Podcasts about bmis

In this compelling episode of Parallax, Dr Ankur Kalra explores South Asian cardiovascular health with preventive cardiology experts, Dr Jaideep Patel from Johns Hopkins, and Dr Romit Bhattacharya from Massachusetts General Hospital. The conversation begins with both specialists sharing personal motivations behind their focus on South Asian heart health, from family losses to scientific curiosity about potential genetic and metabolic distinctions. They examine whether South Asians truly face different cardiovascular risks - discussing observations of earlier disease onset, unique lipid patterns, and metabolic dysfunction at lower BMIs - while emphasizing that fundamental prevention strategies remain effective across populations. The episode culminates with powerful closing insights on prevention as an investment—how small, consistent lifestyle modifications can prevent cardiovascular disease onset even in those with genetic predispositions, ultimately enabling fuller, more functional lives in later years. Questions and comments can be sent to "podcast@radcliffe-group.com" and may be answered by Ankur in the next episode. Host: @AnkurKalraMD and produced by: @RadcliffeCARDIO

In this episode of Better Edge, Christina E. Boots, MD, MSCI, associate professor of Reproductive Endocrinology and Infertility at Northwestern Medicine, discusses the impact of obesity on reproductive outcomes and the promising role of GLP-1 agonists in treating obesity and infertility. Discover how these groundbreaking medications are reshaping reproductive health, offering hope for patients with higher BMIs. Learn about the latest insights and clinical considerations for their use in preconception care plans.

This week on Diving in Deep, Sara Evans reunites with renowned songwriter, Marcus Hummon! The two of them look back on what it was like to write some of Sara's hit songs like "Born To Fly." Marcus also dives into his newest personal project of transcribing Emily Dickinson poems into an EP he released back in November. They both open up about the vulnerability of songwriting, writing together for the first time, and what it means to white trash dance. Tune into this week's episode to get the inside scoop on Sara's songs!Listen to Unbroke: (https://ffm.to/seunbroke)About Marcus Hummon:Grammy winner and two-time NSAI Songwriter's Hall of Fame nominee, Marcus Hummon has enjoyed a successful career as a songwriter, recording artist, composer, playwright, and author. His songs span many genres, including pop, R&B, gospel, and most notably, country. Several of his songs have been nominated for Grammys, ACMs, CMAs, and BMIs, and in 2005, his song ‘Bless The Broken Road' won the Grammy for ‘Best Country Song' in both 2005 and 2007. In the realm of theatre, Hummon has written 6 musicals and an opera featured in various festivals and winning multiple awards. He released his new single, “I Never Saw A Moor,” on October 18th of this year for his highly-anticipated Emily Dickinson-inspired EP, Songs For Emily. Stream it wherever you listen to music now!LET'S BE SOCIAL:Follow Marcus Hummon:Instagram – ( @marcushummon)Tiktok – (@marcushummonsongwriter)Twitter/X – (@marcushummon)Facebook – (@marcus.hummon)Website – https://www.marcushummon.netFollow Diving in Deep Podcast:Instagram –(@divingindeeppod)TikTok – (@divingindeeppod)Twitter – (@divingindeeppod)Facebook – (@divingindeeppod)Follow Sara Evans: Instagram – (@saraevansmusic)TikTok – (@saraevansmusic)Twitter – (@saraevansmusic)Facebook – (@saraevansmusic)Produced and Edited by: The Cast Collective (Nashville, TN)YouTube – (‪@TheCastCollective‬)Instagram – (@TheCastCollective)Twitter – (@TheCastCollective)Directed by: Erin DuganEdited By: Sean Dugan, Corey Williams, & Michaela Dolph

Learn more about becoming an Insider: https://www.benbikman.comThis week, Dr. Bikman's lecture focuses on metabolic surgeries (also called bariatric surgeries), their mechanisms, and their impacts on weight loss and metabolic health.Ben begins by explaining the qualifications for these surgeries, which often serve as a last resort for individuals with severe obesity or comorbidities like type 2 diabetes. Common qualifications include a BMI of 40 or higher, or lower BMIs with conditions like hypertension or diabetes. These surgeries aim to address obesity and related health complications when traditional methods, like diet and exercise, fail.Dr. Bikman describes four primary types of metabolic surgeries: Roux-en-Y gastric bypass, sleeve gastrectomy, biliopancreatic diversion with duodenal switch, and adjustable gastric banding. He explains their procedures, including how they alter digestion, absorption, and stomach size, leading to weight loss through restriction and malabsorption. These surgeries also bring significant hormonal changes, such as increases in GLP-1 and reductions in ghrelin (hunger hormone), contributing to satiety and metabolic improvements.While these surgeries can dramatically improve insulin sensitivity, reduce glucagon levels, and improve conditions like type 2 diabetes, they come with risks. Nutrient deficiencies, surgical complications, dumping syndrome, and weight regain are significant concerns. Younger patients are particularly prone to weight regain, especially if they don't adopt sustainable eating habits. Dr. Bikman emphasizes the need for education on managing macronutrients and maintaining long-term behavioral changes.Ben concludes that metabolic surgeries can be a valuable tool for those with severe obesity and related complications. However, he warns of their limitations and advocates for coupling them with lifestyle changes to optimize long-term success.Show Notes/References:For complete show notes and references referred to in this episode, we invite you to become a Ben Bikman Insider subscriber. As a subscriber, you'll enjoy real-time, livestream Metabolic Classroom access which includes live Q&A with Ben, ad-free Metabolic Classroom Podcast episodes, show notes and references, Ben's Research Reviews Podcast, and a searchable archive that includes all Metabolic Classroom episodes and Research Reviews. Learn more about becoming an Insider on our website: https://www.benbikman.com Hosted on Acast. See acast.com/privacy for more information.

On this episode of sMater, we discuss obesity in pregnancy with Dr Jinwen He, an obstetric medicine fellow at Mater Mothers' Hospital.Jin provides advice on treating pregnant patients who are overweight or obese, and explores the increased risks during conception, pregnancy and the post-partum period for women with high BMIs. She also delves into the impacts of bariatric surgery on women who are trying to conceive as well as the risks associated with Ozempic and other weight loss remedies.Resources: Guideline: Obesity and pregnancy (including post bariatric surgery)To learn more about Mater, visit https://www.mater.org.au/

What is next for BMISn Ladies and gentleman I will be bringing you a lot of episodes every Monday regarding a lot of the different things that I see that's going on in our communityAnd the things that are relevant to black women and men in Urban Nation so stay tuned every Monday. Your boy is back, I'm here to set them free. #BMIS --- Support this podcast: https://podcasters.spotify.com/pod/show/bmis/support

What's the most significant impact you can make with your career—medicine or engineering? For Sarah Kim Wandelt, PhD, this question has a personal twist! While Sarah originally set out to become a medical doctor, her career led her to the fascinating world of neuroengineering and neurotechnologies. Meanwhile, her twin sister, who had dreamed of being an engineer, is now a medical doctor. So, how did they end up switching roles, and what insights can Sarah share with aspiring professionals in neuroscience and neurotechnology? In this episode of Neurocareers: Doing the Impossible!, your Podcast Host, Dr. Milena Korostenskaja from the Institute of Neuroapproaches, interviews Dr. Sarah Wandelt on her exciting journey, from her groundbreaking work on Speech Brain–Machine Interfaces (BMIs) to her cutting-edge research on decoding internal speech signals. As a Neural Engineer at the Feinstein Institutes and a former Postdoctoral Scholar at Caltech, Sarah has been at the forefront of developing technologies that translate brain signals into speech—offering life-changing solutions for people who have lost their ability to communicate. Her publication, "Representation of internal speech by single neurons in the human supramarginal gyrus" in Nature Human Behaviour, showcases how decoding internal speech is not just a possibility but a reality. Sarah will share insights into how Brain–Machine Interfaces can decode internal speech and how her work is opening up new frontiers in neurotechnology. Curious how a career in neuroengineering can impact lives? Or how decoding the brain's inner voice is revolutionizing communication? Tune in to this episode as Sarah shares her journey, career advice, and her fascinating work in speech BMIs. Get ready for an inspiring conversation about innovation, neurotechnology, and building a career that makes a difference! About the Podcast Guest: Dr. Sarah Wandelt is a researcher specializing in Neuroprosthetics, focusing on developing technologies to restore motor and sensory function for individuals with spinal cord injuries. Her academic path began at École Polytechnique Fédérale de Lausanne, where she pursued a Master's degree in Bioengineering with a minor in Neuroprosthetics, gaining experience in non-invasive EEG and EMG devices. This foundation led to her PhD at the California Institute of Technology, where she explored the representation of grasp and speech signals in brain recordings of participants affected by spinal cord injury under the mentorship of Professor Richard Andersen. Her work involved decoding internal speech from multielectrode unit recordings from the posterior parietal cortex, earning her the Dr. Nagendranath Reddy Biological Sciences Thesis prize. Currently, as a Neural Engineer in Professor Chad Bouton's lab at the Feinstein Institutes for Medical Research, she aims to restore function and sensation in participants with spinal cord injury.     Get in touch with Sarah Wandelt, PhD: Social Media: @sarah_wandelt on X LinkedIn: Sarah Kim Wandelt https://www.linkedin.com/in/sarah-kim-wandelt-25a509b3/   Link to Representation of internal speech by single neurons in human supramarginal gyrus: https://www.nature.com/articles/s41562-024-01867-y/metrics Data and code availability: https://zenodo.org/records/10697024   Link to Decoding grasp and speech signals from the cortical grasp circuit in a tetraplegic human: https://www.sciencedirect.com/science/article/pii/S0896627322002458 Code availability: https://zenodo.org/records/6330179 Data availability: https://zenodo.org/records/7618556

Outrageous windfalls for BigPharma, healthcare CEOs create spiraling medical costs; Microbiome connections to atrial fibrillation, atherosclerosis; FDA fast tracks epi nasal spray for severe allergic reactions; Majority of Americans consume inflammatory diet; Ultra-processed foods linked to gall stone disease, soaring childhood BMIs; Lawsuits over increased fracture risk from Fosamax; Natural solutions for gas/bloating; Benefits of resistance exercise for anxiety/depression; Weekend warriors may garner nearly as much disease protection as regular exercisers.

A trip to the doctor to get a physical resulted in Jake being called fat. We use a BMI calculator to determine our listener's BMIs and we break down why most people who lean to the right politically tend to also be disciplined when it comes to the gym and their health.  Also on the show, we react to President Biden's appearance on The View and we list off the names that shouldn't belong on the Rock & Roll Hall of Fame. See omnystudio.com/listener for privacy information.

This week, the Steelers' battle over QB1 has officially been settled by Coach Tomlin in a decision that most fans saw coming since March. But that's not stopping some in the media from feeling 'bamboozled.' The offensive line is covered in question marks, but there are fans who think they have all the answers. The receivers room is set (for now?), and the hater verdict is in: Is this the worst Steelers wide-outs in 20 years or all-time? There are some who want to give Nick Herbig a promotion at the expense of a Pro Bowler. We'll figure out where he rates on a scale of Tuzar to TJ. The 53-man roster is here, but we still can't find some Special Teamers. Plus, the quarterbacks with the biggest BMIs and where Russ ranks. And, why Vegas is rooting against the Steelers. What Yinz Talkin' Bout is the conversation about the Steelers social media conversation, exposing the week's hot and toxic takes. Hosted by Kyle Chrise and Greg Benevent. Listen to "Steelers Songs Vol 1" on your favorite streaming services. Write an iTunes review to enter our next giveaway!

Send us a Text Message.Join us as we welcome Dr. Halaharvi , a fellowship-trained, board-certified breast surgeon who faced her own breast cancer journey just 8 months after completing her fellowship. Her unique perspective of experiencing both sides of the diagnosis has profoundly influenced her approach to patient care. She reflects on her immigrant upbringing, the strong work ethic instilled by her parents, and how her personal battle with cancer reshaped her mission and dedication to the breast cancer community.Dr. Halaharvi shares her story, emphasizing the importance of listening to one's body and the critical role of early detection. Her journey in selecting a surgeon underscores the value of compassionate care, effective communication, and second opinions. As a surgeon-turned-patient, she delves into how her personal experience has deepened her empathy and commitment to providing holistic, patient-centered care and maintaining strong patient-doctor relationships.Discover the latest in breast reconstruction options, tailored for women with high BMIs, smokers, diabetics, and others who might not be suited for traditional methods. Dr. Halaharvi discusses an innovative, one-stage surgery, called the "Goldilocks" method, designed to offer equitable care, especially for Medicaid patients. Breast Doctor on TikTok Dr. Halaharvi The Breast Cancer Podcast on Instagram Dr. Halaharvi's Website Dr. Halaharvi on YouTube Dr. Deepa Halaharvi on Facebook Dr. Halaharvi's Favorite Resources:BreastCancer.org National Comprehensive Cancer Network Guidelines Breast 360 - Engage/Educate/Empower  Are you loving the Test Those Breasts! Podcast? You can show your support by donating to the Test Those Breasts Nonprofit @ https://testthosebreasts.org/donate/ Where to find Jamie:Instagram LinkedIn TikTok Test Those Breasts Facebook Group LinkTree Jamie Vaughn in the News! Thanks for listening! I would appreciate your rating and review where you listen to podcasts!I am not a doctor and not all information in this podcast comes from qualified healthcare providers, therefore may not constitute medical advice. For personalized medical advice, you should reach out to one of the qualified healthcare providers interviewed on this podcast and/or seek medical advice from your own providers .

You've seen the Olympics, but have you seen the discourse around if Olympians are healthy? In today's episode we discuss this, including, Olympians food choices, BMIs, and body size this and what it says about health. Mentioned: Ilona Maher's Instagram Let's connect: Mallory's Instagram Book a Free Discovery Call Live Unrestricted - My signature program The Body Love Club Community Submit Podcast Requests Free Resources: Sign up for the BFFS with food masterclass by clicking here. Sign up for the Unconditional Body Acceptance masterclass by clicking here

Direct oral anticoagulants (DOACs) are the standard of care for stroke prevention in most patients with nonvalvular atrial fibrillation (NVAF). Data on the safety and efficacy of DOACS in patients with obesity are limited and, at times, contradictory.  What would you recommend for a patient with a BMI>40: warfarin, which requires periodic monitoring and dose adjustments, or a DOAC, which may not be as effective? Guest Authors: Taylor M. Benavides, PharmD, BCPS and Elizabeth B. Hearn, PharmD, BCACP Music by Good Talk

Welcome back to another episode of The Lex and Lux Podcast! This week, we're diving into the crucial topic of dating safely. Join Lexi and Brian as they share personal anecdotes, discuss online dating safety tips, and offer advice on how to navigate the unpredictable world of first dates. Lexi shares her preference for dating men with low BMIs, while Brian talks about his experiences getting back on dating apps. They also touch on the importance of having a trusted friend know your location and how to exit a date if you feel uncomfortable.00:00

In this episode of the Physical Activity Researcher Podcast, host Dr. Olli Tikkanen continues his engaging conversation with Dr. Elise Brown, Associate Professor of Wellness and Health Promotion at Oakland University. Dr. Brown delves into the practical aspects of prescribing resistance training for individuals with type 2 diabetes, providing invaluable insights for both researchers and practitioners. Dr. Brown emphasizes the importance of proper warm-up and cool-down routines, particularly given the musculoskeletal and cardiovascular risks associated with diabetes. She highlights the necessity of starting slowly and gradually increasing exercise intensity, tailoring programs to accommodate the reduced exercise tolerance commonly observed in individuals with type 2 diabetes. She also discusses the need for modifying exercises for those with neuropathy or higher BMIs, ensuring both safety and effectiveness. Addressing common misconceptions, Dr. Brown suggests varying rep ranges and intensities to maintain interest and effectiveness in training programs. She advocates for prioritizing multi-joint movements over single-joint exercises to maximize time efficiency and overall benefits. Additionally, she underscores the importance of developing mastery and confidence in specific exercises to enhance adherence to resistance training programs. Dr. Brown also explores the barriers faced by individuals with type 2 diabetes, including environmental and psychological challenges. She shares her personal experience of virtually training her father, adapting exercises to accommodate his arthritis and other comorbidities. Her approach emphasizes making the exercise experience enjoyable and motivating, highlighting the quick feedback loop that strength training provides. Overall, this episode offers a wealth of practical advice and scientific insights into the prescription of resistance training for diabetes management, making it a must-listen for professionals in the field. ________________________________ This podcast episode is sponsored by Fibion Inc. | Better Sleep, Sedentary Behaviour, and Physical Activity Research with Less Hassle. --- Collect, store, and manage SB and PA data easily and remotely - Discover ground-breaking Fibion SENS. --- SB and PA measurements, analysis, and feedback made easy.  Learn more about Fibion Research. --- Learn more about Fibion Sleep and Fibion Circadian Rhythm Solutions. --- Fibion Kids - Activity tracking designed for children. --- Collect self-report physical activity data easily and cost-effectively with Mimove. --- Explore our Wearables,  Experience sampling method (ESM), Sleep,  Heart rate variability (HRV), Sedentary Behavior and Physical Activity article collections for insights on related articles. --- Refer to our article "Physical Activity and Sedentary Behavior Measurements" for an exploration of active and sedentary lifestyle assessment methods. --- Learn about actigraphy in our guide: Exploring Actigraphy in Scientific Research: A Comprehensive Guide. --- Gain foundational ESM insights with "Introduction to Experience Sampling Method (ESM)" for a comprehensive overview. --- Explore accelerometer use in health research with our article "Measuring Physical Activity and Sedentary Behavior with Accelerometers". --- For an introduction to the fundamental aspects of HRV, consider revisiting our Ultimate Guide to Heart Rate Variability. --- Follow the podcast on Twitter https://twitter.com/PA_Researcher Follow host Dr Olli Tikkanen on Twitter https://twitter.com/ollitikkanen Follow Fibion on Twitter https://twitter.com/fibion https://www.youtube.com/@PA_Researcher

Join Dr. Emily Cooper, Andrea Taylor, and Mark Wright on Fat Science for an engaging conversation on "How Much Body Fat is Too Much?" The hosts explore societal pressures and health concerns, and Dr. Cooper dissects the limitations of BMI as a health measure. Andrea Taylor discusses media-driven body image issues, while Dr. Cooper explains the importance of lean mass and demonstrates why higher BMIs can sometimes be healthier for older adults.  Key Discussion Points:  The flaws in BMI and why it's not a reliable gauge of health.  How medications like Mounjaro and Ozempic impact fat burning. The evolutionary benefits and essential functions of body fat.  Resources from the episode: Learn more about Fat Science here. Connect with Dr. Emily Cooper on LinkedIn.  Connect with Andrea Taylor on LinkedIn. Connect with Mark Wright on LinkedIn.   Fat Science is a podcast on a mission to explain where our fat really comes from and why it won't go (and stay!) away. In each episode, we share little-known facts and personal experiences to dispel misconceptions, reduce stigma, and instill hope. Fat Science is committed to creating a world where people are empowered with accurate information about metabolism and recognize that fat isn't a failure. This podcast is for informational purposes only and is not intended to replace professional medical advice.  If you have a show idea, feedback, or just want to connect, email Mark Wright at mark@beatsworking.show.  --- Send in a voice message: https://podcasters.spotify.com/pod/show/fatscience/message

