothing, but there's still a lot of opportunity. Uh in medical school, it was identify the deficiency and the food that will correct it. And so you would say, this is scurvy, eat more vitamin C. You would say, This is, you know, night blindness, that's vitamin A deficiency. And so that was kind of what we were covering in in medical school. What was really frustrating about that is you're not getting the behavioral in the day-to-day aspect of a person living their life who is making all of these different food decisions and doesn't likely have these vitamin and mineral deficiencies. During residency, it was pretty minimal, just which is unfortunate. But you go through medical school and residency, and most doctors think that they're getting less than about 30 hours of formal nutrition training. There could be more that they're just not recognizing as someone is sharing different tips and pearls with them. Uh, but in residency, it was kind of how to identify patterns that shouldn't be followed if in someone who has obesity or diabetes and other things. And then it was a lot of let's try and connect them with someone. What I tried to do during residency was build a program with other interested students where we looked at the different lifestyle and evidence-based components and we tried to incorporate those. So we actually created a study group and we went through about 30 hours in six months of just kind of rigorous evidence-based study material.

Yeah, it's interesting because some schools actually do focus a lot more on nutrition and lifestyle as opposed to others. So, really, when people say doctors get no medical nutrition training, it's technically not true. And you can't say that across the board because I do know of some really good programs that do incorporate it really well. All right, so let's talk a little bit about how you kind of think through and maybe work through caring for your patients if they have rapid weight gain or a BMI that is in the obesity range. Because there are a lot of facets that you need to think about before you decide your next steps. So, can you kind of walk us through your thought process there?

Yeah, you bet. So I'll start with what happens when I see them as adults, because I'm an internist and that's what I do. But I'll I want to marry it with being a father and someone who's very interested in the health of kids. And so there's a surprising amount of genetic components for obesity. We know that about 40 to 70 percent of obesity is related to genes. And as the the weight increases, it becomes about a 60 to 80 percent genetic predisposition. And so we don't have a magic way to fix that, and that's really challenging. But it is important to acknowledge sometimes if a kid is struggling with their weight, there could be something within their ability to sense fullness and hunger that is abnormal, and they might need early intervention to help assist with that with that before it becomes a much larger problem much later down the road. So that's one thing to keep in mind. But the other is I I always think of the example where we're very good at trying to identify the root cause. And when we're we're talking about obesity, sometimes the root cause is the environment. Everything is to blame. And so we have to be careful about that because it's like telling a fish swimming in dirty water that the problem is the water you're swimming in. And that the the fish just can't do much about that. And so we have to keep that in mind when whenever we're counseling with people, we need to say, what is your environment? And what are the the small wins we can add up over time? For kids, it's you know, are we are we working outside? Are we moving? Do we like to be physically active? Um, what are what's our relationship with food? Like, what foods do we have available at home? Do we have easy access to lots of foods that are hyper palatable, high calorie options, or are we okay with things like fruits and vegetables? Because some kids just there's a whole range of of what kids enjoy and what they don't. And we really need to understand before we start to dive in and just start making recommendations.

Yeah, I really like your approach. And I always tell my colleagues, you need to get curious before you get corrective, because you could just waste so much time giving advice that really doesn't match the needs of that person in front of you. So you really got to find out about their lifestyle and everything else before you can give good advice. Now, you mentioned something interesting. You mentioned hunger and fullness cues. And I'm curious if you think it should be taught to children. And if so, how do we teach that to kids?