Dr. Allison Zibelli and Dr. Megan Kruse discuss the potential benefit of endocrine therapy in ER-low breast cancer; the efficacy and tolerability of triplet therapy in PIK3CA-mutated, HER2-negative locally advanced or metastatic breast cancer; and more key research that will be featured at the 2024 ASCO Annual Meeting.  TRANSCRIPT Dr. Allison Zibelli: Hello, I'm Dr. Allison Zibelli, your guest host of the ASCO Daily News Podcast today. I am an associate professor of medicine and a breast medical oncologist at the Sidney Kimmel Cancer Center of Jefferson Health in Philadelphia. My guest today is Dr. Megan Kruse, a breast medical oncologist and director of breast cancer research at the Cleveland Clinic Taussig Cancer Institute. We'll be discussing key abstracts in breast cancer that will be featured at the 2024 ASCO Annual Meeting.  Our full disclosures are available in the transcript of this episode, and disclosures related to all episodes of the podcast are available at asco.org/DNpod.  Megan, it's great to have you back on the podcast. Dr. Megan Kruse: Thanks, Alison. Happy to be here. Dr. Allison Zibelli: So, let's begin with Abstract 505. This was another analysis of the SWOG S1007 (RxPONDER) trial, which was the trial that was looking at premenopausal women with intermediate risk oncotype scores. And do they benefit from chemotherapy? If you analyze the whole group, they do benefit from chemotherapy, but what this study questions is whether we can pull out the subset of these patients that actually benefit from chemotherapy? And what they tried doing was measuring various endocrine reproductive hormones and found that anti-mullerian hormone over 10 was the only one that predicted for chemotherapy benefit. What are your key takeaways from this study? Will it help us figure out who is truly postmenopausal biochemically? Dr. Megan Kruse: I think this is really promising. This is one of the toughest situations in clinic, honestly, when you have a premenopausal woman who has an intermediate oncotype risk. We know that chemotherapy is not going to make a huge difference potentially in their breast cancer outcomes, but it may add to some small differential benefit. I think that many of our patients are really afraid about leaving any impactful therapy on the table. And so, it'd be nice to have another marker to help sort out who in this group will really benefit. And the AMH levels, I think, are something that are very accessible for most practices, easily orderable. And it seems like this cutoff of 10 is a very well-known cut point in the AMH interpretation, and a pretty clear-cut point. So, I think it gives a little bit more objective view of who may actually benefit or not.  When you look at the results shown in this abstract, for the women in the recurrence score less than 25 receiving chemotherapy followed by endocrine therapy, they had a benefit in five-year invasive disease-free survival of 7.8%. When you look at those oncotype reports and they suggest how much benefit you might get, that's right around the same number you see. So, I think that's supporting that this is the subgroup that's benefiting.  When you look at those patients with AMH less than 10, they actually had a negative 1.7% difference in overall survival. So, you wonder, are we harming these patients by giving them chemotherapy? I think that's too far of a stretch to say. I wouldn't be worried about harm. But hopefully, we can stop giving chemotherapy to patients who truly are not going to benefit if we have an additional biomarker of response. That's what the promise is for this.  So again, another potentially actionable abstract that we can put into practice pretty quickly. It's going to be hard to know how to use this, also in the context of the upcoming OFSET study or BR009, which is of course the study in the same group of premenopausal patients with node-negative or 1-3 lymph nodes involved, and intermediate oncotype scores, randomizing them to endocrine therapy with ovarian suppression versus chemoendocrine therapy. It would be kind of nice to see the AMH levels incorporated into that model to see if the same trend holds true. But I think we go back to the TAILORx and RxPONDER studies many times as good quality data, and the trend here is really striking.  Dr. Allison Zibelli: I really like this study because one of the things I often struggle with in the clinic as a practicing breast oncologist is who's really in menopause. And we end up having these fights with the gynecologists where sometimes our opinions differ. And it would be really nice to have something this clear cut to say, “You're in biochemical menopause or you're not.” So, I look forward to seeing this used in a lot of different ways in the future.  Dr. Megan Kruse: Yeah, I agree. And I think it's based on the other markers we have with estrogen levels, with FSH levels. If you're checking those sequentially in patients, we know they go up and down, and it's really hard to tell what we are capturing at this single point in time. And maybe that's what we're seeing in this analysis is that the AMH is a little bit more stable and reliable marker. So, I really love that. And I don't know about you, but in clinical practice it can be really hard. A lot of our patients have had uterine ablations or hysterectomies but have intact ovaries. And so, figuring out ovarian function status is actually much, much harder than it may seem superficially.  Dr. Allison Zibelli: Okay, so let's focus on Abstract 513. I thought this was really interesting. It's a group of patients that we don't have much data for, and that's women that are ER-low, with an ER of 1% to 10% in early-stage breast cancer. Right now, national guidelines are sort of on the fence about whether these women benefit from endocrine therapy. So that's what this study tried to focus on. How will this study change how we approach this group of patients? Dr. Megan Kruse: This study really gave me pause and made me rethink what I'm doing on a day-to-day basis, because here, what the authors found in a very large NCDB analysis was that for women with ER-low status, so ER 1% to 10% positive, they actually did have benefit receiving endocrine therapy, it seems. What they found, after you adjust for many other confounding factors like age, comorbidity, and PR status, is that patients with ER-low breast cancer when they did not receive endocrine therapy actually had worse overall survival outcomes with a hazard ratio of around 1.2 to 1.3.  This is a group where I have typically not pushed endocrine therapy very strongly. I think the patients, especially now, are receiving such intense therapy with chemoimmunotherapy in the preoperative setting, by the time they reach their adjuvant phase with immunotherapy, maybe with capecitabine, maybe with a PARP inhibitor, endocrine therapy seems, “Oh, why bother after we've done all of this?” And we know that the toxicities of endocrine therapy are real and can be very problematic. And so, I have often felt like it's the least important part of therapy and questioned whether we should even bother. But I think this analysis really challenges that and makes us think twice. And I think it speaks to a theme that we're seeing more and more about the heterogeneity of these breast cancer subtypes. And again, talking about clear-cut points in analysis, nothing is truly black and white. So maybe that little bit of expression does mean something.   It does kind of stand in contrast to what we see in studies of ER-low behaving a bit more triple-negative like, but maybe they're their own category, and maybe it gives us a place to look for other therapy synergy in the future. But it certainly will make me stop and think again when I see a ER 4% patient. Should I talk to them about endocrine therapy?  Dr. Allison Zibelli: Yeah, I totally agree with everything you said there. And we know that this is a biologically different group of patients than the ER strongly positive group, but maybe not as different as we once thought. Dr. Megan Kruse: Yeah. And I think there's still a lot of unknowns here about what if they're ER truly negative and PR a little bit positive. So, these clinical situations don't come up that frequently, but when they do, they're humbling, because I think we really, as much data as we have in breast cancer, it's pretty limited for these types of patients.  Dr. Allison Zibelli: So, let's move on to Abstract 1003, which was a new combination in the INAVO120 trial. It was palbociclib plus fulvestrant with either inavolisib or placebo in patients with PIK3CA-mutated hormone receptor-positive, HER2-negative, locally advanced metastatic breast cancer in the second line, who relapsed within 12 months of adjuvant endocrine therapy completion. This is a big group of patients for us. Can you tell us about the study? And does this triple therapy, in your mind, represent a new standard of care? Dr. Megan Kruse: Yeah, this study was initially presented at our 2023 San Antonio Breast Cancer Symposium, and there I felt like it was a little bit of a surprise. There's been so much talk about PI3K-AKT-PTEN pathway impactful drugs and targetable mutations. We've heard a lot about alpelisib and capivasertib, and how these drugs are fitting into our practice. Then all of a sudden, we have this data with inavolisib that I wasn't really expecting to see. And perhaps I think one of the reasons that this study came about so suddenly, seemingly, and so quickly is because it looks at a really high-risk patient population. And so, these are those patients that are having relapses of their breast cancer within their initial, while on adjuvant AI therapy or within 12 months of stopping. And so, having a marker of this patient group that is developing, I think, early endocrine resistance and it's another space where it's kind of hard to identify who these patients are upfront. And so their response to therapy tends to be one of the best markers of risk moving forward.   So, when this trial was originally presented, what was quite striking is that the progression-free survival was more than doubled for the triplet combination compared to the control arm. And those numbers were PFS of 15 months versus 7.3 months for the triplet versus the control. The response rate was also significantly improved, with the triplet going above 50%, versus a response rate in the control of about 25%. So, the results were really striking. But they clearly come with some caveats, which are that this is a very defined patient population of risk. Of course, they have to have the biomarker of a PIK3CA mutation, and in the control arm here, there was no PIK3-targeted medication. And so you wonder, are we just getting better results by including that more specific targeted therapy earlier on? It's hard to know, but I think that could certainly be a big part of this.  And the other caveat, when I'm looking at the data, is how might we think about this in our real population? Because as we know, drugs that impact this pathway tend to have a lot of toxicity concerns, primarily hyperglycemia, diarrhea, and rash. And with this particular agent, there was also notable stomatitis, which is something we've seen with everolimus, of course, in this pathway, but not maybe as much with alpelisib and capivasertib. When you're thinking about all of those toxicities, keep in mind that this trial population included patients with a pretty tight fasting blood sugar requirement, A1c of less than 8, and not requiring insulin. So all of that being said, I think this combination seems really intriguing for efficacy. This is a patient population I'm worried about, because we know that these patients are likely not going to get the same upfront benefit of CDK4/6 inhibitor-based therapy, like maybe we see for a patient with long disease-free survival or de novo metastatic breast cancer. But I think it's going to have some meaningful issues in clinic regarding tolerability. And then, of course, the regimen is more complex. We're talking about two different oral agents and an intramuscular injection, which could be hard for some patients, and it's going to have some decent financial toxicity associated with it.  So, I think it's really, really exciting and has the potential to make an impact in first-line therapy. But I don't envision it being the standard of care first-line therapy for everyone, particularly in light of some of the other data we have in the first line questioning, like from the SONIA trial, how important is CDK for everyone? Again, this is I think where we're starting to get subsets within subsets of this first-line patient population of who needs escalation of therapy and who may benefit from more de-intensified therapy. Dr. Allison Zibelli: I agree, these agents have significant toxicity, and especially financial toxicity is something that we at the academic setting frequently forget about because a lot of our patients are on trials. So, it will be interesting to figure out how we're going to use these agents in real life.  So, for our final abstract, I wanted to discuss Abstract 10508, which was a prevention trial. I think pretty much everybody's patients are going to be asking them about this because it's about GLP-1 inhibitors. We know that bariatric surgery does prevent obesity-associated cancers. This study explored whether the GLP-1 agonists could offer a similar result to bariatric surgery in patients with BMIs over 35. What do you think about this study?  Dr. Megan Kruse: I thought this was such an interesting and timely study and question. These drugs are out there – Ozempic, Mounjaros, and Wegovy – and our patients ask about them. And I think there has been a lot of interest for years now about the impact of lifestyle factors on cancer incidence, particularly in breast cancer, where we know that obesity does seem to be related to cancer incidence. And with all of our concerns about hormonal exposure and extra weight, extra adipose tissue being a source of potential extra estrogen, this is a really key topic.   Talking about financial toxicity, again, I think that is honestly probably the bigger hurdle because this study does reinforce that patients who are receiving GLP-1 receptor antagonists and those who have had bariatric surgery do benefit in terms of cancer-related survival and all-cause related survival. So, I think the impact on metabolic factors is making a difference in cancer incidence and outcomes. But access and equity will be the big issue here, right? Dr. Allison Zibelli: Yes. Dr. Megan Kruse: Can we get patients on these drugs? I certainly have had patients with a history of breast cancer who have been on these medications, and they have done great with them in terms of weight loss. We know that our therapies, many times, do have the side effect of weight gain. So, I wonder if there is a part of weight management that maybe we haven't talked about so much as oncologists that we need to talk about moving forward and would be very welcome by our patients. But it'll have its own caveats, of course. Not only the financial issue but there's the durability issue. And I think when you look at the degree of impact of these medications versus bariatric surgery, you do see a greater impact from bariatric surgery, in not only the degree of weight loss but also the sustainability of that weight loss. So, I think for the right patient at the right time, bariatric surgery may still be the better option, but that's not going to be an option for a lot of patients. It is a huge shift in lifestyle and medications and many ways might be easier, so more to come.   I also wonder about looking at this data through the lens of different cancer types. What will we find out? Is the trend for colon cancer going to be different from the trend for breast cancer? Will the trend within breast cancer be different for breast cancer subtypes? I would very much welcome more data in this space, and it is nice to see a first step forward. Dr. Allison Zibelli: I thought the most interesting thing about this study was that while bariatric surgery patients lost more weight, GLP-1 patients had a higher decrease in obesity-related cancer risk. So, it shows to me that there is something beyond just weight. It is something in metabolism that is driving these cancers.  Dr. Megan Kruse: Yes, and I think that that goes back to some things we have thought about for a long time with insulin levels and insulin-like growth factor, and all of these things that I think when our patients look at more metabolic approaches to cancer control, this is probably what we are trying to get at. We have just never had great ways to measure it or influence it, and perhaps now we finally do. I would love to see some partnering work here in the future with oncologists and endocrinologists and digging into these patients who have great responses to see what we are actually seeing at the hormone level. Dr. Allison Zibelli: Well, thank you so much, Megan, for your great insights today on the ASCO Daily News Podcast. We really appreciate you coming to talk with us again. Dr. Megan Kruse: Thank you. It has been a great conversation. Thank you for opening my eyes to these abstracts, and I am happy to see what else ASCO brings. Dr. Allison Zibelli: And thank you to our listeners for joining us today. You will find links to all the abstracts we discussed today in the transcript of this episode. Finally, if you value the insights you hear on the ASCO Daily News Podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts. It really helps other people find us. Thank you for listening.   Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. The guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Follow today's speakers: Dr. Allison Zibelli Dr. Megan Kruse @MeganKruseMD   Follow ASCO on social media: @ASCO on Twitter ASCO on Facebook ASCO on LinkedIn   Disclosures: Dr. Allison Zibelli: None Disclosed   Dr. Megan Kruse: Consulting or Advisory Role: Novartis Oncology, Puma Biotechnology, Immunomedics, Eisai, Seattle Genetics, Lilly

This is one of my first black men and suit shorts about killer Samuels response to a young black man when it came to how much money you made and him being a house Dad.... --- Send in a voice message: https://podcasters.spotify.com/pod/show/bmis/message Support this podcast: https://podcasters.spotify.com/pod/show/bmis/support

"God has made men to be men, to be distinct from women, to have testosterone and defined musculature. Yet the average 22 year old man today has the same testosterone levels that the average social security eligible man had a little over 20 years ago. All you have to do to see this in the most vivid way you can is to compare what people look like today to your parents or grandparents wedding photos. The fattest person in those ruffled tuxedos or bridesmaid dresses with puffy sleeves would look emaciated by comparison today. Everyone had normal BMIs. Obesity, much less morbid obesity, was extremely rare. Why is this the case? Why are we so fat? And why do we keep getting fatter?" Excerpt from The Boniface Option by Andrew Isker Binge-watch all of the episodes by joining our Patreon at https://patreon.com/rightresponseministries Purchase The Boniface Option here: https://a.co/d/3iKPLj2 Ministry Sponsors Armored Republic - https://www.ar500armor.com/ Honoring Christ by equipping Free Men with the tools of liberty necessary to preserve God-given rights.

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses a modern approach to carpal tunnel syndrome (CTS), including when central findings are present. Lindsey discusses examination and treatment, including the use of the rehabilitation every-minute-on-the-minute style (rEMOM) exercise dose. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. LINDSEY HUGHEYGood morning, PT on ICE Daily Show. How are you? Welcome to Clinical Tuesday, my favorite day of the week. I am Dr. Lindsay Hughey from our extremity management team, and I am here to chat with you today about an ortho-cert approach to carpal tunnel syndrome. And what do we do when it's not just the carpal tunnel, when we also see some central symptoms? So I am going to unpack what a fitness-forward approach looks like, how we will use our manual therapy to modulate symptoms, and then what psychologically informed looks like for this condition when we think about combining all the courses from our OrthoCert and putting that all together in an integrative way, how we can approach this condition. and then I'll leave you with a couple rehab e-moms at the end, so stay for that. CARPAL TUNNEL SYNDROME OVERVIEW So first off, let's briefly review what the subjective and objective presentation with someone with carpal tunnel syndrome and then possible central considerations that are present as well. Think double crush is kind of a common medical term present. So for that CTS, that carpal tunnel syndrome, we'll see classic sensory anesthesias or paresthesias in those first three fingers and then possibly that radial half of the ring finger. There may be motor deficits in our first and second lumbricals, opponent's pollicis, abductor pollicis brevis. So think about in your objective exam, thub abduction and thumb flexion may be weak. We'll also see, from an objective perspective, locally we'll see a positive phalanx and tonels, and then our carpal compression test. Patients will complain of interruption in gripping and daily tasks. They may even drop objects or have to shake out their hand to ameliorate symptoms. Often symptoms are worse at night, and then when they first wake up in the morning, and then tend to improve as the day goes on. When we also consider there might be some central things going on, it's that person that not only complains of what I just told you and had objective exam findings, but they also say they have some numbness tingling along that C5, C6 dermatome. They may complain of some local neck tightness or achiness in that mid to lower cervical spine area. on exam, you will find a UPA or central PA will elicit those familiar symptoms when you're around C5, C6. In addition, that dermatome distribution will be impaired and then reflex changes in that biceps reflex might be abnormal compared to that uninvolved side and we really understand the whole clinical picture when we use a body chart right and we really listen to that subjective and dial in their ags and eases so you find out when all of that's on board that there's two things going on at the same time and here's where we'll need our ortho hats where we need to put into practice what we know in our cervical class and what we know from our extremity class. APPLYING FITNESS FORWARD So first off what is fitness forward? when that's one of our primary pillars. So what does that mean for this condition and in general? Well, we are going to approach the whole human in front of us. We know that this typically affects females later in that fourth and fifth decade. they are two times females are two times more likely than males to have this condition and so appreciate that in that decade that's either you know a career focused time or family focused or a mix of the two so consider the stressors for that human that may or may not be involved in that decade. And then we see some links to obesity as well. So thinking about the whole human holistically, we see worsening symptoms for those that have higher BMIs. So not only will we consider the whole human from a fitness forward perspective, but we're going to think about how can we attack local tissue getting irritability down. So think about local tissue in the hand and even in that C5, C6 area of cervical spine. And then we'll start with local treatment but then eventually we're already thinking about how globally will we make this human more resilient and robust in their grip strength and their overall upper quarter strength. So even day one when we're trying to just calm symptoms we're thinking fitness forward. How fit will you let me get you? We're gonna consider those system influence that I already mentioned, sex and possible stressors in life. We're gonna consider mindset, the physical activity levels of that human, because again, I said there's links to increased BMI and obesity. So we're dealing with an underlying systemic inflammation probably on board as well. We'll think about what's that sleep hygiene like? Are they getting the eight to nine hours of sleep? How's their diet and hydration? Are they getting half their body weight in ounces? Are they eating colorfully? That is all a part of fitness for it. So it's not just loading them up locally, globally, making tissues robust, but really we want a whole system-wide robustness. MANUAL THERAPY FOR CARPAL TUNNEL SYNDROME And the way we'll first approach these humans is through symptom modulation, through our manual therapy techniques. This is how we'll really get trust and buy-in when we're dealing with carpal tunnel syndrome, or CTS, and then there's central possible involvement as well. double crush, whatever kind of terminology makes you comfortable. I tend to think labels limit. And if you've been to our extremity course, you know that. So symptom modulation locally first looks like bracing, actually. So an over-the-counter splint at night is first-line defense because that's when symptomatology is worse because we're sleeping in that phalanx position. And if there's worsening symptoms in the day, we'll even recommend a wearing schedule during the day. But we first start with night. We'll educate on any ags and easing postures, right? If moving in and out of postures is really important. We don't want someone hunched over like this all the time, and we also don't want someone being perfectly erect. So depending on their job and life and family functions, we'll give some advice there as well, as our education starts to dampen irritability and symptomatology. Our manual therapy perspective though, so here's our second pillar coming to play. is that we are going to target the CT junction and then an upper T spine. And we're going to use manipulation. You'll hear at our course that if you have any upper quarter symptoms and you have a pulse, you are going to get some kind of thoracic manipulation. for that neurophysiologic effect. So what you learn in your cervical and total spine thrust courses, you're going to bring forward here. And this is going to help dampen pain, not only centrally right in the cervical spine, but also we see pain dampening and increase motor output in our upper quarter when we use those techniques. So those will be our go-to techniques, prone CT junction, and then our upper T-spine manip. In addition, doing some lateral gliding for a pumping action in those higher irritability stages targeted at that C5, C6 area. Follow up for that will be some cervical retractions to get a pumping action centrally. And we may or may not combine that with some traction. a manual therapy perspective from extremity management local to those carpal bones and that wrist, we'll actually start doing some wrist mobilization. Extension's often a common impairment here, so we'll work into progressive extension, mobilizing those carpals, and we'll even do this nice soft tissue splay technique. If you've been to the course, you know, and if you're on the fence, you'll join us to learn this, but a splay technique to just open up right where that median nerve travels through where all of our flexor retinaculum is, it gets tight in there when there's inflammation on board. So just doing some soft tissue mobilization and splay. And it's interesting is this is a tech, the technique we teach is one that was actually used in that PTJ study in 2020 from De La Penas and crew, where they looked at four-year follow-up of those with carpal tunnel syndrome that did conservative care, which was only three bouts of PT, and this splay stretch was included in the 30 minutes of manual therapy that these folks got, and they compared this group to those that went on to get surgery, and they followed them over four years. What was similar about both groups is both groups got education and they got tendon and nerve glides. And what we saw is similar similarities. So meaning pain and function was the same whether you got surgery or conservative care, which lets us know that our conservative care, our manual therapy techniques like this splay technique can be a really powerful resource for our patients to modulate symptoms and to lower that irritability in their tissues. In addition, not only will we do some wrist extension mobs, do that splay stretch, but we'll also work locally at that thenar eminence. And we will target our wrist flexors with myofascial decompression, soft tissue massage, and or dry needling. So targeting wrist flexors, forearm pronators, and the thenar eminence anywhere where that median nerve could be compressed. So those are our manual therapy targets. PSYCHOLOGICAL CONSIDERATIONS FOR CARPAL TUNNEL SYNDROME Moving on to our next pillar, psychologically informed, how do we address psychological considerations for this human that has CTS and then symptoms along that C5, C6 dermatome with reflex changes as well? Well, we're going to have a conversation about lifestyle, about what we call meds health. Simply that is M is mindfulness, E is exercise, D is diet, and sleep. And this is a nice framework to address lifestyle behaviors. Now we might not address them all at once and we'll choose our education and dose it wisely, right? We don't want to fire hydrant lifestyle behavior modification to patients, but we do want to make sure all the pillars and how they're functioning are in the background of our mind. So consider M mindset. or mindfulness what we're thinking here is what can we give this human that's kind of stressed and in pain to just calm their system and one really great way to bring them into a more parasympathetic state is doing breathing so breathing in just five minutes a day physiologic sighing right, where you do that two inhalations through your nose and exhale has been found to be beneficial in reducing physiologic factors like heart rate and just calming our system. So consider that can be an easy thing to integrate into a patient's life that is stressed or maybe suggesting some green space, go out for a walk and or journaling if that is their thing. from an e-perspective, exercise, what I want you thinking about is just what's their physical activity like? Are they getting their 10,000 steps daily? Are they meeting the daily requirements of physical activity, which is 30 to 60 minutes every day, right? We want a total of 150 to 300 minutes a week. Is this human getting that activity? And if we consider some of the common profiles, which is obesity and being female in that later decades of life, we need to consider what is that like and how can we influence them to move more to help with this inflammatory state that's going throughout their body. D is diet, so education on what is your diet like? Are you eating enough protein to support healing and function? Can you reduce that sugar intake to calm inflammation? Can you eat colorfully, eating more plants, again, to help control inflammation? How's your hydration? Are you getting half your body weight in ounces? These are additive behaviors that we can help, always trying to add first and then take away if necessary. And then finally that final pillar, sleep. How is sleep hygiene? Talk to this human about maybe very dark in the room an hour before bed, no heavy big meals or your phone or TV. This can help just with quality of sleep. So consider that psychologically informed piece is so important. And you'll kind of notice that there's always a synergy between our pillars, right? You can't be fitness forward, right? And build up local tissue and global tissue robustness if you don't first symptom modulate through manual therapy, right? And our manual therapy needs to be excellent and executed well with the right dosage so that we can be effective in symptom modulation, which gives us this modulating window of opportunity to then load them better locally and then globally when we think about the upper quarter. And then the psychologically informed piece, we need solid education and lifestyle counsel to help this whole human, this whole system be more robust in their world. And that's why the trifecta and the synergy of the pillars is so important. USING THE rEMOM FOR CARPAL TUNNEL SYNDROME I want to leave you with two rehab EMOMs inspired by exercises that we learn in our cervical course and then exercise that we prescribe in our extremity course. So, and if you want to write it down, feel free, but early in our care with high irritability, I would suggest a 12 minute rehab EMOM that looks like this. We're thinking about someone that has lots of numbness, tingling, lots of inflammation on board. All ADLs and IADLs are limited. their sleep sucks, right? They need a massive blood pump. Minute one, we're going to do a UBE, a salt bike, or echo, or rower, whatever the patient loves. Minute two, we're going to do tending glides because we see tending glides in some of our RCTs being superior than our nerve glides and helping create a local pump to our flexor tissues. Number three, minute three, is nerve glides, right? We're going to do a slider glider for that median nerve and even try to get that cervical spine involved. And then number four, we're going to do cervical retraction with or without traction. So we put that band on a secure surface and there's this traction environment where we're offloading the lower to mid cervical and then doing some pumping action cervical retraction. We'll do that three rounds and that's why it's a 12 minute rehab EMOM, early in care, high inflammation on board. I'm going to leave you one more EMOM, and then we'll call it a day for PTL Nice. But later in care, when irritability is dampened, right, and we more are at that lower irritability stage, there's no longer numbness and tingling symptoms. We're thinking about robustness of local and global tissue, and we're working on resilience, we want to layer in more volume and intensity. So we'll use that same structure, 12 minutes. Minute one, we're going to do grip training. So we are going to specifically target doing a spherical grip. So you would turn that kettlebell upside down and work on carries, which works on the whole upper quarter, arm at side or arm here. So we get that cuff firing up as well. And we'll work on that. You can even work on your tip grip or palmar grip as well to really target median nerve and the muscles that feeds. That's minute one. Minute two, we're going to do some wrist flexion and wrist extension exercise. Recommend rehab dose if you've been to one of our courses, you know, that's 8 to 20 reps 3 to 4 sets Anywhere from 30 to 80 percent intensity, right? You'll meet the patient where they're at minute two again just a repeat wrist flexion extension exercise and then minute three will be pronation supination and then finally minute four we'll actually do prone cervical retraction off the table to start building up robustness of the cervical extensors. These are just two examples of how when you take our ortho cert courses specifically our spine courses and then our extremity courses it's helpful to prepare you for management for something like cts when there's also that double crush right there's involvement um centrally and distally. SUMMARY Our author's cert, we would love you to be a part of it and learn more about it. If you're interested or the first time you're hearing this, check us out on ptlonice.com and it'll tell you all the courses required, total spine thrust, cervical, lumbar, extremity management, and testing for this is free. You just take those courses and you test out at the end. It's been a blast kind of talking to you about how we integrate our classes. From an extremity management perspective, class is coming up. Mark and I are both on the road this weekend, and there's still, there's one spot left in Mark's course in Fayetteville, North Carolina. There's lots of spots left in Burlington, New Jersey, if you want to join us. And then the following weekend, we're at it again. We will be in Highland, Michigan, and then Scottsdale, Arizona, and we have spots. So again, ptonice.com to check out OrthoCert, and then check out extremity management courses. Thank you for your time this morning and in listening to that OrthoCert approach to CTS. Happy Tuesday, everyone. And if you think about it, wish our CEO a happy, happy birthday. He'll love that. See y'all later. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan defines interrectus distance and how to measure it, how to functionally measure core strength, and the limitations of focusing on interrectus distance with patients. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALEXIS MORGAN Good morning, PT on Ice. Getting both our cameras going here. Good morning, PT on Ice Daily Show. My name is Dr. Alexis Morgan, and I am excited to be with you on this morning, this new year. Happy New Year, everyone. And let's talk about measuring IRD or inter rectus distance versus measuring strength. Which one matters more? So to jump right into the topic here, Interrectus distance is a common measurement that individuals are going to be taking in pelvic health. WHAT IS INTERRECTUS DISTANCE (IRD)? So interrectus distance is the distance or the measurement of the linea alba width. It's that linea alba between the rectus abdominis on the left compared to on the right. What is that distance between? That's our interrectus distance. Many people advocate for measuring interrectus distance. Number one, it's measured in a lot of our scientific studies that is looking at diastasis recti. There's a lot of studies that are looking at it. And so if they're looking at it in the studies, well, maybe we should be looking at it in clinic as well. It's also repeatable. We can measure it the exact same way and we can see if there is change. And we like data that we can measure and we can see if there is change. So people are definitely advocating for its use. There are some benefits from measuring change. Obviously, you're here at ICE, you know that we are recommending to be able to test and retest to see those differences in all aspects of care. So, of course, we should be recommending that here, right? Well, we do recommend testing and retesting in this space. MEASURING STRENGTH However, we recommend measuring strength. So, measuring strength entails getting functional with your clients. One of our favorite tests is the sit-up test. We talk about it in our online course, and it is a way in which you can measure how strong an individual's rectus abdominis is. So they're sitting up. How much support do they need from their legs? How much support do they need from their arms? Do they need to whip themselves up or can they control themselves up? Do you need to hold onto their feet or not? This gives you a score. And with that score, we can then track change over time. It's extremely functional. This is what individuals are doing when they're getting out of bed or when they're getting up out of the floor with their little ones. This is also very functional for all populations. So not just the postpartum individual, but this is also helpful for individuals who are post hernia surgery or pre-hernia surgery. This is great for individuals with varying levels of adiposity. You don't have to measure, you don't have to assess something and be distracted or be, oh, I don't really know what I'm looking at because there's adiposity. We're just measuring strength. We're just testing the functionality. LIMITATIONS OF IRD When we think about the limitations of measuring the interrectus distance, Really, I could go on for a long time here. There's actually no known pathological number or centimeter or measurement. There's no known measurement that we all are in agreeance of like, yes, that number is pathological. We don't have that. In 2021, a recent paper came out and actually I believe Rachel did a podcast on this exact paper. So I'm not going to go into all of the details. You can search back to listen to this, but in 2021, a paper came out looking at individuals ages 20 to 90 males and females of all BMI sizes, looking at their CT scans and they measured the interrectus distance. With all of these people, 57% had greater than two centimeters in that interrectus distance. Now for reference, over the last 70 years, much of the data, much of the science that is looking at diastasis is using measurements, oftentimes in centimeters, and they vary. There's no agreeance in these studies. So sometimes there are two, sometimes it's 2.2, sometimes it's 2.5, that that one particular study calls pathological because there's no known pathological. But around that two centimeter mark, Well, now we have this study just in 2021, looking at what is normal. And we see that 57, so over half of the individuals actually had greater than two centimeters. So there's a problem here. We can't call this pathological of more than half of the individuals of all ages, of all BMIs, parity being one risk factor, but BMI and age also being risk factors. We can't use that. Not to mention in all these studies there's a variety of tools that are being used. So measuring with just fingers, measuring with calipers, measuring using a ultrasound machine. There's a lot of different ways to measure and of course those are going to be different between different tools. We don't have any standards. We don't know where exactly should we measure. In all of these studies, sometimes it's a couple centimeters above the belly button, sometimes it's more, sometimes it's less, sometimes it's right at, sometimes they avoid. There is no absolute on where we should measure, nor the type. It's all over the place. And one of the aspects that I think is the most concerning here is that, well, I've just laid out one, the fact that we don't have any agreement on any of this. Why are we doing, why are we measuring? FOCUS ON FUNCTION AND NOT APPEARANCE But number two, when we're measuring, we are perpetuating this focus on the looks. We're focused on what they look like and what that measurement is has nothing to do with their function. We talk a lot in our level one course on diastasis and a big aspect that I'll have to leave for another podcast on another day, or you can join us in our course, but another aspect of this is body image. And many individuals are very concerned and have body image dissatisfaction. If we can help them by shifting the focus to function in our little space, absolutely we recommend referring out to mental health professionals to help with that. But in our little space that is the physical world, If we can help by shifting the focus to physical and to function, then why would we not do that? Especially when there's a lack of evidence for clarity on measuring that inter-rectus distance. Our newest research in this space in the last handful of years, our newest research has shifted in this direction. it shifted in measuring abdominal torque. the rotational torque that is that one can generate power. Why? Because that's functional. Or that sit-up test, like I mentioned, it's functional. Our newest evidence is heading in this direction. Let's not wait 20 years. Let's go ahead and jump on this train and let's start measuring function today, this year, for 2024. Let's measure function and let's focus on what matters. for our clients, and let's follow this research. And when we do that, we know we can absolutely help them increase in their function. We've got no doubt about it. I know for sure if you can't do a full setup, I'm gonna give you the modifications and I'm gonna give you that home exercise program that will allow you to do a full setup in due time. I have no doubt about it. I can sell that so easily and I would hope that you can too. So let's stop focusing on interrectus distance. Let's start focusing on function. Our recommendation is that if somebody comes in and asks for an interrectus distance measurement, if they're asking you to measure, and they fully believe in its importance in their rehab, that would be the only time in which you would use measurement. Other than that, other than they're asking for it and there is a significant belief in its importance, If those two things are not both on the table, then we need to set the measuring IRD aside and focus in on strength. Thank you so much for joining me this morning. I hope it made you think. It's something we've been thinking a lot about, both in reading the evidence and in practicing clinically. And I hope it helps you focus in on what matters this year for your patients. This material and a whole lot more is in our online level one course. Our course starts next week. It's absolutely sold out. We are closing, we will be selling out for the March cohort well before March as well. So if you are wanting to get into this level one course, it's been revamped, all brand new. If you want in, you should go ahead and register for that March cohort. If you've taken our online courses before, online level one before, then you will be interested in our online level two course. And that is a brand new course, which starts April 30th. If you want to catch us live, we're going to be on the road a lot in 2024. All of that's on the website. You can see it. I'll just mention the few that are coming up in January and February. We are going to be in Raleigh, North Carolina, January 13th and 14th, Hendersonville, Tennessee, January 28th and 29th, and Bellingham, Washington, February 3rd and 4th. We are so excited to see you all out on the road in 2024 and can't wait to see you all online as well. Have a great day. Happy New Year. And we'll catch you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Our final Q&A episode of the year tackles two medical ethics questions in the news recently. The first is Wegovy, the ground-breaking anti-obesity drug which has been a controversial sensation in the United States. It is now available (in very limited supply) on the NHS here in the UK, but only for those with quite serious obesity with BMIs of 35 or higher. Should Christians hail this a brilliant medical advance tackling a serious public health issue, or a worrying example of big pharma trying to medicate away our self-control? Next, we discuss a new push by some scientists to soften the ground ahead of a campaign to extend the current 14-day limit on human embryo research. Why do researchers want to keep embryos alive in petri dishes for longer, and will it actually benefit any of us in the end really? Some Wegovy links: • A Guardian news story abiout the introduction of the drug on the NHS https://www.theguardian.com/society/2023/sep/04/nhs-in-england-to-start-prescribing-weight-loss-jab-wegovy-despite-low-supply • The NHS's own website on how Wegovy will be prescribed https://www.nhs.uk/conditions/obesity/treatment/ • And, in a sign of how much public interest there is, the Department for Health has a page explaining more about how to access Wegovy https://healthmedia.blog.gov.uk/2023/09/04/accessing-wegovy-for-weight-loss-everything-you-need-to-know/ • The BBC News story about the campaign to extend the 14-day limit https://www.bbc.co.uk/news/health-67204553 • Subscribe to the Matters of Life and Death podcast: https://pod.link/1509923173 • If you want to go deeper into some of the topics we discuss, visit John's website: http://www.johnwyatt.com • For more resources to help you explore faith and the big questions, visit: http://www.premierunbelievable.com

All we want is world peace and low BMIs.

Despite some falloff in consumer interest, anti-obesity drugs are still likely to have profound implications at both the macro and sectoral level.----- Transcript -----Welcome to Thoughts on the Market. I'm Ed Stanley, Morgan Stanley's Head of Thematic Research in Europe. Along with my colleagues, bringing you a variety of perspectives, today I'll give you an update on the all important obesity theme and how it's impacting a wide range of industries. It's Thursday, November the 9th at 2 p.m. in London. GLP-1s, a type of anti-obesity medicine, have been on the market since 2010, but it's taken until 2023 for this theme to really come to life. We believe that GLP-1s will clearly have profound implications over the long term, both on a macro and micro level. Obesity has far reaching implications for the global economy as it leads to lost productivity and significant health care costs. We estimate the macro impact of obesity at 3.6% of US GDP, with potentially $1.24 trillion in lost productivity indirect costs. Anti-Obesity drugs have the potential to address at least some of this economic burden and at a reasonable cost. The micro implications on businesses year-to-date have seen about a $600 billion swing in market cap. That includes, to the upside, $340 billion for the GLP-1 makers and over $260 billion lost in market value for the stocks that are potentially disrupted. For context, that compares to a total US drug market of $430 billion annually. 2023 saw an impressive surge in investor interest in anti-obesity drugs. Yet and perhaps surprising to some based on hashtag and web traffic data we track, consumer interest appears to have waned in recent weeks. We think this notable dip from the peak in activity is driven in part by supply constraints, paused geographic expansion and curtailed promotional activity. Importantly though, this fade in initial consumer excitement is occurring at the same time that company transcript mentions of obesity or GLP-1 by non-pharma companies are reaching new highs. This disconnect between sain street moderation and excitement versus Wall Street's rise in excitement, is very typical of short term hype cycle tops in equity markets, particularly given the current environment of higher interest rates. But even as the initial buzz around obesity drugs is fading back to more moderate levels in the near term, we do believe there will be wide ranging implications over the long term that are hard to deny. And our global analysts have been all over this on a sector by sector basis. First off, we believe that US alcohol beverages per capita will correct due to abnormally high consumption in recent years and longer term structural challenges such as demographic, health and wellness. For beer growing adoption of obesity medication presents an incremental risk factor to consumption, although many of these companies are already working on healthier options. Across packaged foods, patients on anti-obesity medications have been cutting back the most on foods high in sugar and fat, such as confections, baked goods, salty snacks, sugary drinks and alcohol. Companies with a weight management or better for you portfolio appear to be better positioned for here. Within US food retail, we think dollar stores which target lower end consumers with outsized exposure to high calorie foods, will be the most adversely impacted in the context of increased adoption of these drugs. Separately, insulin pump makers should be only minimally impacted, we think, by GLPs by 2027, which suggests that the share price reaction to the downside for these stocks year-to-date may be materially overdone. Obesity has a direct impact on osteoarthritis, with about twice the prevalence of arthritis in obese versus non obese patients. A much higher need for arthroplasty with higher BMIs and obese patients having higher surgical complications. GLP-1 usage could have some complex effects on these ortho stocks. We also see longer term risk for most of the US and European fast food industry. The same goes for carbonated sugary drinks and for chocolate lovers out there, the rising GLP-1 adoption could pressure chocolate consumption longer term. But the magnitude of these impacts remains uncertain, as indulgence will still remain a core consumer need even in this new GLP-1 paradigm. All in all, we remain bullish on the anti-obesity drug market, particularly given the staggering 750 million people globally living with obesity, and this continues to be a dynamic space for investors to watch closely. Thanks for listening. If you enjoyed this show, please leave a review on Apple Podcasts and share Thoughts on the Market with a friend or a colleague today.