I'm so glad you brought this up. So I, as a rule, I tend to think that most kids, there are exceptions for these genetic forms that that come up on my obesity medicine boards and such. But most kids, when they are born, they have a very good sense of enough. And they know. And I have a five-month old, and he knows when he's hungry, and he knows when he's full, and it's very hard to overfeed him. But then somewhere along the line, you know, they turn into three, four, five-year-olds, and we watch them and they're playing a lot during dinner, and we say, Oh my gosh, you need to come and sit down and eat three more bites, you know. That that is something that a lot of people grew up with. And the kids resist and it becomes this battle and this struggle and this duel. And it just creates some problems. And so, how do we teach hunger and satiety cues? I think that there's just an exploration. Like you mentioned, curiosity. I love that, I use that too. But to ask your children, how are you feeling? Do you feel hungry right now? Do you feel like you got enough to eat? Or does your stomach hurt a little bit? Like, you know, did we eat too much? Some of those questions and just getting curious, I think that's one thing, but to try not to be overly prescriptive. You need to eat this amount before you can go play, but just trying to provide some patterns so that they can recognize.

Yeah, I agree. I think teaching kids hunger and fullness cues is really, really important and something they can carry with them into adulthood. We'll get back to the episode in just a minute, but I'm curious, have your patients ever asked you if you could just give them a meal plan? But what's interesting is patients are actually asking for structure and guidance around nutrition without feeling so overwhelmed. That's why I love the Peas and Hoppy Meal Guides app, who's built by my friend and registered dietitian Ann Kent. Every week she provides simple, flexible meal plans your patients will actually follow, giving them more variety and nutrition without adding to their mental load. Check out peasandhoppiness.com slash exam. And if you use code exam room, you'll get 20% off. All right, now let's get back to the episode. All right, now you had mentioned something about highly processed foods. And as clinicians, as parents, we know that they are not the most nutritious, but conversations around these foods often sound really restrictive and judgmental. So I'd love to hear how you counsel families and patients, or maybe even what you do in your family, to kind of discuss these foods in a way that supports health without creating that guilt or fear around those foods.

I love that. So as a rule, I try and avoid dogma and I try and avoid just sweeping statements of this is bad, this is good, and we we won't have this, we won't have that. I got asked by one of the residents who was training with me, and and he said, you know, he was telling me this story. He said, the other day I'm I'm driving down the road and we pass McDonald's, and my daughter's like, what is that place? Like, why don't we ever go there? And he said, and I got embarrassed because how do you tell your daughter, like, no, we just don't go there. I'm doing this obesity medicine rotation. And I thought, well, shoot, I I take my kids to McDonald's. And it's it's not, you know, it's it's not like McDonald's is is the wrong choice or any restaurant or any category of food. It's it's the choices you're making within it. And so things that I try and emphasize, it's very hard to go wrong with vegetables. It is like I don't know if you can overdo vegetables. You tend to get an upset stomach before you run into other problems. And so incorporating some of those into every meal is helpful. Um, trying to build in some protein, um, that makes such a difference when you're trying to stay full, when you're trying to maintain a growing body. It's important in puberty, but it's also important in in my adult patients when they are trying to maintain their strength with weight loss, is is to focus on getting some protein. And then you get into the other carbohydrates and things. And so I try and help people put it into an a very often, uh sometimes and a all-the-time category of eating.

Yeah, I really love that. I think patients thrive with categories because if you tell them to avoid or don't eat, it's usually their favorite foods or their comfort food. And immediately our human response is to crave that food that we are restricting. So I really love how you're kind of teaching that moderation. And my favorite thing that you do is you have an add-in approach. And I think that approach is much more sustainable, and that's really our ultimate goal.

Well, and it only works if they can do it. And I and I will tell people, I'll say the only plan that will work is the one that you can do for the rest of your life. And so if you cannot sustain this forever, then we need to reevaluate. And I'll I will also tell my patients this, but but I call it thoughtful indulgence. I'll say if there is something that you absolutely are craving right now, and you know it's not consistent with your long-term goals, ask yourself, what is the smallest amount I can eat and be satisfied? And is it worth it? If you're if you are starving, everything is going to be worth it. But if but if you you have the right amount of hunger and you just say, that just sounds good, then say, well, how little of a piece can I try and and then feel okay? And then you just eat it and move on.