Diet-related disease such as cardiovascular disease and diabetes create a crushing burden on individuals, families, and the healthcare system in the United States. However, Produce Prescription Programs where medical professionals prescribe fruits and vegetables and health insurers pay, promise to improve nutrition and health. Today we will talk with Dr. Kurt Hager from the University of Massachusetts Chan Medical School and lead author of the largest assessment of Produce Prescription Programs to date. Interview Summary   So, let's get into it. Before we dig into the study itself, can you tell our listeners more about Produce Prescription Programs?   So, the programs that we evaluated in our study gave participants electronic cards. So, either a debit card, a gift card, or a loyalty card that they could use at retail grocery stores and some farmer market partners as well to get free fruits and vegetables of their choice. The food could be either fresh or frozen fruits and vegetables. These programs acknowledge that nutrition education alone likely is not sufficient to increase healthier eating for many low-income households, for which just the cost of healthier foods is really the primary barrier in improving their diet. These programs seek to overcome that barrier, and it's really exciting to see that clinics across the country are turning to these. I think physicians, from our conversations with the clinics we partnered with in this study, are really excited to have a tool they can use and provide to patients to offer higher-quality care and help improve their nutrition when they're talking with their patients about managing diet-related illnesses like diabetes, hypertension, or obesity.   Thank you, Kurt. Could you tell me a little bit about why you and the team decided to do this particular study?   Food insecurity has been consistently associated with poor health outcomes, higher healthcare costs, and lower dietary quality. Many food insecure households tend to have higher rates of diet-related chronic illnesses. We worked with a wonderful organization called Wholesome Wave. They have operated Produce Prescription Programs across the US, and they have been collecting data on these programs for about five years now. Wholesome Wave reached out to our research team at Tufts University's Friedman School. They wanted to see if these programs are working at improving health outcomes. The key thing, I think, to contextualize where this study stands, is prior to this work, there had been a handful of studies that had shown, not surprisingly, that Produce Prescription Programs can improve dietary quality and improve food insecurity. However, very few had gone that extra step to see if Produce Prescription Programs were associated with improvements in really important clinical outcomes. Things like hemoglobin A1C, which is an important measure of average blood sugar levels in the past three months. This is critical for managing diabetes, and outcomes like blood pressure and obesity and overweight. Previous studies had found mixed results on these outcomes, and most had been very small, maybe about 50 participants. We built on this by doing the largest analysis to date. Our study had nearly 4,000 participants from 22 programs across the US, from 12 states. These ranged from cities like Los Angeles to Minneapolis, to Houston, to Miami, Idaho - so all over the US.   So, it was the fact that previous studies have had relatively small samples, and some of these other studies did not take all of the sort of important measures of health into consideration. So, you were able to build on that past work in a unique way in this study?   Exactly. I think the key thing is that Wholesome Wave had excellent relationships with their partner clinics. This meant that the clinics were willing to share medical record data with us. This is always just very challenging and many other studies weren't able to go that extra step. We were blessed with access to a lot of medical record data and we were able to do analyses that looked at important clinical biomarkers. I will say though, our study is a step in the progression. I'll be the first to admit, we did not have a comparison group in this analysis. So, the results that we found also could have occurred due to other reasons. Such as, for example, perhaps when someone is referred to a Produce Prescription Program, their physician might also make other referrals, or perhaps change their medications because this patient has been identified as high need. We certainly built on previous literature by having a much larger sample size and pooling data across the US, and to me, our findings really provide us with a strong rationale to continue research into this area. But also, to confirm our findings with randomized trials similar to what you would do, for example, for drug research.   That is helpful to hear. One of the things that's really important about what I understand of this study is the fact that you worked with Wholesome Wave, and that allowed you access to a lot of different programs across the US as you described. Could you give us a little bit of a sense of what some of those programs were, and how did they provide the support that you were able to study in this project?   Most programs provided the benefits on electronic card. It's similar to in WIC or SNAP, where participants have an EBT card, they can use it at retail settings. It's administratively very simple. From interviews among SNAP participants and other research, this tends to be lower stigma - when you're using a card at a checkout. These cards gave about $50 a month for six months on average for the adult programs, and $110 a month for the pediatric programs. Some of the children's programs were also a little longer. Some of the child-focused programs that we include in the analysis were up to 10 months.   So I understand from this description that the Produce Prescription Programs also look different. There were some programs for children, some for adults. How did you manage that? There's a lot of other things that could be going on. How do you sort of do that in this work?   Participants were referred to these programs because they were either food insecure or were recruited from a clinic that served a low income community and were very likely to be food insecure. Individuals also had a risk factor for poor cardiometabolic health. So, this means that they either had diabetes, high blood pressure, or were overweight or obese at baseline. That was really the common thread across all of these programs. We did all the analyses for adults and children separately. So, we report changes in fruit and vegetable intake, and changes in self-reported health status separately. Food insecurity - we did assess at the household level, but then for other outcomes, for example, hemoglobin A1C, we restricted that to the adult population that had diabetes when they enrolled into the program. For blood pressure, we restricted those analyses to adults with hypertension at baseline. For Body Mass Index, we restricted analyses to adults who were overweight or obese at baseline, and then did those same analyses separately for children for age and sex, only looking at children with overweight or obesity at the start of the study.   This is really important then. Thank you for that clarification. You know, you've talked about some of these critical measures such A1C for diabetes. You've talked about obesity measured in BMI. Can you tell us a little bit more about the importance of these findings and what they mean in real terms for participants' health?   Absolutely. So, we found that participation was associated with improvements in dietary quality and food insecurity. For example, among adults, they were reporting that they were eating, on average, about 0.8 more cups per day of fruits and vegetables by the program end. And food insecurity rates were cut by about a third. So, the program seemed to be working as intended, which was excellent to see. But then looking at the clinical biomarkers, for example, hemoglobin A1C among those with diabetes dropped by 0.3 percentage points. And among those with uncontrolled diabetes, those having chronically high blood sugars that are very difficult to manage, dropped by about 0.6 percentage points. So, to put that in context, that's about half the effects of commonly prescribed medications to manage high blood sugar levels. So, for just a simple change in diet, that is I think fairly impressive and very encouraging to see. And the effects on the reductions on blood pressure were also about half as large as we would see with commonly prescribed medications. I think it's really important to highlight that, one, we don't know if these changes will be sustained long-term when the program ends. There might be some participants where this program caught them in a moment of crisis perhaps, in which this helped stabilize them, and maybe they would be able to maintain these new improvements in dietary intake long-term. But I suspect many participants might not be able to maintain this healthier eating because the cost of healthier foods was the main barrier to healthier eating at the onset of the program. And so, this is an area that we're really interested in looking at in future research. But I will say, if one were to maintain these improvements that we would see in hemoglobin A1C, blood pressure, and BMI among adults, they really were clinically meaningful. And if sustained long-term, it could reduce risks of things like heart attack or stroke years down the line. Any reduction in these biomarkers can really have a meaningful impact on patient quality of life. Things even like averting diabetes complications with damage to the circulatory system, to nerves, to the retinas in the eyes and having vision loss. So, sustained long term, I think these really are meaningful impacts on health and wellbeing. The last thing I'll say, is for children, we did not see a change in BMIs for age and sex. I'm not too surprised, given it's a relatively short program on average six months. But also, child BMI is a notoriously challenging metric to move. But I do want to highlight that among the households with children, we did see an improvement in fruit and vegetable intake, and reduction in food insecurity, and self-reported rates of higher health status. And I think if we're thinking about childhood development, to me, that is still an important success. We know that having enough access to food in the household and having higher dietary quality is really, really important for childhood development and wellbeing. There's certainly a nutrition causal pathway here. But it's important not to forget that there's so much stress and anxiety when someone is experiencing food insecurity, about not knowing necessarily where your next meal is going to come from. Just worrying constantly about managing household budget, about trade-offs, say between buying healthier food, paying for medications, paying for other needs. So, I suspect these programs are improving health outcomes both through a nutritional pathway, but also through like a mental health pathway, perhaps reducing anxiety for some households as well, which can also have an impact on things like blood pressure.   So, given these results, it says that there's some important implications of these Produce Prescription Programs for the health and wellbeing of the participants in this study. I mean the fact that just changing fruit and vegetable consumption through a program like this had an effect similar to half the effect of some medications is really a powerful finding. I have got to ask, what are the policy implications of this work?   There is very exciting momentum across the US federal programs, promoting produce prescriptions and other forms of, for better or worse, what is known as food as medicine. And these programs all provide free healthy food to patients in partnership with the healthcare system or through a physician's office. So, Produce Prescriptions are the focus of this study, but the other Federal programs also include things like medically tailored meals, which are healthy, home-delivered meals, often to patients with even more advanced chronic disease who also might have activity limitations or disabilities that makes it really challenging for them to shop and cook independently. Last fall there was a historic White House Conference on Hunger, Nutrition & Health, in which the Biden administration in the summer prior engaged at a national level, major stakeholders in the anti-hunger space, large health systems, researchers, and government agencies to bring together a policy agenda to address hunger in the US, and the really high rates of diet-related chronic diseases. And it's important to note that, I think it is the first recommendation in the section of the final national strategy from this White House conference under the healthcare sector highlights Produce Prescriptions as a policy priority and expanding them in Medicare and Medicaid. So currently Medicaid, which is the federal health insurance program for individuals with low incomes or who have a disability, Medicaid is managed in partnership between each state and the federal government. And this means that states have some flexibility in how they manage their Medicaid program. They can apply for what is known as Section 1115 waivers. The federal government can approve these waivers if the state makes a good case that if they propose an innovative pilot, an innovative change, that they can make the case is likely to improve health outcomes and remain budget neutral, then the federal government can approve them to pilot this idea. So, currently in Massachusetts, we are several years into an 1115 pilot that is actually paying for produce prescriptions and medically tailored meals through the state Medicaid program. And currently about 10,000 people in Massachusetts have received some sort of nutrition support through the state Medicaid program. About 10 other states now have either similar waivers approved or pending approval to allow other Medicaid programs to do something similar. So, this is a really exciting area where expanding access to these programs is happening. And then in Medicare, which is the health insurance program for older adults, in Medicare Part C, which is the Medicare private health plans, those health plans can choose to cover Produce Prescriptions as a benefit. They're not required to, but they have the flexibility to offer that service if they would like. And then finally, I'll just say that there's also new pilots that were announced in Indian Health Services and the Veterans Health Administration. All these examples show that across the federal government there are exciting pilots and expansions occurring to cover Produce Prescriptions, and other foods and medicine programs. However, they remain unavailable to the vast majority of Americans who might benefit. And so, they're not a core component of any of those programs at the moment. And rather, these are pilots that are being tested, but very exciting movement, nonetheless.   Thank you for that really comprehensive set of examples of how policy is implicated in this work and potentially the need to expand this work. It makes me think of USDA's Gus Schumacher Nutrition Incentive Program. That would be another way that folks could access some of the benefits of federal dollars to support produce-type prescription programs. How do you hope to build off this study in future research?   At UMass Medical School, we're the official independent evaluator for the state Section 1115 waiver, which means we are essentially responsible for evaluating if things like the Produce Prescription Program in the Massachusetts Medicaid program is improving health outcomes. So, that is what we are working on right now. In our partnership with the state, we actually have access to all of the claims and encounters data within Medicaid. And we also are working with several health systems that are also sharing medical record data with us so we can evaluate the impacts of food as medicine programs on hemoglobin A1C, blood pressure, and BMI, so similar outcomes to this study. We actually have a large study funded by the NIH in partnership with former colleagues at Tufts University that is doing a deep dive on the Medicaid medically tailored meal program. And we're hoping to do something similar for the Produce Prescription Program in Massachusetts Medicaid. And the nice thing about these studies, they aren't randomized trials. Since this is a kind of a policy rollout, anyone who's eligible for these programs can receive the benefits. But we will be improving upon this study that we just published by leveraging two really strong comparison groups, and using some statistical techniques to make sure we're identifying patients who are as similar as possible to those who are receiving services, but ultimately didn't enroll. So, we're excited to have these results a couple years down the line and see if these programs are working in the context of a large state Medicaid pilot. Bio Kurt Hager is an Instructor in the Department of Population and Quantitative Health Sciences at UMass Chan Medical School. Dr. Hager's interests lay at the intersection of structural determinants of health, food insecurity, and government nutrition and health programs. He is currently evaluating the effectiveness of the Flexible Services Program, which addresses food and housing insecurity in Massachusetts Medicaid. His involvement in state and federal policy initiatives underscores his commitment to translating science into policy, including initiatives with the Task Force on Hunger, Nutrition and Health and the National Produce Prescription Collaborative.  

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses the significance of addressing the underlying ecosystem challenge to achieve better outcomes for patients. She specifically highlights the prevalence of poor diet and obesity as contributing factors to this challenge. Lindsey points out that there is evidence suggesting a link between these factors and knee pain, as overweight and obesity are often observed in individuals experiencing knee pain. Lindsey emphasizes that focusing solely on physical therapy interventions, such as knee range of motion and strength exercises, is insufficient. Instead, she argues that healthcare professionals, including physical therapists, need to consider the broader ecosystem in which patients exist. This includes addressing mindset, mindfulness, exercise, diet, and sleep. To guide patients along this path, Lindsey  suggests that physical therapists can play a role by providing support and education. She compares physical therapists to shepherds, who can assist patients in navigating and making positive changes in their overall lifestyle. By addressing the underlying ecosystem challenge, Lindsey believes that better outcomes can be achieved for patients. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 LINDSEY HUGHEY Good morning, PT on Ice Daily Show. How's it going? Welcome to Clinical Tuesday. I'm Dr. Lindsay Hughey coming to you live from Edgerton, Wisconsin. So good to see you all today. I am going to chat with you about playing offensive medicine in our folks with degenerative meniscal injury. Before I dive in to what that looks like, I'd love to share with you a little bit about courses Mark and I have coming up in extremity management. So we have a couple options in August and actually one of them, well we did have a couple options, we only have one now because all the tickets in Fremont, Nebraska August 19th and 20th are actually sold out. So our last ticket went I think yesterday. So the only option in August to check us out and learn all things best dosage and tendinopathy care of the upper and lower quarter is Rochester Hills. So August 12th and 13th I will be teaching there and so join me if you can. And then in September Mark has two options for you on September 9th and 10th out of Amarillo, Texas and then September 16th, 17th out of Ohio. So Cincinnati will be coming your way. And then some fall and winter courses but again opportunities are dwindling. We hope if we don't see you this summer to see you in the fall or winter. 01:48 STOP THE SCOPE But let's chat about how do we play offense for degenerative meniscal injury because today is really a call, another call to stop the scope. I've hopped on here before over a year ago, I'm kind of charging us with those folks that have that gradual onset of symptoms of pain in their knee, maybe a little bit of swelling but have no specific injury or twisting event that happened that's more related to a degenerative process or like or I would like to refer to as a living life process. They don't need arthroscopic meniscectomy. And so we had more literature just come out this year to really bolster that argument of why physical therapy is really the number one choice, exercise medicine is the way to go. But I would like to first highlight that new literature that came out in January of why it's not appropriate to have surgery for these folks and then to also take a moment to reflect on why are we still seeing the arthroscopic partial meniscectomies being done if we keep finding literature that says let's not do this. And then also reflect on how can we do better as a profession to stop this continued over medicalization. So I first just want to briefly review in January 2023 we had a systematic review and meta-analysis come out from the Osteoarthritis and Cartilage Journal and we actually did share that on hump day hustling a while back. But this systematic review and meta-analysis again let us know that degenerative meniscal injury, the scope is not the way. And so let me unpack a little bit about this study because it was pretty inclusive this systematic review and meta-analysis. They looked at tons of RCTs so that the pool data of all patients was 605 patients. The study populations in each of the RCTs ranged somewhere between 44 and 319 so decent size overall in each study. The mean age of these folks was about 55 with the standard deviation of 7.5 so kind of that middle age and then majority were female about 52.4 percent. So you also see an even distribution almost of males and females in this study and then mean BMI was 26.5 standard deviation 3.7 you know below or above that. And what they investigated was the effectiveness of using arthroscopic partial manisectomy and they compared that via non-surgical so either sham which was exercise treatment or some form of exercise program so every RCT they looked at had to have the comparator of exercise. And degenerative meniscal findings were confirmed on MRI in all of the studies. The primary outcomes were knee pain, overall knee function, and then health-related quality of life and they looked at outcomes for up to two years so we see again a long-term follow-up in these RCTs this collection of RCTs that they looked at. And so the conclusions January 2023 so we're you know over six months out over half a year through and the conclusion was for insidious onset of knee pain so non-traumatic with MRI confirming degenerative meniscal tear in adults arthroscopic partial manisectomy is not the answer. 05:15 "NO CLINICALLY RELEVANT EFFECTS OF PARTIAL ARTHOSCOPIC MENISECTOMY" Literally if I'm going to quote verbatim no clinically relevant effect of arthroscopic partial meniscectomy was detected for overall knee function health-related quality of life or mental health. They did find one small marginal difference in pain levels a couple points but there was no evidence that there was superiority in having surgery. In fact they even took a look to see are there subgroups of patients right that might have a greater benefit from APM that were just not recognizing and when they looked and compared again the non-surgical to sham exercise therapy they did not see a subgroup that existed. They made other conclusions to say most degenerative meniscal tears are going to improve over time without the need for that arthroscopic partial menisectomy. Other findings that I think are really important to point out before we kind of reflect on why if we have this evidence do we keep seeing surgeries being done is that when they looked at the individuals in the studies those with BMI over 30 so obese individuals compared to the healthy BMIs less than 25 they had a 4.7 fold increased risk of progressing to knee osteoarthritis whether they had surgery or not. It was really a call to action when they found this in this pool data of all these folks is that body weight reduction strategies need to be on board for pain and function effects. 07:28 "...NO SIGNIFICANT ADVANTAGE OVER NON-SURGICAL TREATMENT" So just to send it home about this study and what they said one of the final things that they wrote in their conclusion was and I'm going to read it verbatim we recommend that physicians minimize the use of arthroscopic partial mastectomy to treat patients with degenerative meniscal tears because there is no significant advantage over non-surgical treatment. This is the osteoarthritis journal right this is a pretty high tier journal osteoarthritis and cartilage journal making this statement. So why are we still seeing a ton of them? Why does this keep happening where we see patients I have one of my caseload right now right why is this happening? Well we're obviously not reading the literature as a health care team and as physicians right because patients still think this is a primary defense. I'd love to reflect on that even 10 years ago in 2013 we had a study from Yim et al where they compared meniscectomy versus non-operative strength care and this was in 103 patients them and the same exact message was there there are no significant difference between arthroscopic meniscectomy and non-operative management with strengthening exercises again when we look at knee pain function and satisfaction at the two-year mark. So even 10 years ago we had this evidence but yet it's not translating to practice that's a lot of surgeries a lot of over-medicalization so I we need to really step it up here in our not only in ingesting this information but advocating that this is not a new message. In this article they point out that in 2017 so the systematic review and meta-analysis that we just reviewed that in 2017 an expert panel that regarding the degenerative meniscal injury said that the use of arthroscopic partial meniscectomy in nearly all patients with degenerative knee disease that several guidelines do not support this procedure. They've literally made clear statements against it again yet we're still seeing it so we can do better here and that probably takes some building relationships with surgeons right and chatting with them and letting them know like PT first get them to us right but really advocating that message in the community because we know that's not always going to work talking to the health care team. I think this message needs to be broadcasted widely more widely than it is currently. The other reason I think we keep seeing it besides like poor translation from what we're reading to the general public is there's this image mismatch so we see this a lot in the extremities and if you've been to our extremity of course you know we have a lot of conversations around this in different areas of the body shoulder hip knee but you see degeneration on the MRI right but there is no clear link that that's the cause of their pain symptoms it's an incidental finding but yet patients think oh you know my knee is really banged up right they leave hearing this message of harm rather than hearing you know I'm glad this is a normal age-related change so there's the image is linked inaccurately to pain and so again another opportunity to educate in this space and then the other reason I think that we keep seeing a ton of them being done regardless of what we know in the literature regardless of what we know that imaging doesn't tell the whole story is that there's this message put out about the fear of progression right if you do not get this meniscectomy you will go on to having knee OA or early onset knee OA which will lead to a knee replacement. 11:12 "IT'S DOING MORE HARM THAN GOOD" Let's stop allowing this message to be passed on it is harmful right it's doing more harmful than good and we don't actually know that right any fear-based messaging is not the way and so that message that is a thought virus and if our patients are coming into us or even like people in our community right our family or friends um we have to really um call BS on that right because we don't know that for sure and we're not seeing that link so finally kind of the background of the that we just had in January 2023 tell us that having surgery is not the way we've kind of reflected on why do we keep seeing this so what do we actually finally do about it well promote PT first faster right when someone's knee is starting to ache right stop ignoring it get into PT stop going to a medical provider even primary care orthopedic first come to physical therapy first so we can help you um with your hip and your knee pain and your um any associated muscle weakness or swelling so that we can get these healthy messages into our folks and into the community these folks get lost in the system letting them know that it is very common what they're experiencing and a plan for success that's our job that's our wheelhouse we need to manage expectation too so folks right some of our patients are going to want to do the surgery anyway right despite any of the things we can tell them about the evidence right they're set on it their belief and expectation it's going to help well i need you to manage those expectations as well because surgery after surgery i don't know about you all but all the ones i see doesn't actually take away their pain and swelling in fact the surgeons have actually told my patients you can expect swelling for up to six months which is literally the reason they came in there they want to feel better and they want the swelling to go away well guess what at least for six months it's not going to happen folks so letting them know that in a kinder less passionate way probably so while these folks might return to work or sport they're going to have ongoing symptoms and that's swelling so letting them know that that even if they opt for that it's still going to be a challenge they're still going to need pt so i tend to want to say why not play offensive time along those six months where you don't have to um respect healing time frames after surgery where we can really get after strength around that that knee and that hip the other thing we need to reflect on and how we can do better is that it's not just promote pt faster it's not just managing expectation but we have to understand the underlying ecosystem challenge that is present in a lot of these folks we see and especially in the systematic review and analysis that came out in january 2023 we see an underlying poor diet and we the reason we can know that it's related somehow to diet is it's we see overweight and obesity being precedent being present excuse me and so we have to understand that we have to intervene in these folks not just on knee range of motion and knee and hip strength and proprioception but we actually have to consider there's that underlying ecosystem piece and here's where pts can help too right we can help with mindset mindfulness exercise diet sleep and really guide them along that path as a shepherd we can help so we need to know that we can help right so some of us maybe don't even realize that our own you know 2018 cpg guidelines at the josp t let us know that exercise is medicine and whether patients do opt for surgery not that guideline really points out that supervised exercise so how many folks you see after arthroscopic partial metastatic go on they have the surgery and then the docs just give them a standard h.e.p. right so they go on having swelling quad like because they don't have an individualized program with progressive resistance exercise let those folks know too you need to be a part of their care in our own clinical practice guidelines say that it's not good enough to just do a an h.e.p. that's not tailored to the individual and then what that cpg highlights is we're always going to do a mix of hip and knee strengthening we will have manual therapy on board we will do proprioceptive activity and neuro re-ed for those joining this morning thank you to summarize where we are at when thinking about our degenerative meniscal care we need to advocate against surgery with that insidious onset of knee pain we need to share this evidence far and wide that it is not recommended as frontline defense we need to stop the fear messaging as a health care profession and let folks know that degenerative changes found on images are normal signs of living their life and that pain does not equate to imaging findings we need to dose hope and let folks know that at that two-year mark we can see just as great of improvements in pain function satisfaction of care with just p.t. right and i don't take the just p.t. lightly we don't need that overmedicalization p.t. first is the way i'd rather see a patient taking control of their ecosystem and knee health for two years rather than that wait and see approach will surgery help stop the scope folks have a happy tuesday and thank you for joining me 16:35 OUTRO Hey thanks for tuning in to the PT on ICE Daily Show if you enjoyed this content head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the institute of clinical excellence if you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home check out our virtual ice online mentorship program at pt on ice dot com while you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading head over to www.ptonice.com and scroll to the bottom of the page to sign up