So simple. I love how you teach that thoughtful indulgence. That's really, really smart because holidays happen. Uh, we need to celebrate birthdays, right? Cake is going to happen. So learning how to handle those foods when they do come up, but also giving yourself permission to enjoy them as well because it's just part of life. We use those foods as culture, celebration, comfort. And it's really important to learn how to incorporate them in a healthy way. So I am very curious to hear how do you define success in weight care with your patients? Are you looking for weight loss? Are you looking for a combination of things? And then how do you talk about this with your patients?

I use weight as one data point. It is an important data point in many of the patients that come and see me. But I use weight and waist circumference primarily to help guide. Uh BMI is is okay. If the BMI is this is for adults, and you can convert it to feeds for me. But if if the BMI is over 35, then almost invariably there's going to be excess fat adiposity. And so losing fat tissue is going to be a benefit. As that happens, the weight will decrease. And so there is some, yes, we're trying to lose weight. But the goal is fat loss and muscle preservation, lean tissue, organ, all of these other things that keep us alive. We want to preserve and keep healthy. So when I'm looking at how a person is doing, I look and I see what happened to the weight in between the appointments. And if there's a decrease and we started a medication, then I say, okay, that's great. My suspicion is that it is because of this. And I ask, I say, How are you eating? How are things going? Have you noticed your appetite has decreased? And if they say yes, it's been great. I've noticed all of these, these really challenging hunger cues that I had in the past have gotten a lot better. I think, okay, that fits. If they come in and they say, no, I haven't really noticed anything, but you know, the last week and a half I've been deathly ill and throwing up and I lost 15 pounds. I think, whoa, hold on a sec. That is not what we're going for. And so the context really matters. And I'm not just trying to see the scale go down. I want to see are these sustainable habits? Because I'm not just trying to hit some number that we pick out of the sky. I want to make sure that you are living a life that you can sustain and that you find meaningful.

I really love that you're not solely numbers focused. Maybe the patient's goal is weight loss, but maybe not. So, you know, the number on a scale is a singular data point that we can monitor. But there are so many other non-scale victories that I think should be the forefront of our minds and our patients' minds as well. Now, are there labs that you're looking at as well when someone is on a weight loss journey?

Absolutely. So, of all the vitamins that we have, vitamin D is the most commonly deficient in patients with obesity. Various theories for that, but it's important to measure. But we're also checking your insulin sensitivity, which is the what drives the diabetes. And so I check an A1C. If that comes back, and I'm still suspicious that we have insulin resistance, but the A1C didn't correlate, I'll go ahead and check fasting insulin levels. I check lipids. I want to see what, you know, what is the blood chemistry, the lipid profile showing us, your electrolytes, your liver function, your kidney function, and your thyroid as well. Because that can that can impact our metabolism and our ability to maintain, lose, or sometimes gain weight.

So can you walk us through how you have a conversation with a patient who is maybe questioning starting a weight loss medication? And how do you decide if this is the right choice for them?

Absolutely. So I I definitely approach it as a medical comorbidity, and I'm looking for the problem that we have a solution for. And there are increasing opportunities for these medications. They do wonderful things that we struggled with in the past. And so I'm I'm trying to find that fit. And if I don't find it, and someone is still looking for, you know, this will sometimes come up, but someone will have lost a significant amount of weight, they'll now be in a normal weight, and we won't have any metabolic comorbidities. And they'll say, but I I'm very hungry. Then we'll tell them, we'll say, that's how your body stays alive. And so this is something that is okay. It is okay to fill hunger cues and to eat. We've been following you for three, six months, and you have maintained your weight and your health. You're doing great. Just let your body do its thing. That's one way to have the conversation. The other, if someone's looking for a weight loss of 10 pounds for an event, it's really important to point out the side effects that come with this. These are long-term medications. And as we take them, almost 50% of people will have GI distress and they will not feel great at some point on, especially the GLP1 medications. And so we really want to weigh that out and say there's a reason that we would reach for this, and the risks must outweigh the benefits. And if and if the benefit is is a small and marginal gain for for some social event, that's probably not worth the risk. So that that would be how I would approach those conversations in that social context.

I think that's really helpful. Dr. Reese, I'd also love to hear how you approach the question about compounding weight loss medications, especially GLP ones, which used to fill the gap when we had a shortage. So I'm just curious your thoughts on that.

Yeah, so a little bit of a history lesson and policy will be helpful, but compounding is approved by the FDA during periods of shortage. And we had significant shortages when Wigovi, which is semaglutide, and trzepatide were first released. It came out dramatic results. Everyone was desperate to get on them, and for good reason. And the demand very quickly outpaced the production. And so compounding became an approved and an open opportunity for that. And that's where a lot of people went. What has since happened is the shortages have ended, but compounding remains a very prevalent option. And so people are still using it. And the reason they're able to use it is that enforcement has not begun. And so that's and that's just kind of where things are. If you are compounding, a few things to be aware of is one is that you are getting different oversight than the FDA approved for the studied medication. You are getting it instead of on the FDA national, international level, you are getting it at the level of the state. And it's more specific to the location where it is compounded. There are often additional ingredients that are added to meet the criteria of a of like a copy formulation, where it's it's not quite the medication, but it's very similar. And so you have to be aware what are the other things being added? You know, do I have a vitamin B12 deficiency really? Because that's what a lot of people are adding. And if you don't, then why would you need additional B12? And so uh I I approach that one cautiously. I know a lot of people who are who are doing it and I know the motivations for it, but I do think that there is a regulatory piece. Doesn't mean there aren't quality ways to do it, but it's just you have to be very careful and know what you're stepping into.

Yeah, thank you for that thoughtful answer. And I agree. And you know, maybe in a year, five years, we might have a totally different conversation about compounding weight loss medications. Who knows? But, you know, we want to practice evidence-based medicine. And for now, I agree with you the safest medications are going to be the FDA approved ones. All right, I want to talk about something that I am seeing a lot on social media, and your patients are probably coming in concerned about their cortisol or blaming their hormones for their weight gain. So, how do you educate or talk to your patients about hormones in general and their impact on weight?

It's such a good question. I realize when when I tell someone that obesity affects your hormones and that we can see that as a disease state, I am thinking about leptin, ghrelin, neuropeptide. Y why. I am thinking about hormones within the digestive tract. And I realize that when I say hormones, people are thinking reproductive, thyroid, and we're just we're having a different conversation. So what do we know about cortisol? One is that cortisol is a hormone released during periods of stress. And it's important for our daily function. When it is released, think in the evidence that you're trying to escape a claw, chemical or claw for kind of these sympathetic responses. If you're being chased by something dangerous or you're trying to go capture some food, you need that surge of energy. And so with the cortisol, you will have a slight insulin resistance just so that you can more fully pull the energy out and not accidentally put it back into the cells. And so when we do are stressed, we do see some insulin resistance comes in small amounts. So the theory is that being stressed and overwhelmed at all times is raising the level of our insulin resistance, promoting that visceral fat deposit in things. I think there is something there, but I also think that there's there's a place for cortisol as well. When we exercise, we see an increase in our cortisol. We are not trying to reduce the cortisol that comes from exercise. We want our body to experience some of that increase in stress and increase in inflammation because that's how it heals. That's how it responds and does better. And so, as a rule, I think that the same good lifestyle hygiene habits still apply in the context of cortisol. We still want to get a good night's sleep. That reduces our cortisol levels the next day. We want to get meaningful exercise. I sometimes view exercise as burning off excess adrenaline. We want to let our body experience something close to fatigue because that's gonna help. We want to manage our our mood and try and stay on top of those tasks. And you and I, we we take on probably more than we need to, but it's to try and and help manage those things and and keep yourself mentally in in a spot of I I can do this. And so that's without answering your question, that's kind of how I approach cortisol. And I don't know if any of that landed with No, no, it did.