Size matters, right? In our formative years, we likely heard (directly and indirectly) from the media, in advertising, from teachers and leaders, from doctors, and likely our parents and our peers that the size and shape of our body matters. It matters socially, and it matters for our health. That's the truth, right??So how can I know if my body is the “correct” size? The American medical industry began to use BMI, or body mass index, more consistently in the 1980s, and curiously changed the cutoffs of what was considered “normal” abruptly in 1998. Overnight, this action changed about 25 million Americans from a category of “normal” to overweight. So what's the science behind it? Where did this measurement come from? Why should we care about it? Is it helpful to put our bodies in “categories”? Do these categorizations actually help us understand and ultimately prevent disease? Are there other ways of assessing our health that could be more reliable and beneficial?Thankfully, meaningful research exists to provide helpful data on how to navigate these questions. AND BOY, DO WE HAVE THE EXPERT FOR IT! Ragen Chastain is a speaker, writer, researcher, Board Certified Patient Advocate, multi-certified health and fitness professional, and thought leader in weight science, weight stigma, and healthcare. Utilizing her background in research methods and statistics, Ragen has brought her signature mix of humor and hard facts to healthcare, corporate, conference, and college audiences.WE ARE SO FORTUNATE TO HAVE HER WITH US!Topics in this episode include:Where did the BMI calculation come from?What about kids? How are kids BMIs measured?Why did BMI cutoffs abruptly change in 1998?How can the BMI cutoffs create situations where people can be vulnerable to discrimination?What is the "success rate" (according to research) for attempting intentional weight loss?What is "weight cycling"? How is it harmful?Other than body shape/size/fat percentage - what other measures of health have been studied that are good (maybe better) predictors of disease risk?What is the new “clarifying” policy the AMA adopted recently to address the role of BMI in medicine?Ragen has a Substack titled "Weight and Healthcare". Check it out!Ragen recommends the HAES (Health At Every Size) Health Sheets for a great comprehensive, evidence-based resource. Her Instagram handle is @ragenchastain, and her Twitter handle is @danceswithfatRagen also recommends the following resources:NAAFA- The National Association to Advance Fat Acceptance (@naafaofficial on IG)FLARE- Fat Legal Advocacy, Rights, and Education (@flareforjustice on IG)Dove's work to end body size discrimination. Matheson, et al research- "

Episode 144: Risk Factors for Pediatric Overweight and ObesityFuture Dr. Lal describes multiple risk factors associated with childhood overweight and obesity. Dr. Arreaza adds comments about caring for pediatric patients with obesity. Practice guidelines are mentioned throughout this episode.Written by Krustina Lal, MSIII, Western University College of Osteopathic of the Pacific. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction:Obesity is one of the most common pediatric chronic diseases affecting 14.4 million children and adolescents (about twice the population of New Jersey).A recent simulation study from the US found that by 2030, a staggering 55–60% of today's children will be obese.1 in 4 children in California have obesity.Research shows that the ages between 0 and 5 years is a critical period in the development of overweight and obesity. Obesity has complex genetic, physiologic, socioeconomic, and environmental contributors. Pediatricians and other primary care physicians need to be aware of the risk factors for pediatric obesity to provide early anticipatory guidance for prevention, close monitoring, and early intervention when the weight trajectory increases.We will discuss the risk factors for children and adolescents to develop overweight and obesity, we will be diving deep into general, environmental, and familial factors. This is based off the AAP (American Academy of Pediatrics) “Clinical Practice Guidelines for the Evaluation and Treatment of Children and Adolescents with Obesity.” This guideline was published in February 2023, it is available online for free, and this is the first edition.A. General Factors- Socioeconomic StatusA longitudinal analysis of predominantly non-Hispanic white children in the United States found that low socioeconomic status before 2 years of age was associated with higher obesity risk by adolescence in both boys and girls.Poverty is associated with toxic stress, limited access to healthy foods, and low physical activity.-Children in Families That Have Immigrated to the USRecently arrived immigrants tend to be healthier than their US-born counterparts. However, as immigrants try to adjust to a new culture, they may adopt Americanized foodways, which are high in fat, sugar, and salt.Second-generation Hispanic immigrants are 55% more likely to have obesity than nonimmigrant white children, whereas first-generation Asian immigrants had a 63% lower risk of having obesity.Larger body sizes may be an indication of health and wealth in some cultures. This cultural factor may make it more difficult for parents to understand the gravity of their children's obesity.Comment: This is a common concern among Hispanic families that bring their children to the clinic to get “vitamins” to gain weight because they look “sick,” but their BMIs are normal. PCPs should be prepared to address that concern in the clinic.B. Neighborhood and Community Environments-School EnvironmentThe presence of fast foods, vending machines, and/or sweetened beverages in schools may negatively influence children's food choices, this effect is larger in younger grades.One day I went to have lunch with Devin, I liked that they had to go through the salad bar before they went to get other foods. They had the choice between vegetables or fruits.-Lack of Fresh Food AccessNeighborhood food environment has been shown to have a mixed association with children's BMI.Children and families in these settings may be unable to access fresh fruits and vegetables and safe physical activity spaces. There may be limitations in transportation, cost, affordability, and availability.-Fast food proximityLow-priced, calorie-rich fast foods with elevated levels of saturated fat, simple carbs, sugar, and sodium are commonly sold in fast food restaurants. Because they are easily available, they taste good, and they are strategically marketed, fast foods tend to be popular among children and adolescents.Some studies, not all, have shown an association between fast food locations near schools and obesity in children; a stronger association is seen in populations with lower socioeconomic status.-Access to safe physical activityGreater exposure to green space has been shown to be associated with higher levels of physical activity and a lower risk of obesity.That is something we have to recommend during our well-child visits. We are seeing a lot of aversion to going outside among the new generations. Going out seems to be torture when they find so much fun inside their houses (countless amounts of videos, video games, air conditioning/heater, etc...). A strategy for parents can be recommended 1 hour of playing outside before allowing screen time.-Environmental Health  Exposure to environmental hazards during the prenatal period, infancy, and childhood can have impacts on the health and well-being of children.Exposure to endocrine-disrupting chemicals may occur through breastfeeding, inhalation, ingestion, or absorption through the skin. We are basically surrounded by hazardous chemicals used in cleaning agents, food packaging, pesticides, fabrics, upholstery, etc. Exposure during early childhood can affect the programming of several systems, including endocrine and metabolic systems, which may affect BMI, cardiovascular, and metabolic outcomes later in life. C. Family and home environment factors-Parenting feeding styleFour types of parent feeding styles have been described:AuthoritativeAuthoritarianPermissive or indulgentNegligentAuthoritative feeding is considered protective against excessive weight gain. Children tend to eat more healthy foods, be more physically active, and have healthier BMI compared with children raised in homes with authoritarian, permissive or indulgent, or negligent parenting styles.-Sugar-sweetened beverages within the homeA systematic review of 20 prospective cohort studies and randomized controlled trials from 2013 to 2015 found that sugar-sweetened beverages (SSBs) were positively associated with obesity in children in all but 1 study.Comment: Sugary drinks are an easy way to get calories in your body. People tend to think that drinks don't count, but they can be loaded with carbs. Orange juice can have up to 25 grams of sugar in a cup, some sodas may have double, and both are high in sugar.-Portion sizes and snacking behavior Positive association but need long-term studies-Dining out and family mealsEating outside of the home—irrespective of the type of restaurant establishment visited—is associated with a higher risk of weight or BMI gain.Conversely, 2 meta-analyses found that an increased frequency of eating family meals was associated with a lower risk of childhood obesity.-Screen time – This is one of the major struggles we have as parents. It's a daily fight.A recent meta-analysis reported a 42% greater risk of being overweight or obese with more than 2 hours per day of television (TV) compared with 2 or fewer hours.Meta-analysis showed that even short exposure to unhealthy food and beverage marketing targeted at children resulted in increased dietary intake and behavior during and after the exposure.Marketing occurs via television, websites, online games, supermarkets, and outside schools.Male children and adolescents tend to spend more time on media screen devices and other Internet technology than female children and adolescents do.There is no conclusive guideline about it, but in general, we can recommend sleep hygiene to avoid insomnia or abnormal sleep patterns, such as avoiding “screens” 1 hour before bed.-Sedentary behaviorNo association. However, many confounding factors include physical activity, screen time, and unhealthy food intake.-Sleep durationChildren 13 years and younger with short sleep duration (∼10 hours) had a 76% increased risk of being overweight or obese compared with their counterparts with longer sleep duration (12.2 hours).Sleep restriction may be associated with increased calorie consumption, fatigue, and decreased physical activity.-Environmental smoke exposureChildren under 8 years old exposed to environmental tobacco smoke (ETS) have been found to have higher BMI compared with their nonexposed counterparts.I wonder If this is a direct or indirect effect of smoke.-Psychosocial stressA meta-analysis showed that prenatal psychological stress was associated with a higher risk of childhood and adolescent obesity.Psychosocial and emotional issues may lead to weight gain through maladaptive coping mechanisms, including eating in the absence of hunger to suppress negative emotions, appetite up-regulation, low-grade inflammation, decrease in physical activity, increase in sedentary behavior, and sleep disturbance. Depression has been shown to be a risk factor in both pediatric and adult obesity.-Adverse childhood experiencesACEs include a history of physical, emotional, or sexual abuse; exposure to domestic violence; household dysfunction from parental divorce or substance abuse; economic insecurity; mental illness; and/or loss of a parent because of death or incarceration.A study found that having many ACEs increased two times the risk of children having overweight or obese compared with children with no history of ACEs. Stress may result in abnormal coping strategies—such as binge eating, eating in the absence of hunger, impulsive eating, and poor sleep hygiene—which may result in further weight gain.Summary: The consequences of childhood obesity are far-reaching and extend beyond physical health issues. Children with obesity are more likely to experience a range of health complications, including type 2 diabetes, high blood pressure, sleep apnea, joint problems, and psychological issues such as low self-esteem and depression. Moreover, children with obesity are at a higher risk of carrying their weight-related problems into adulthood, increasing their susceptibility to chronic conditions such as cardiovascular disease, certain types of cancer, and premature mortality. As medical providers, we all need to keep general, environmental, and familial factors in mind when discussing weight changes among our pediatric patients. Having knowledge of such influences will help us intervene and prevent further progression. ______________________________Conclusion: Now we conclude episode number 144, “Risk Factors for Pediatric Overweight and Obesity.” Future Dr. LaL reminded us that childhood obesity is a disease linked to multiple risk factors, including but not limited to: low socioeconomic status, lack of access to safe spaces for exercise, parenting feeding styles, sleep disturbances, and adverse childhood events. Dr. Arreaza emphasized the importance of providing obesity care with kindness and empathy, especially when caring for pediatric patients.This week we thank Hector Arreaza and Krustina Lal. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Sarah E. Hampl, Sandra G. Hassink, Asheley C. Skinner, Sarah C. Armstrong, Sarah E. Barlow, Christopher F. Bolling, Kimberly C. Avila Edwards, Ihuoma Eneli, Robin Hamre, Madeline M. Joseph, Doug Lunsford, Eneida Mendonca, Marc P. Michalsky, Nazrat Mirza, Eduardo R. Ochoa, Mona Sharifi, Amanda E. Staiano, Ashley E. Weedn, Susan K. Flinn, Jeanne Lindros, Kymika Okechukwu; Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics February 2023; 151 (2): e2022060640. 10.1542/peds.2022-060640. https://publications.aap.org/pediatrics/article/151/2/e2022060640/190443/Clinical-Practice-Guideline-for-the-Evaluation-and?autologincheck=redirected.Weihrauch-Blüher, S., Wiegand, S. Risk Factors and Implications of Childhood Obesity. Curr Obes Rep 7, 254–259 (2018).Hemmingsson, E. Early Childhood Obesity Risk Factors: Socioeconomic Adversity, Family Dysfunction, Offspring Distress, and Junk Food Self-Medication. Curr Obes Rep 7, 204–209 (2018).Royalty-free music used for this episode: "Latina Havana Boulevard." Downloaded on October 13, 2022, from https://www.videvo.net/ 

The DoctorXDietitian duo chat with Jason about his emotional childhood struggles and sneaking food to cope, succeeding on Fen-Phen only to regain all the weight back. He felt trapped, scared, and alone in his 520-pound body.Being unable to drive his young daughters alone was the breaking point that led him to bariatric surgery. Dr. Dovec recounts one of the most challenging conversations she's ever had with a patient in the pre-op waiting area and Jason's reaction to her tough love.Jason vulnerably recounts life's highs and lows and how he's maintaining a 300-pound weight loss these days at a fit 220 pounds.June is Men's Health Month and Father's Day marks the end of Men's Health Week which raises awareness for a man's physical and mental health, and social connection.Bariatric surgery is the most effective treatment for severe obesity. It significantly lowers BMI, improves comorbidity severity, and decreases mortality. Despite these benefits, there is a marked gender difference in patients undergoing bariatric surgery. Nationally, only 19% of all bariatric surgeries were performed on men despite them having higher BMIs and comorbidities than female patients. Men, this is your reminder to take charge of your health! Jason hopes he inspires someone to change their life - maybe, it's yours.

Will Page returns to the show for a “state of the industry” episode. In last year's appearance he correctly called out the slowdown in streaming subscriptions, bubbles in web3, and more.Will believes the value of copyrighted music could hit $45 billion annually when the 2022 numbers are calculated — up $5 billion from 2021, which is already an all-time high for the industry.  Another massive shift is glocalisation”: the trend of local music dominating the domestic charts, as opposed to Western artists. This phenomenon isn't just being felt in music, but across every industry, from film to education.We covered both these trends, plus many more. Here's all our talking points: 1:33 Why the music industry is actually worth $40+ billion annually7:03 Physical music sales on the up and up10:47 How publisher and labels split up copyright value16:59 The rise of “glocalisation” will impact every industry34:39 DSP carnivores vs. herbivores 40:23 Why video vs. music streaming isn't a perfect comparison 46:31 Music as a premium offering in the marketplace 51:38 How to improve streaming royalties  1:06:05 AI music benefits that goes overlooked 1:10:07 Will's latest mix pays homage to Carole KingGlocalisation report: https://www.lse.ac.uk/european-institute/Assets/Documents/LEQS-Discussion-Papers/EIQPaper182.pdfWill Page's 2023 Believe in Humanity:https://www.mixcloud.com/willpagesnc/2023-believe-in-humanity/Listen: Apple Podcasts | Spotify | SoundCloud | Stitcher | Overcast | Amazon | Google Podcasts | Pocket Casts | RSSHost: Dan Runcie, @RuncieDan, trapital.coGuest: Will Page, @willpageauthorThis episode is sponsored by DICE. Learn more about why artists, venues, and promoters love to partner with DICE for their ticketing needs. Visit dice.fmTrapital is home for the business of hip-hop. Gain the latest insights from hip-hop's biggest players by reading Trapital's free weekly memo. TRANSCRIPT[00:00:00] Will Page: I put so much emotional time and effort into making these mixes happen and going out for free.They get your DJ slots, but more importantly, it goes back to what makes me wanna work in music, which was a lyric from Mike G and the Jungle Brothers from that famous album done by the forties of Nature, where he said, it's about getting the music across. It's about getting the message across. It's about getting it across without crossing over.How can I get art across an audience without delegating its integrity? And it's such an honor to have this mixed drop in this Friday I mean, that's, made my year and we're not even into June yet.[00:00:30] Dan Runcie Intro: Hey, welcome to the Trapital Podcast. I'm your host and the founder of Trapital, Dan Runcie. This podcast is your place to gain insights from executives in music, media, entertainment, and more who are taking hip hop culture to the next level.[00:00:56] Dan Runcie Guest Intro: Today's episode is all about the state of the music industry, and we're joined by the One and Only, Will Page. He is a fellow at the London School of Economics. He's an author of Tarzan Economics and Pivot, and he is the former chief economist at Spotify. Will's second time on the podcast. Now, the first time we talked all about the future of streaming and where things are going in music, and we picked that conversation, backed up.We talked about a bunch of trends including the glocalisation of music, which is from a new report that Will had recently put out. We also talked about why he values the music industry to be close to a 40 billion industry, which is much higher than a lot of the reports about recorded music itself.And we also talk about a bunch of the topics that are happening right now, whether it's ai, how streaming should be priced, the dynamic between record labels and streaming services, and a whole lot more love. This conversation will always brings it with these conversations, so I hope you enjoy it as much as I did. Here's our chat.[00:02:00] Dan Runcie: All right, today we have the one and only Will Page with us who is recording from a beautiful location. I don't know if you're listening to the pod you can't see, but will tell us where you are right now.[00:02:09] Will Page: So great to be back like a boomerang on Trapital. Dan, and I'm coming to you from the Platoon Studios. Part of the Apple Company Platoon is our label services company, which is owned by Apple. They're doing great stuff with the artists like Amapiano music from South Africa. And the best place I can describe to you here, it's like a Tardus.Have you've ever seen Dr. Who? There's a tiny door in this tall yard music complex in North London just behind Kings Cross. When you enter that tiny door, you enter this maze of the well class spatial audio recording studios of Apple. And it's an honor they've given me this location to come to Trapital today.[00:02:41] Dan Runcie: Well we're gonna make the best of it here and it's always great to have you on, cuz Last year, last year's episode felt like a state of the industry episode, and that's where I wanna start things off this year with this episode.A couple months ago, you put out your post in your Tarzan economics where you said that this industry is not a 2020 5 billion industry, the way others say. Mm-hmm. You say, no, this is almost a 40 billion industry. So let's break it down. How did you arrive there and what's the backstory?[00:03:12] Will Page: I get goosebumps when you say that you think like 10 years ago we were talking about a 14 billion business and now it's a 40, you know, skews a slurred Scottish pronunciation, but let's just be clear from one four to four zero, how did that happen?Well the origins of that work, and you've been a great champion of it, Dan, is for me to go into a cave around about October, November and calculate the global value of copyright and copyright is not just what the record labels publish, that famous IFPIGMR report that everyone refers to, but it's what collecting studies like ask F and BMI collect what publishers generates through direct licensing.You have to add A plus B plus C labels, plus collecting societies plus publishers together. Then the complex part, ripping out the double counting and doing all the add-backs, and you get to this figure of 39.6 billion, which as you say, you round it up, it begins with a four. And I think there's a few things that we can kind of get into on this front.I think firstly we should discuss the figure. I'll you a few insights there. Secondly, I think we should discuss the division. And then thirdly, I want to cover the physical aspect as well. So if you think about the figure, we've got 39.6 billion. We know it's growing. I think what's gonna be interesting when I go back into that cave later this year to redo that number, it's gonna be a lot bigger.Dan, I'll see it here on Trapital First. I think a 40 billion business in 2021 is gonna be closer to a 45 billion business in 2022. And one of the reasons why it's not labels and streaming, it's a combination of publishers are reporting record collections, essentially they're playing catch up with labels, booking deals that perhaps labels booked a year earlier.And collecting studies are gonna get back to normal after all the damage of the pandemic. And when you drive those factors in where you have a much bigger business than we had before. So for the people listening to your podcast who are investing in copyright, this party's got a waiter run. You know, don't jump off the train yet cause this thing is growing[00:05:18] Dan Runcie: And the piece I want to talk about there is the publishing side of this. If you look at the breakdown of the numbers you have, the publishing is nearly, publishing plus is nearly 13 billion itself. The major record labels own most of the largest publishers right now. Why isn't this number just automatically included? Wouldn't it be in everyone's advantage to include the fact that yes, Universal Music Group and Universal Music Publishing Group are together, part of the entity that make this, whether it's them, it's Warner Chapel, it's others. Why isn't this just the top line number that's shared in all of the other reports?[00:05:56] Will Page: It would be nice if it was, and indeed, I think the publishing industry around about 2001 used to do this. They haven't done it since. But it's like spaghetti. It's the best way I can describe it. I mean, how do you measure publisher income? You know, is it gross receipts by the publisher? Is it the publisher plus the collecting Saudi? That is money that went straight to the songwriter and didn't touch the publisher. So what the publisher holds onto what we call an industry, a net publisher, shares all these weird ways of measuring this industry that we have to be clear on.And it's, not easy. but I think what we do in the report is we try and make it bite size. We try and make it digestible to work out how much of that publisher's business came through, CMOs, the S gaps and BMIs this X over here PS music and how much do they bring in directly? And that allows you to understand a couple of things.Firstly, how do they compare vi to vis labels in terms of their overall income? And secondly, how do they compare when they go out to market directly, let's say putting a sync and a TV commercial or movie versus generating money through collective licensing that is radio or TV via ASCAP or bmr. So you get an interpretation of how these publishers are making those numbers work as well.[00:07:03] Dan Runcie: That makes sense. And then when we are able to break it down, we see a few numbers that roll up into it. So from a high level, at least what you shared from 2021, we have that 25.8 billion number from the recorded side. So that does fall in line with what we see from what the IPIs and others share. 10 billion Sure.From the publishing. And then you do have, the next 3.5 and then a little sliver there for royalty free and for the publishers' direct revenue that doesn't come from the songwriters. The next piece though, within the elements of how all of the revenue flows into that. We've talked a lot about streaming and we've talked, we'll get into streaming in a little bit, but I wanna talk about the physical side cause that was the second piece that you mentioned.We've all talked about vinyl, but it's not just vinyl. So could you talk a bit about where the trends are right now with physical sales and why this is such a huge factor for this number?[00:07:56] Will Page: Who would've thought on a Trapital podcast in May, 2023. We'll be talking about physical as a second topic on the agenda, but it's worth it. I mean, it's not a rounding era anymore. It's not chump change. in America, physical revenues largely vinyl outpaced the growth of streaming for the second year straight. It's not as big as streaming, but it's growing faster and it has been growing faster for two years now. That's crazy. Here in the uk the value of physical revenues to the UK music industry has overtaken the value of physical to Germany.Quick bit of history. For years, decades, Germans used to buy CDs. that's fallen off a cliff. They've given up on CDs. Whereas over here in Britain, we've all started buying vinyl again. So the value of vinyl in Britain is worth more than the value of CDs to Germans, that type of stuff you didn't expect to see.And if you go out to Asia, you see the CD market still strong. You've still got people who buy more than one copy of the same cd, of the same band. Don't ask me to explain the rationale for that, but it happens and it moves numbers. But after all this, when the dust settles, I mean a couple of observations, all the data to me is suggesting that 55, 60% of vinyl buyers don't actually own a record player.So I think it was Peter Drucker who said, the seller really knows what they're selling, and I don't think you're selling intellectual property or music cop right here. What we're actually selling is merchandise, you know, Taylor Swift, I got an email from Taylor Swift team saying they've got a marble blue vinyl coming out this week.Now we're talking about vinyl in the same way we used to talk about stone wash jeans, marble blue. This is like the fourth version of the same 11 songs priced at 29 99. Let's just figure that out for a second. I'm willing to give you 10 bucks a month to, access a hundred million songs on streaming services, but I'm also, it's the same person.I'm also willing to give you 30 bucks to buy just 10 of them. This is expensive music and I might not even be listening to it cause I don't even have a record player.[00:09:55] Dan Runcie: This is the fascinating piece about how we're calculating this stuff because the vinyl sales and all of that has been reported widely as a great boom to the industry and it has been.We've seen the numbers and in a lot of ways it brings people back to the era of being able to sell the hard copy of the thing itself, but it's much closer to selling a t-shirt or selling a sweatshirt or selling some type of concert merchant. It actually is the actual physical medium itself. So it'll be fascinating to see how that continues to evolve, how that embraces as well. On your side though, as a personal listener, do you buy any vinyls yourself that you don't listen to, that you just keep on display or?[00:10:34] Will Page: It's like your shoe collection, isn't it? Yes, right. Is the answer to that. But no, I mean, I will say that I got 3000 fi funk records in the house and they're all in alphabetical chronological order.So if they haven't been listened to, at least I know where to find them.[00:10:48] Dan Runcie: That's fair. That makes sense. So let's talk about the third piece of this, and that's the division of this. So you have the B2C side and you have the B2B side. Can we dig into that?[00:10:59] Will Page: Sure. this is, I think the backdrop for a lot more of the sort of thorny conversations happening in the music industry is now, you may have heard that in the UK we've had a three year long government inquiry into our business.We had the regulator turn over the coals, and so there's a lot of interest in how you split up this 40 billion dollar piece of pie. who gets what? And the division I'm gonna talk about here is labels an artist on one side. Songwriters and publishers on the other side as it currently stands, I would keep it simple and say two thirds of that 40 billion dollars goes to the record label and the artist, one third goes to the publisher and the songwriter.Now, when I first did this exercise back in 2014, it was pretty much 50 50, and when you see things which are not 50 50 in life, you're entitled to say, is that fair? Is it fair that when a streaming service pays a record label a dollar, it pays the publisher and the songwriter around 29 cents? If you're a publisher, a songwriter, you might say, that's unfair, cuz I'm getting less than them.I have preferences, issues, and I have any issues with this division. Well, let's flip it around. If you look at how B2B world works, licensing at the wholesale level, let's say you're licensing the bbc, for example, if your song's played on the bbc, you're gonna get 150 pounds for a play. 90 pounds goes to the songwriter and the publisher, 60 pounds goes to the artist and a record label.Now, is that fair? Why does the publisher win in the B2B market? By the record, label wins in the B2C market. And the one, the lesson I want to give your listeners is one from economics, and it's rarely taught university these days, but back in 1938, 1939, in a small Polish town called la. Now part of the Ukraine, ironically, free Polish mathematicians sat in a place called a Scottish Cafe, ironic for me, and invented a concept called Fair Division.And the question they posed was, let's imagine there's a cake and there's two people looking at that cake getting hungry. There's Dan Runcie over in the Bay Area and there's Will page back in Edinburgh. What's the best way to divide that cake up? And the conclusion they came up with is you give Will page, the knife.Aha, I've got the power to cut the cake. But you give Dan Runcie the right to choose which half. Damn, I've gotta make that cut really even otherwise, Dan's gonna pick the bigger half and I'll lose out. And this divider two model gave birth to the subject of fair Division and it simply asked, what makes a fair division fairer?How can I solve a preference? How can I solve for envy? I want that slice, not that slice. I'm unhappy cause Dan got that slice and not that slice. There's a whole bunch of maths in this. We had a third person that gets more complex. But I just wanna sow that seed for your listeners, which is when we ask questions like, why is it the label gets a dollar and the publisher gets 29 cents?There's gotta be some rationale why you know who bets first? Is it the label that bets first or the publisher who commits most? Is it label that commits most marketing spend or the publisher? These types of questions do with risk, often help answer questions of fair division, or to quote the famous Gangstar song, who's gonna take the weight?Somebody's gotta take a risk when you play this game, and perhaps there's a risk reward trade off, which is telling us who gets what Share of the spoils.[00:14:15] Dan Runcie: Let's unpack this a little bit because it's easy to see. May not be fair, but it's easy to see why the record labels get preference on the B2C side because as I mentioned before, the record labels have acquired a lot of the publishers, and especially in the streaming era, they were prioritizing that slice of the pie, their top line, as opposed to what essentially is the subsid subsidiary of their business, the publishing side.Why is it flipped with sync? Well, how did that dynamic end up being that way?[00:14:47] Will Page: That's an anomaly, which is actually blatantly obvious. You just don't think about it. And the way it was taught to me is anyone can record a song, but only one person can own a song. So I think, let's give an example of, I don't know, a Beach Boy song where I could ask for the original recording of that Beach Boy song to be used in the sync.Or I could get a cover band. So let's say I got a hundred thousand dollars to clear the rights of that song, and the initial split should be 50 50. If a band is willing to do a version of it for 10,000, the publisher can claim 90,000 of the budget and get the option. If the record label objects and says, well, I wish you used a master.Well, you got a price under the 10,000 to get the master in. So this kind of weird thing of bargaining power, if you ever hear. Let me scratch that again. Let me start from the top. Let me give you a quick example, Dan, to show how this works. One of my favorite sort of movies to watch when you're Bored and killing Time is The Devil's Swear, Prada great film.And then that film is a song by Seal called Crazy, incredible song, timeless. That guy has, you know, timeless hits to his name, but it's not him recording it. Now, what might have happened in that instance is the film producer's got a hundred thousand to get the song in the movie, and he's looking to negotiate how much you pay for publishing, how much you pay for label.Now the label is getting, you know, argumentative, wanting more and more, and the publisher is happy with a certain fee. Well, the film producer's got an option. Pay the publisher of the a hundred thousand, pay him 90,000, given the lion share of the deal. And then just turn the label and say, screw you. I'm gonna get a covers bant and knock me out.A decent version of it. And this happens all the time in TV films, in commercials, you'll hear covers of famous songs. And quite often what's happening there is you gotta pay the publisher the lion share of your budget and then just cough up some small chains to the covers bant to knock out a version.And then, so just a great reminder, Dan of anyone can record a song, but only one person can own the song that is the author. And that's why negotiating and bargaining power favors publishes in sync over the record labels.[00:16:59] Dan Runcie: That makes sense. And as you're saying that, I was thinking through five, six other examples of cover songs I've seen in many popular TV shows and movies.And this is exactly why?[00:17:08] Will Page: It's always car commercials. For some reason, every car commercial's got cover in a famous song. You think, remember that weird Scottish guy down Ronie Trapital? Yeah. That's what's happened. The publishers pool the rug from under the record label's feet at negotiation table.Another super important observation about the glocalisation trend, Dan, is I'm gonna take one of those 10 countries as our spotlight, Poland. Now the top 10 in Polands or Polish, the top 20 in Poland, or Polish. In fact, if you go to the top 40, it's pretty much all Polish bands performing in Polish, and you could say that's localization.But stop the bus. Most of those acts are performing hip hop, which is by itself a US genre. So perhaps we've got glocalisation of genre, but localization of language and artist. And that's a very important distinction for us to dissect. And perhaps it's for the anthropologist, the sociologist, to work out what's going on here.But it's not as straightforward as it's just local music. It's local music, but it's global genres, which is driving us forward.[00:18:08] Dan Runcie: And that's a great point for the people that work at record labels and other companies making decisions too, because there's been so much talk about hip hop's decline. But so much of that is focused on how this music is categorized and a lot of it's categorized solely on.What is considered American hip hop. But if you look at the rise of music in Latin America, which has been one of the fastest growing regions in the world, most of that music is hip hop. Bad Bunny considers himself a hip hop artist. You just brought up this example of Polish hip hop being one of the most popular genres there.So when we think about. How different genres get categorized, which genres get funding. Let's remember that key piece because hip hop is this culture and it's global, and that's gonna continue. So let's make sure that we are not taking away from a genre that is really one of the most impactful and still puts up numbers if we're categorizing it in the right way.[00:19:04] Will Page: Damn straight. I mean, I think genres are often like a square peg trying to fit into a round hole and in a paper published by London School of Economics, I was honored to use that line that I think I said on trap last time, which is rap is something you do. Hip hop is something you live. Rap could be the genre, hip hop could be the lifestyle.Maybe what those Polish acts getting to the top of the charts of doing is representing a lifestyle, but they're doing it in their mother tongue.[00:19:28] Dan Runcie: Well said. Agreed. Well, let's switch gears a bit. One topic that I wanna talk about, and I actually gave a talk recently, and I referenced you from this term, and its of music, was the glocalisation of music and why this is happening and what it means for Western music specifically in the us. But first, if you could define that term and explain why this is so important in music right now.[00:19:53] Will Page: Well, I'm so excited to be on Trapital talking about this because we are now officially published by London School of Economics, so I'm gonna make my mom and dad proud of me. At last Backstory, paperback of my book, guitars in Economics, retitled to Pivot. Apparently WH Smith's Travel and Hudson Travel said books with economics in their titles Don't sell an airport.So we've rebranded the whole book to Pivot and it's in airports, which is a result. that book, that paperback came out on the 6th of February and that night I was on the BBC one show and they had this great happy, clappy family friendly story. They wanted to bounce off me. They said, Hey, will, Isn't it great that the top 10 songs in Britain last year were all British ex?For the first time in 60 years, Britain got a clean sweep of the top 10 in the music charts. And I said, curb your enthusiasm because we're seeing it elsewhere. The top 10 in Germany, were all German. Top 10 in Italy, all Italian, ditto France, deto Poland. And if you go to Spain, the top 10, there were all Spanish language, but largely Latin American.So it's not just a British thing that we've seen this rise of local music on global streaming platforms. We're seeing it everywhere, cue some gulps and embarrassments live in the TV studio. But I made my point and I came out of that interview thinking. Well that stunned them. It's gonna stu more people.And I said about working on a paper called glocalisation, which with a Scottish accent, it's hard to pronounce. Let's see how you get on with it. Not localization and not glocalisation. Emerging to by definition and by practice glocalisation. I teamed up with this wonderful author, Chris Riva, who'd be a great guest on your show.He did a wonderful blog piece you may have read, called Why is There No Key Changes in Music anymore? It's a really beautiful piece of music writing and there isn't. Nobody uses key changes in the conclusion of songs. And we set out to do this academic study to explain to the world what's been happening in music and why it's relevant to everyone else.And what we saw across 10 European countries was strong evidence of local music dominating the top of the charts in these local markets on global platforms. Now history matters here. We didn't see this with local High street retailers, America, British, Canadian music dominated those charts. We still don't see it in linear broadcast models like radio and television, you know, it's still English language repertoire dominating those charts. But when it comes to global streaming, unregulated free market, global streaming, we see this phenomenal effect where local music is topping the charts. And you know, you look at what does it mean for us English language countries like ourselves?It means things get a little bit tough. It means exporting English language repertoire into Europe becomes harder and harder. Maybe I'll just close off with this quite frightening thought, which is Britain is one of only three net exporters of music in the world. The other two being your country, United States and Sweden.Thanks to a phenomenal list of Swedish songwriters and artists. And I can't think of the last time this country's broken a global superstar act since Dua Lipa in 2017. Dan, we used to knock them out one, two a year. 2017 was a long time ago, and it's been pretty dry since.[00:23:13] Dan Runcie: And that's a great point for the people that work at record labels and other companies making decisions too, because there's been so much talk about hip hop's decline. But so much of that is focused on how this music is categorized and a lot of it's categorized solely on.What is considered American hip hop. But if you look at the rise of music in Latin America, which has been one of the fastest growing regions in the world, most of that music is hip hop. Bad Bunny considers himself a hip hop artist, you just brought up this example of Polish hip hop being one of the most popular genres there.So when we think about, how different genres get categorized, which genres get funding. Let's remember that key piece because hip hop is this culture and it's global, and that's gonna continue. So let's make sure that we are not taking away from a genre that is really one of the most impactful and still puts up numbers if we're categorizing it in the right way.[00:24:07] Will Page: Damn straight. I mean, I think genres are often like a square peg trying to fit into a round hole and in a paper published by London School of Economics, I was honored to use that line that I think I said on trap last time, which is rap is something you do. Hip hop is something you live. Rap could be the genre, hip hop could be the lifestyle.Maybe what those Polish acts getting to the top of the charts of doing is representing a lifestyle, but they're doing it in their mother tongue.[00:24:32] Dan Runcie: Well said. Agreed. This is something that's been top of mind for me as well because technology in general has a way of making regions and making people in particular regions closer together than it does making the world bigger. It's like in, in a sense, technology can make the world seem bigger, but it actually makes it seem smaller, right? And I think that algorithms and bubbles that come from that are another symptom of this.But this is going to have huge implications for Western music. You mentioned it yourself. All of these markets that are used to being export markets, when they no longer have the strength to be able to have those exports, how does that then change the underlying product? How does that then change the budgets, the expectations of what you're able to make? Because if you're still trying to maintain that same top line revenue, you're still trying to maintain those airwaves you have, it's gonna cost you more money to do that, because you can't rely on the few Western superstars that you have to get, that you have to have equivalent of a superstar or at least a middle tier star in every region that you once had strong market share that you could export in.And it's gonna change cost structures. It's gonna change focus. And a lot of these expansions that we've seen of record labels, especially Western record labels, having strong footprints in different regions across the world, they're not just gonna need to have presence, they're gonna need to have strong results.And in many ways, try to rival the own companies that are in those comp, in those regions, the homegrown record labels, because every country is trying to do their own version of this and it's gonna be tight. This is one of the challenges that I think is only gonna continue to happen.[00:26:14] Will Page: You're opening up a real can of worms. I get it. Pardon to your listeners, we're getting excited here. Day of publication, first time we've been able to discuss it on air, but I know I'm onto something huge here and you've just illustrated why just a few remarks. One, some of the quotes that we have in the paper were just phenomenal. We have Apple included in the paper. We have Amazon, Steve Boom, the head of that media for Amazon in charge of not just music, but Twitch audio books, the whole thing. He's looking at all these media verticals. He makes this point where he says, as the world becomes more globalized, we become more tribal. Stop right there, as he just nailed it.What's happening here? It's The Economist can only explain so much. This is what's so deep about this topic. I wanna toss it to the anthropologist of sociologists to make sense of what I've uncovered, but it's massive. Now let's take a look at what's happening down on the street level with the record labels and the consumers. You know, the record labels are making more money and they're devolving more power to the local off seats. You know the headcount in the major labels, local off season, Germany, France, and Vietnam or wherever is doubled in the past five years. It hasn't doubled in the global headquarters. That's telling you something.If you look at how labels do their global priority list, maybe every month, here's 10 songs we want you to prioritize globally. So I had a look at how this is done, and across the year I saw maybe 8, 10, 12 artists in total, and there's 120 songs. There's not that many artists. You think about how many local artists are coming out the gate every week hitting their local labels or local streaming staff, up with ideas, with showcases and so on.Not a lot of global priority. Then you flip it and you think about the consumer, you know, they've had linear broadcast models for 70 years where you get what you're given. I'm gonna play this song at this time and you're gonna have to listen to it. FM radio, TV shows now they're empowered with choice and they don't want that anymore.They want what's familiar. What comforts them. They want their own stars performing in their own mother tongue topping those charts. So this has got way to go. Now, a couple of flips on this. Firstly, what does this mean for artists? And then I'm gonna take it out of media, but let's deal with artists.Let's imagine a huge festival in Germany. 80,000 people now festival can now sell out with just German X, no problem at all. So when the big American X or British X commanded like a million dollars a headlining fee, you wanna go play that festival. That promoter can turn around and say, sorry man, I can't generate any more money by having you on my bill.How much are you gonna pay me to get on stage? Price maker, price taker? You see what happens. And then the last thing, and there's so much more in this paper for your listeners to get to, and let's please link to it and you'll take, I'll take questions live on your blog about it as well, but. There's a great guy called Chris Deering, the father of the Sony PlayStation. Did you play the Sony PlayStation back in the day? Were you're a fan of the PlayStation.[00:29:08] Dan Runcie: Oh, yeah. PS one and PS two. Yeah. Okay.[00:29:11] Will Page: You, oh, so you, you're an OG PlayStation fella. So he's the father of the PlayStation and launching the PlayStation in the nineties and into the nineties. He offered us observation, which is when they launched a SingStar, which was karaoke challenge.In the PlayStation, he says, we always discussed why the Swedish version of SingStar was more popular in Sweden than the English version Science. Intuitive enough. Let me break it down. Gaming back then was interactive music was not, you interacted with your PlayStation, that's why you killed so much time with it. Music was just a CD and a plastic case that broke your fingernails when you tried to open it. That's how the world worked back then and gaming offered you choice. I could try and do karaoke with those huge global English language hits where I could go further down the chart and buy the Swedish version and sing along to less well known Swedish hits. And the consumer always picked the Swedish version. So as a bellwether, as a microcosm, what I think Chris Ding was teaching us was we saw this happening in gaming long before you started seeing it happen with music. 20 years ago when there was interactive content, which gaming was, music wasn't, and consumers had a choice, which gaming offered a music didn't.They went local. Today, Dan, we're dealing with music lists, A interactive, and B offers choice. And what we're seeing is local cream is rising to the top of the charts.[00:30:33] Dan Runcie: And we're seeing this across multimedia as well. We're seeing it in the film industry too. Even as recent as five, 10 years ago, you release any of the blockbuster movies that were successful in the us, almost all of them had some overseas footprint.Some of them definitely vary based on the genre, but they were always there. But now China specifically had been such a huge market for the Hollywood and Box office specifically, but now they're starting to release more of their own high ed movies and those are attracting much more audiences than our export content can one.Two, the Chinese government in general is just being very selective about what they allow and what they don't allow. And then three, with that, that's really only leaving certain fast and furious movies and Avatar. That's it. The Marvel movies are hit and missed depending on what they allow, what they don't allow, and how, and it's just crazy to see the implications that has had for Marvel Studios for everyone else in Hollywood as well.When you think about it, and we're seeing this across multimedia, I think there's a few trends here that makes me think about, one is. Population growth in general and just where those trends are and how different corporations can approach the opportunity. Because I look at Nigeria, you look at Ethiopia, these are some of the fastest growing countries in the world.And you look at the music that is rising more popular than ever, whether it's Amapiano or it's Afrobeats, that's only going to continue to grow. And that's only from a few regions in the huge continent of Africa. So when we're thinking about where success is gonna come from, where that lines up with infrastructure, people have been seeing it for years.But the reason that we're seeing the growth in Africa, the growth in Latin America, the growth in a lot of these markets is this trend of glocalisation and it's only going to increase. So if we're thinking about where we wanna invest dollars, where we wanna build infrastructure in the future, we not just being folks that live in the western world, but also elsewhere in the world, this is where things are heading.[00:32:37] Will Page: Let me come in down the middle and then throw it out to the side. So, Ralph Simon, a longtime mentor of mine, is quoted in the paper and where he's actually gonna moderate the address here at the Mad Festival here in London, which is for the marketing and advertising community here, where he says, what you've uncovered here that headwind of glocalisation is gonna affect the world of marketing and advertising this time next year.That's what will be the buzzword in their head. So if you think about, I don't know, a drinks company like Diagio, maybe they've got a globalized strategy and a globalized marketing budget. When they start seeing that you gotta go fishing where the fish are and the fish are localized, they're gonna devolve that budget and devolve that autonomy down to local offices. So the wheels of localization, this rise of local, over global, they've only just got started, if I've called it right. We're onto something way bigger than a 20 minute read LSE discussion paper. This goes deep, deep and far beyond economics. But then you mentioned as well China, I mean just one offshoot observation there, which is to look at education.If you look at the UK university system, about a third, if not more, of it is subsidized by the Chinese government and Chinese students here. Great for business, slightly dubious in its business, besties, charging one student more than another student for the same product. But that's what we do over here.And I recently, we made a fellow of Edmar University's Futures Institute, which is an honor to me, you know, gets me back home more often. Fine. And I was learning from them that. The quality of students coming from China to study here in Britain and across Europe is getting worse and worse. Why? Cuz the best students have got the best universities in China.They no longer need to travel. So there's a classic export import dilemma of, for the past 10, 15 years, universities have built a complete treasury coffer base of cash around selling higher education to the Chinese. And now the tables are turning. I don't need to send my students to you universities anymore.I'll educate them here. Thank you very much. So, like I say, this stuff is a microcosm. It's got a can of worms that can open in many different directions[00:34:39] Dan Runcie: And it's gonna touch every industry that we know of to some extent, especially as every industry watches to be global to some extent. This is going to be a big topic moving forward.Let's shift gears a bit. One of the terms that was really big for us. That came from our podcast we did last year. We talked about herbivores and we talked about carnivores, and we talked about them in relation to streaming. We haven't touched on streaming yet, and this will be our opportunity to dig down into it, but mm-hmm.For the listeners, can we revisit where that came from, what that means, and also where this is heading? What does this mean for music streaming right now as it relates to the services and competition?[00:35:24] Will Page: Well, when I first came on Trapital, that was in a small Spanish village of Cayo De Suria and I didn't think I'd come up with an expression that would go viral from a small village in Spain to be, you know, quoted from in Canada, in America.And Dan, this is quite hilarious. we have a new secretary of state of culture here in the UK. The right Honorable MP, Lucy Fraser KG, Smart as a whip. Brilliant. And when I first met her, you know what the first thing she said was, I listened to you on Trapital. I wanted to ask you about this thing you've got going called herbivores and carnivores.So right the way through to the corridors of power, this expression seems to have traveled. What are we talking about? Well, the way I framed it was for 20 years we've had these streaming services, which essentially grow without damaging anyone else. Amazon is up. Bigger subscriber numbers. Apple's got bigger subscriber numbers.YouTube and Nancy's bigger subscriber numbers. And then Spotify. Nancy's bigger subscriber numbers. Everyone's growing each other's gardens. That's fine. That's herbivores. What happens when you reach that saturation point where there's no more room to grow? The only way I can grow my business is stealing some of yours.That's carnivores. And the greatest example is simply telcos. We're all familiar with telcos. We all pay our broadband bills. How do telcos compete? Everybody in your town's got a broadband account, so the only way you can compete is by stealing someone else's business. The only way here in Britain Virgin Media can compete is by stealing some of skies.The only way that at and t competes is by stealing some of com. So that's carnival competition. Now, the key point for Trapital listeners is we don't know what this chapter is gonna read like cuz we've never had carus pronounce that word correctly. Carus behavior before. We've never seen a headline that said, Spotify's down 2 million subs and apple's up 2 million, or Amazon's up 3 million and you know, YouTube is down 3 million.We don't know what that looks like. So I think it's important for Trapital to start thinking about logical, plausible scenarios. You kick a one obvious one, which is again, a lesson from the telcos. When we do become carnivores, do we compete on price or do we compete on features? Let me wheel this back a second, you know, we'll get into pricing in more depth later. But downward competition on price tends to be how carnivores compete, and that'll be a fascinating development given that we've not seen much change in price in 22 years in counting or as we saw with Apple, they roll out spatial audio, they charge more for it, they've got a new feature, and they charge more for that feature.So do we see downward competition blood on the carpet price competition, or do we see. Upward competition based on features. I don't know which one it's gonna be. It's not for me to call it. I don't work for any of these companies. I've worked with these companies, but I don't work for any of them directly.But we have to start discussing these scenarios. How's this chapter gonna read when we start learning of net churn amongst the four horseman streaming services that's out there. It's gonna be a fascinating twist, and I'm beginning, Dan, I'm beginning to see signs of con behavior happening right now, to be honest with you.I can see switchers happening across the four, so I think we're getting there in the US and the UK. What are those signs you see? I'm just seeing that in terms of subscriber growth, it's a lot bumpier than before. Before it is just a clear trajectory. The intelligence I was getting was, everyone's up, no one needs to bother.Now I flag, you know, I signed the siren. I'm beginning to see, you know, turbulence in that subscriber growth. Someone could be down one month, up the next month. Maybe that's just a little bit of churn. The ending of a trial period, you don't know. But now for me, the smoke signals are some of those services are seeing their gross stutter.Others are growing, which means we could start having some switching. I can add to that as well. Cross usage is key here. I really hammered this home during my 10 years at Spotify, which is to start plotting grids saying, who's using your service? This person, that person, and next person now ask what other services are they using?And some data from America suggests that one in four people using Apple music are also using Spotify. And one in four people using Spotify are also using Apple Music. Cross usage confirmed. So if that was true, what do you make of that? With a public spending squeeze? With inflation, with people becoming more cost conscious in the economy with less disposable income, maybe they wanna wheel back from that and use just one, not two. And that's where we could start seeing some net churn effects taking place as well. So, you know, imagine a cross usage grid in whatever business you're working on. If your Trapital listeners and ask that question, I know who's using my stuff, what else are they using? Um, that's a really, really important question to ask to work out how this carnivore scenario is gonna play out.How are we gonna write this chapter?[00:40:23] Dan Runcie: This is interesting because it reminds me of the comparisons that people often make to video streaming and some of the dynamics there where prices have increased over the years. I know we've talked about it before to tend to a 12 years ago Netflix was cheaper than Spotify was from a monthly, US price group subscription.And now tough, tough. It's right. And now it's nearly twice the price of the current price point. That it is. The difference though, when we're talking about when you are in that carnival, when you're in that carnival market, what do you compete on? Features or price? Video streaming, you can compete on features essentially because the content is differentiated.If you want to watch Wednesday, that Netflix series is only one platform that you can watch it on. Yeah, you need to have that Netflix subscription, but in music it's different because if you wanna listen to SZA's SOS album, that's been dominating the charts. You can listen to it on any of these services.So because there are fewer and fewer limitations, at least, if your goal, main goal from a consumption perspective is to listen to the music, how do you then differentiate, which I do think can put more pressure on price, which is very interesting because there is this broader pricing debate that's happening right now about why prices should be higher.And we've seen in the past six plus months that Apple has at least raised its prices. Amazon has done the same, at least for new subscribers. Spotify has announced that it will but hasn't yet and this is part of that dynamic because on one hand you have these broader economic trends as you're calling them out, but on the other hand you do have the rights holders and others pushing on prices to increase.And then you have the dynamic between the rights holders and then the streaming services about who would then get the increased revenue that comes. So there's all of these fascinating dynamics that are intersecting with this her before shift to carnivores[00:42:23] Will Page: For sure. Let me just go around the block of those observations you offered us. All relevant, all valid and just, you know, pick off a few of them. If we go back to Netflix, I think Netflix has a, not a herbivore. I'm gonna talk about alcohol here cause it's late in the day in the UK. A gin and tonic relationship with its competitors. That is, if Dan Runcie doesn't pay for any video streaming service, and let's say Netflix gets you in and I'm the head of Disney plus, I say, well, thank you Netflix.That makes it easier for me to get Dan to pay for Disney Plus too. They compliment each other. They are genuine complimentary goods. They might compete for attention. You know who's got the best exclusive content, who's gonna renew the friends deal, whatever, you know, who's gonna get Fresh Prince of Bel Air on?That could be a switch or piece of content too, but when you step back from it, it's gin and tonic. It's not different brands of gin, that's really important technology, which is they've grown this market of video streaming. They've increased their prices and the same person's paying for 2, 3, 4 different packages.If I added up, I'm giving video streaming about 60 quid a month, and I'm giving music streaming 10 and the sixties going up and the music's staying flat. So it's bizarre what's happened in video streaming because the content is exclusive. Back to, how do music carnivores play out again? Could we see it play out in features?I listen to airport cause they've got classical and I listen to Spotify because it got discovered weekly. Is that plausible? Personally, I don't buy it, but you can sow that seed and see if it takes root, as well. I think just quick pause and Apple as well. I think two things there. They've launched Apple Classical. That's a very, very good example of differentiating a product because it's a standalone app like podcast as a standalone app. The way I look at that is you can go to the supermarket and buy all your shopping. You can get your Tropicana orange juice, you can get your bread, get your eggs, get your meat, get your fish or you could go to a specialist butcher and buy your meat there instead. Apple Classical for me is the specialist butcher as opposed to the supermarket, and they're offering both in the same ecosystem. It'd be incredible if they preload out the next iOS update and give 850 million people an Apple classical app.Imagine if they did that for Jazz, my friend. Imagine if they did that for jazz. Just if Apple's listening, repeat, do that for jazz. So there's one example. The other example from Apple is to go back to bundling. You know we talk about 9.99 a month. I chewed your ear off about this topic last time I was on your show.Just to remind your listeners, where did it come from? This price point in pound Sterling, in Euro in dollar that we still pay for on the 20th of May, 2023. It came from a Blockbuster video rental card that is when reps, he got its license on the 3rd of December, 2001. Not long after nine 11, a record label exec said if it cost nine 90 nines, rent movies from Blockbuster.That's what it should cost to rent music. And 22 years plus on, we're still there, ran over. But what does this mean for bumbling strategies? How much does Apple really charge? If I give $30 a month for Apple One, which is tv, music, gaming news, storage and fitness, all wrapped up into one price. Now, there's a famous Silicon Valley investi called James Barksdale.Dunno if you've heard of him from the Bay Area where you're based. And he had this famous quote where he said, gentlemen, there's only two ways to make money in business. Bundling and unbundling. What we've had for the past 10 years is herbivores. Unbundling. Pay for Netflix, don't pay for Comcast. Pay for Spotify. Don't pay for your CDs, fine. What we might have in the next 10 years is carnivores bundling, which is a pendulum, swings back towards convenience of the bundle and away from the individual items. So Apple, take 30 bucks a month off my bank balance. Please take 40. All I want is one direct debit. I don't care about the money, I just want the bundle.And I don't want to see 15 direct debits every month. I just wanna see one. I think that's a very plausible scenario for how the next 10 years it's gonna play out as we shift from herbivores to carnivores[00:46:31] Dan Runcie: And the bundle benefits, the companies that have the ability to do that, right? You can do that through Amazon Prime and get your video, your music, your free shipping or whatever is under that umbrella. You could do that through Apple. You mentioned all the elements under Apple one. Spotify has some element of this as well, whether it's exclusive podcasting and things like that. So you're starting to see these things happen, one thing that you mentioned though earlier, you're talking about going through the supermarket and all of the items that you could get there versus going to the specialty butcher.One of the unique aspects of the supermarket thing though, is that. You go into the supermarket, yes, you can get your high-end Tropicana, or you can get the generic store brand, but you're gonna pay more for that high-end Tropicana because you're paying for the brand, you're paying for everything else that isn't gonna necessarily be the same as the generic one.That may not necessarily be the same quality or the same taste. We're seeing this a bit in the streaming landscape now and some of the debates that were happening. You've heard the major record label executives talk about how they don't necessarily want their premium music. They see their content as HBO level and it's being in a playlist next to rain music, or it's next to your uncle that is playing some random song on the banjo and they're getting essentially the same price going to the rights holders for that song.And in the supermarket that's obviously very different, each item has its own differentiator there, or econ has its own price point there and its own cost, but that isn't necessarily the same thing in music. Of course, the cost of each of those tracks may be different, but the revenue isn't. So that's gonna be, or that already is a whole debate that's going on right now. Do you have thoughts on that?[00:48:21] Will Page: Well, you tossed top Tropicana, let me go grab that carton for a second. It's one of the best economic lessons I ever learned was visiting a supermarket in America cuz it's true to say that when you go into one of your American supermarkets, an entire aisle of that precious shelf space, it's dedicated to selling inferior brands of orange juice next to Tropicana.Just very quickly what's happening there, the undercover economist, if you want, is a bargaining power game. Tropicana knows The reason Dan Runcie pulled the car over, got the trolley, went into that supermarket is to get a staple item of Tropicana and other stuff. By the time it gets to the till, Tropicana could be $5.By the time he gets to till he spent $50. So here, subscriber acquisition cost contribution is really high. They're getting you into the mall. What you do once you're in the mall is anyone's business, but they got you in. Otherwise you would've gone to the deli across the street. So they could say to the supermarket, I'm gonna charge you $7 to sell that Tropicana for $5 in my supermarket.Supermarket knows this, they know that Tropicana's got the bargaining paris. They counter by saying, here's an entire shell space of awful brands of orange juice to curb your bargaining power to see if the consumer wants something different. Now is this Will Page taking a stupid pill and digressing down Tropicana Alley. No. Let's think about this for a second today, Dan, there's a hundred thousand songs being onboarded onto streaming services. Is there anybody what? Marching up and down Capitol Hill saying We want a hundred thousand songs. No, the floodgates have opened them. It's all this content. Two new podcasts being launched every minute.All this content, all of these alternative brands to Tropicana. But you just wanted one. And I think the record labels argument here is that one Cardinal Tropicana is worth more than everything else you're offering by its side. So we wanna rebalance the scales. Now this gets really tricky and very contentious, but what is interesting, if you wanna take a cool head on this topic, it's to learn from the collecting studies, which is not the sexiest thing to say on a Trapital podcast, but it's to look at your Scaps and your BMIs and understand how they distribute the value of money for music.Since their foundation in the 1930s, scap has never, ever treated music to have the same value. They have rules, qualifications, distribution, allocation practices, which change the value of music. And they don't have data scientists then. And to be honest, I don't think they have data scientists now, but they always have treated the value of music differently.When they were founded, they had a classical music distribution pot and a distribution pot for music that wasn't classical music. Ironically, their board was full of classical composers, and I think that's called embezzlement, but we'll leave that to the side. What we have here is a story of recognizing music as different value in the world of collecting Saudi.I call that Jurassic Park, but in the world of music streaming with all those software developers and engineers and data scientists, 22 years of 9.99 money coming in and the Prorata model, which means every song is worth the same for money going out, and that's your tension. That's your tension. How do you get off that?Tension is anyone's business. We got some ideas we can discuss. User-centric is one, autocentric is another. I've got a few ideas for my own, but I want your audience to appreciate. In straight no chaser language we call it. That's the undercurrent of what's going on here. How do you introduce Trapitalism to communism?[00:51:38] Dan Runcie: You mentioned there's artist centric, user-centric, but you mentioned some ideas you had of your own. What are those ideas?[00:51:44] Will Page: Can I bounce it off? Use my intellectual punch bag for a quick second. Yes, and I've worked 'em all. I've worked on the artist centric model. I've worked on artist growth models. That's up on YouTube. I've worked on user centric, but I'm just, I'm worried that these models, these propositions could collapse the royalty systems that these streaming services work under. The introduction of user centric or artist centric could become so complex, so burdensome, the royalty systems could break down.That's a genuine concern I have. It's not one you discuss when you talk about your aspirations and the land of milk and honey of our new streaming model that you envisage. Back in the engine room when you see how royalties are allocated and calculated and distributed out to right holders, I mean they're under stress anyway.Any more stress could snap it. So I come at this model, my proposition from the one that's least likely to break the system. I'm not saying it's the best model, but it's the least like least likely to have adverse impact on the system. And it came from my DCMS Select Committee performance in the UK Parliament, which your listeners can watch, we can give the link out, which is I said to the committee in terms of how you could change the model.What about thinking about duration? This wheel back since 1980s when B BBC radio plays, let's say Bohemian Rhapsody, it will pay for that song twice what it would pay for. You're my best friend, members of Queen wrote both songs, both released within three, four years of each other, but one lasts twice as long as another.So duration is not new. We factor in duration a lot in our music industry. We just never thought about it. If you look at Mexico, the Mexican collecting Saudi, which is so corrupt as an inside an army barracks, if you look there, they have sliding scales, duration. They factor in time, but they say the second minute is what?Less than the first. But I'm giving you more for more time just adding, decreasing scale. Germany, they have ranges in your country. America, mechanical licensing collective, the MLC in Nashville, they have overtime songs that last more than six minutes get a 1.2 multiplier. So I've been thinking about how could you introduce duration to this business?And the idea I've come up with is not to measure time. That'd be too complex, too burdensome. Every single song, measuring every second of consumption. How do you audit there? If you're an artist manager, but I wanna measure completion, then I think this is the answer. I want songs that are completed in full to receive a bonus and songs that are skipped before they end to receive a penalty.Not a huge bonus, not a huge penalty, but a tweak. A nudge that says, I value your attention. I value great songs, and you listen to these great songs and it captures my entire attention. You deserve something more. But if I skipped out after the first chorus, you deserve something less. I think that small nudge is a nudge in the right direction for this industry, and it wouldn't break the systems.So there it is. Tell me now, have I taken a stupid pill?[00:54:42] Dan Runcie: What I like about it, and I've heard other people in the industry mention this too, you're able to get something closer to what we do see in video streaming. I forget which app is specifically, but their threshold is 75%. So they acknowledge that yes, if you don't wanna watch the credits, you don't wanna listen to the closeout, that's fine.But if we at least get you for 75%, then we are gonna count that, and then that then can get used internally. That can then get used in different areas. But I think it provides everyone better data and analysis, much better data to be able to break down than. Whether or not you listen to the first 30 seconds, that's such a low threshold, but that's essentially where we are today.I think the biggest thing, regardless of what path is chosen, because as you and I both know, there's trade-offs to everyone. So instead of going through all the negative parts about it, I think it's probably more helpful to talk about it collectively, you accept the fact that there are trade-offs. You accept the fact that people are gonna try to game the system regardless of how you go about it.Because we have seen duration work elsewhere and it does get at that particular thing that we're trying to get at there is help there. And you mentioned other things such as, yes, if you're listening to the Bohemian Rhapsody, you, which I think is at least seven minutes and 15 seconds, most likely longer versus two minute song that is clearly idealized for the streaming era.There still should be maybe some slight difference there because listening to a minute and 30 seconds is very different than listening to five minute and 45 seconds to be able to hit that 75% threshold. So between that and then I've heard other topics such as which artists you start your session with should have some type of multiplier on there, and as opposed to someone that gets algorithmically recommended to you to be able to put some more onus on the on-demand nature of music streaming.The tough thing is that these things do get tough in general. Anytime there's any type of multiplier or factor in, there still is a zero sum pot that we're taking the money out of. So accepting the trade-offs, I like the direction, I think that there's a few ways to go about it that could make it more interesting, but in general, I do think that any of the proposed options I've seen at least, allow a bit more of a true economic reflection of where the reality is as opposed to where things are today.And I understand where things are today. It's easy. It's easy to report, it's easy to collect on and pay people out, relatively speaking. But like anything, there's trade offs.[00:57:14] Will Page: Yeah, it's really easy today. Even drummers can work out their royalties and no offense to drummers, but that's telling you something.But two points on my dura