And you know, I think social media tries to just oversimplify it. And people who are selling products to fix your hormones or balance your hormones, I think are very predatorial and are again oversimplifying a very complex hormone that is beneficial to our bodies. So really, we don't need to be afraid of it. So I appreciate your answer on that. Now, speaking about social media, I would love to hear your least favorite trend that you're seeing on social media right now.

Oh my goodness, my least favorite trend. I I would have to say that the peptides, and and there's so much people get so excited about these peptides. And and back in February, the you know, RFK, who's in charge of the Department of Health and Human Services, he took these 19 peptides that had been put in this not safe for human use, and he grabbed 14 of them and said, We're gonna bring them back and we're gonna we're gonna see what we're missing. And and so overnight, these peptides became available. And the evidence didn't catch up overnight. Nothing really changed to take it from we're we have concerns to we don't have concerns, but they're now available. And so people are asking and they're saying, what do we do with these peptides? Where can I go to find someone who's who's knowledgeable about and can recommend and can provide quality evidence about it? And there's this distrust of doctors and other prescribers because they don't know about the peptides. And I always, you know, I just want to pull my hair out and say, it's because no one studied them. We don't know enough about the peptides because we don't have rigorous studies to support it. There could be something there. We just don't right now have the evidence.

I I kind of can't believe that you went there with peptides because it's such a big topic. It's controversial. And honestly, most of my colleagues, people who follow the evidence, do not support or prescribe them because of those exact reasons. As of the date of this recording, we do not have human studies on safety and efficacy. So by our laws and medicine, really we cannot safely prescribe them. So I love that you brought up peptides. So thank you for that. And again, maybe in five, 10 years, we're gonna be saying something else, but we need the evidence to support it first.

I'm I'm happy to be wrong. I'm happy to change my mind and my stance. I have done that so many times in my career on nutrition topics and other personal practices and how I approach different conditions. It's always evolving, always changing. I'm happy to be wrong, but as the evidence is today, that's where I stand.

So, Dr. Reese, you've got a really wonderful social media presence talking about your new role as a physician with the lifestyle and obesity medicine department at the Tanner Clinic. So I would love for you to share a little bit about what you do there. And if people are looking to connect with you or just want to have good content to follow online, where can they find you?

Yes, so I'm Dr. Reese Checkets. I'm on Instagram and Facebook. Those are my largest platforms. I try and dispel some of the myths around weight loss. As part of this passion, I did create a guide. And people can purchase this and they can go through and they can have everything that I try and provide to patients about how these medications work, how our body loses weight, why it's difficult to maintain weight loss and what you can do about it, as well as how to advocate for yourself, how to take your questions and your concerns back to your provider and have a meaningful and a productive conversation with them. So we're we're very excited about it. Um, the the gap that we're trying to fill is that primary care providers are very busy and they have a lot on their plate. And when patients come and see them, they have different things they want to address. And sometimes if they have knee pain and a sore throat, it's very difficult to get into a dietary recall. And so we're hoping that by building this department that we can help kind of alleviate some of that for these other providers. And we're here to support and to provide these resources to your patients at a level you might not have the time or knowledge of how to do.

Thank you so much for creating that resource. It sounds like a wonderful guide and something that could be helpful for us as clinicians, but also for our patients. So definitely check that out. I will link down to it in the show notes. And please show some support for clinicians like Dr. Reese creating content online. Be sure to give him a follow. Dr. Reese, thank you so much for the gift of your time today. This was so fun talking to you. We barely scratched the surface of obesity medicine, and I would be happy to have you on again to talk about future topics.

I would love that. Thank you so much. This has been amazing, Colleen. Thank you.

And thank you guys for carving out some time for nutrition today. I will see you next week.