Today is a very special episode: You are all going to be the very, very first people to hear me read Chapter 1 of FAT TALK: Parenting in the Age of Diet Culture, which comes out in just 5 days, on April 25. We are excerpting this from the audiobook, which I got to narrate. If you love what you hear, I hope you will order the audiobook or the hardcover (or if you're in the UK and the Commonwealth, the paperback) anywhere you buy books. Split Rock has signed copies and don't forget that when you order from them, you can also take 10 percent off anything in the Burnt Toast Bookshop.If you want more conversations like this one, please rate and review us in your podcast player! And become a paid Burnt Toast subscriber to get all of Virginia's reporting and bonus subscriber-only episodes. Disclaimer: Virginia and Corinne are humans with a lot of informed opinions. They are not nutritionists, therapists, doctosr, or any kind of health care providers. The conversation you're about to hear and all of the advice and opinions they give are just for entertainment, information, and education purposes only. None of this is a substitute for individual medical or mental health advice.LINKSThat photo by Katy Grannanarchived in the National Portrait Gallery's Catalog of American PortraitsAnamarie Regino on Good Morning AmericaLisa Belkin's NYT Magazine articlea report published in Children's Voicea judge ordered two teenagers into foster care2010 analysis published in the DePaul Journal of Health Care LawFat Shame: Stigma and the Fat Body in American CultureFearing the Black BodyHilde Bruch's research papersNational Association to Advance Fat Acceptance (NAAFA)Judy Freespirit and Aldebaran wrote the first “Fat Manifesto”Several studies from the 1960sresearchers revisited the picture ranking experimentthe 1999–2000 NHANES showed a youth obesity rate of 13.9 percentreaching 19.3 percent in the 2017–2018 NHANESData collected from 1976 to 1980 showed that 15 percent of adults met criteria for obesity.By 2007, it had risen to 34 percent.The most recent NHANES data puts the rate of obesity among adults at 42.4 percent.The NHANES researchers determine our annual rate of obesity by collecting the body mass index scores of about 5,000 Americans (a nationally representative sample) each year.A major shift happened in 1998, when the National Institutes of Health's task force lowered the BMI's cutoff points for each weight category, a math equation that moved 29 million Americans who had previously been classified as normal weight or just overweight into the overweight and obese categories.in 2005, epidemiologists at the CDC and the National Cancer Institute published a paper analyzing the number of deaths associated with each of these weight categories in the year 2000 and found that overweight BMIs were associated with fewer deaths than normal weight BMIs.in 2013, Flegal and her colleagues published a systematic literature review of ninety-seven such papers, involving almost three million participants, and concluded, again, that having an overweight BMI was associated with a lower rate of death than a normal BMI in all of the studies that had adequately adjusted for factors like age, sex, and smoking status.But in 2021, years after retiring, Flegal published an article in the journal Progress in Cardiovascular Diseases that details the backlash her work received from obesity researchers.After her paper was published, former students of the obesity researchers most outraged by Flegal's work took to Twitter to recall how they were instructed not to trust her analysis because Flegal was “a little bit plump herself.”the BMI-for-age chart used in most doctors' offices today is based on what children weighed between 1963 and 1994. a 1993 study by researchers at the United States Department of Health and Human Services titled “Actual Causes of Death in the United States.” the study's authors published a letter to the editors of the New England Journal of Medicine saying, “You [ . . . ] cited our 1993 paper as claiming ‘that every year 300,000 deaths in the United States are caused by obesity.' That is not what we claimed.”“Get in Shape, Girl!”The Fat Studies ReaderToo Fat for Chinaas I reported for the New York Times Magazine in 2019, it has become a common practice for infertility clinics to deny in vitro fertilization and other treatments to mothers above a certain body weightMichelle Obama 2016 speech, another speech, a 2010 speech to the School Nutrition Association, 2013 speechMarion Nestle, a 2011 blog postfood insecurity impacted 21 percent of all American households with children when Obama was elected TheHill.com story on SNAP“I could live on French fries,” she told the New York Times in 2009, explaining that she doesn't because “I have hips.”Ellyn Satter's an open letter to Obamaseveral other critiques of “Let's Move"“I don't want our children to be weight-obsessed"The Burnt Toast Podcast is produced and hosted by me, Virginia Sole-Smith. You can follow me on Instagram or Twitter.Burnt Toast transcripts and essays are edited and formatted by Corinne Fay, who runs @SellTradePlus, an Instagram account where you can buy and sell plus size clothing and also co-hosts mailbag episodes!The Burnt Toast logo is by Deanna Lowe.Our theme music is by Jeff Bailey and Chris Maxwell.Tommy Harron is our audio engineer.Thanks for listening and for supporting anti-diet, body liberation journalism! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit virginiasolesmith.substack.com/subscribe

Marissa has been doing some thinking about the American Academy of Pediatrics' recommendations on children with BMIs in the overweight and ob*se range and it's made her want to share some thoughts about the recommendations around weight loss surgery in particular. In this minisode, she resurrects an episode from an old podcast discussing an article on bariatric surgery for teens to illustrate her point. There are so many potential long-term effects to consider when it comes to weight loss surgery and it all begs the question: can someone under the age of 18 truly consent to all of that? Is it really worth the weight loss to put a growing and developing body at profound risk of nutrition deficiencies? The new recommendations pay lip service to the fact that weight is the product of so much more than individual blame yet miss the opportunity to focus on factors that really do profoundly impact a child's health and well-being, such as whether they are safe at home, have access to fresh fruits and vegetables, have stable housing, etc. Conversations centering blame for an individual's weight on the individual are inherently fatphobic and harmful. There is an immense risk of harm to the child when discussions of weight loss and body size are pursued.

One may assume that a socialized healthcare system, in which the government pays for the majority of medical expenses, would be more concerned to prevent illnesses in the first place.  Nevertheless, Dr. Max Gulhane, a general practice registrar, describes the Australian healthcare system as one that operates more like the profit-driven healthcare system of the US. The change in the population's diet and nutrition - one that promotes eating more grains, more bread, and more carbohydrate consumption - has led to an increase in the prevalence of metabolic illnesses. Yet despite the overwhelming support from credible studies that a low-carb diet helps with disease reversals, it still isn't widely accepted.Listen to Dr. Max Gulhane as he talks about animal-based diets as a key to reversing chronic diseases, why doctors are trapped in a system that heavily favors disease management more than disease reversal, and how pharmaceutical industries are weaponizing science.Quick Guide:0:50 Introduction07:17 The comparison of the Australian diet and the American diet11:48 Availability of lambs14:33 Nutritional reason to eat lambs or beef16:15 The state of obesity and diabetes in Australia21:34 What's the community's response toward the low-carb diet26:35 A look at the US and Australia's healthcare system40:14 Glaxo has known Zantac is linked to causing cancer 45:50 Science being weaponized by pharmaceutical industries48:25 Closing and contactsGet to know our guest:Dr. Max Gulhane is an Australian physician who practices family medicine. He advocates animal-based diets for metabolic health and regenerative farming. He also hosts a podcast called Regenerative Health.“Perhaps as long as you have someone in between your relationship with the patient and the doctor, in our case, Medicare, which is a government-funded health care system, who pays us as GPs to administer care to our patients, until there is, I guess, more of a direct relationship with us in the patient, you're gonna get, I guess, outcomes or treatment outcomes that aren't necessarily directed at the patient's disease and reversing the patient's disease. So yeah, no, it's not very land down here from a disease reversal point of view by any means.” - Dr. Max GulhaneConnect with him:https://linktr.ee/maxgulhanemdEmail: regenerativehealth@proton.me Episode snippets:08:32 - 09:57 The common Australian diet14:45 - 15:50 Lamb is nutritionally better than beef16:33 - 17:54 The higher BMIs are now evident in younger people22:41 - 23:10 - The patients are not benefitting from the advice they're given24:43 - 25:25 - A diet that reverses diabetes, but is offensive to the status quo27:47 - 28:55 - What influences the healthcare system37:09 - 39:03 - A financial stake in their health Contact Stay Off My Operating TableTweet with us: Dr. Ovadia: @iFixHearts Jack Heald: @JackHeald5 Learn more: Get Dr. Ovadia's book Stay Off My Operating Table on Amazon. Take Dr. Ovadia's metabolic health quiz: iFixHearts visit Dr. Ovadia's website: Ovadia Heart Health visit Jack Heald's website: CultYourBrand.com Theme Song : Rage AgainstWritten & Performed by Logan Gritton & Colin Gailey(c) 2016 Mercury Retro Recordings

Q&A time people, a couple good ones that get the blood boiling. Please keep an eye out for our episode on Friday where we announce the details of the MAD FF Pod Olympics. Thank you, and don't forget to follow our facebook page!

Could Hacking Into The Brain Make Us Even More Incredible Humans OR Would It Tear Us Apart?It's the next logical step in computing, and that logic is becoming increasingly worrisome. We're standing on the precipice of major developments in what scientists call brain computer interfaces (BMIs)! Will it help us, or hurt us?Could Hacking Into The Brain Make Us Even More Incredible Humans OR Would It Tear Us Apart?KURIOUS - FOR ALL THINGS STRANGE

You have likely observed that humans, especially overweight humans, come in a variety of shapes and sizes. We all know that excess body fat is not a good thing for health, nor for self esteem. But where fat is distributed on the body plays a big role in whether excess fat increases risk for conditions such as type 2 diabetes, coronary disease, stroke, cancer, cognitive decline, dementia, and premature death—or whether it is only a cosmetic issue and a challenge to weight-bearing joints but not for all the common chronic conditions mentioned. Doctors often rely on a measure called the body-mass index, or BMI. BMI is obtained through a simple calculation (or referring to a table that lists BMIs) of height divided by weight. A BMI of 18.5 to 24.9 is considered normal, overweight is 25 to 29.9, over 30 is obese. But BMI suffers from a fundamental flaw: It assumes that body fat is distributed uniformly throughout the body which, of course, it is not. They also rely on total weight which also does not necessarily give you any real health insights. So let's talk about how you can do better than the doctor to make determinations about whether the fat on your body is interfering with your health and longevity or whether it is not.________________________________________________________________________________________________Get your Paleovalley discount on fermented grass-fed beef sticks, Bone Broth Collagen, and low-carb snack bars:Use the coupon code "Defiant" for an additional 15% discount. Go to this pageon the Paleovalley website, enter the code and the discount will be automatically applied to your order.They are currently offering a 12% discount that continues for life for their Wild Pastures grass-fed, grass-finished beef and pastured chicken and pork! Go herefor more information.*Dr. Davis and his organization are financially compensated for supporting Paleovalley and their products. ________________________________________________________________________________________________More about my new book, Super Gut: A Four-Week Plan to Reprogram Your Microbiome, Restore Health, and Lose Weight:https://www.wheatbellyblog.com/super-gut/For more information on Dr. Davis' programs:Books:Super Gut: The 4-Week Plan to Reprogram Your Microbiome, Restore Health, and Lose WeightWheat Belly: Lose the Wheat, Lose the Weight and Find Your Path Back to Health; revised & expanded editionWheat Belly 10-Day Grain DetoxThis Old TreeHeritage trees and the human stories behind them.Listen on: Apple Podcasts   Spotify

VIDEOS: Niall Ferguson – Woke Totalitarianism (0:19 to 18:14) How Ukraine – Not Russia – Floods Social Media With War Propaganda (0:00 to 1:20) Here's why no one trusts CNN (3:35) The Green New Deal's Bad Science (8:14) JUST IN: Matt Gaetz Says Kevin McCarthy Could Ask Democrats To Help Make Him Speaker Forbes Breaking News 1.35M subscribers Subscribe (5:19) Neil Oliver asks why we should be expected to sweep Covid hysteria under the rug? (0:36 to 5:32) Jimmy Dore – Tim Robbins Apologizes To Unvaccinated For Being Wrong On Covid Policy (0:00 to 9:13) Grape Powder Could Extend Lifespan by 4-5 Years Long Island University, November 3, 2022 In a study the authors called “remarkable,” researchers found that giving grape powder to mice reduced the risk of non-alcoholic fatty liver disease and extended lifespan. To see if grape powder could modulate the harmful effects of a high-fat diet, researchers fed mice a typical Western (high-fat) diet. Half then received 5% standardized grape powder while the other half didn't. Compared to mice not fed the grape powder, the mice given grape powder saw beneficial increases in antioxidant genes, reductions in fatty liver, and extended lifespans. The lead author estimated that when translated to humans, the extended lifespan would correspond to an additional 4-5 years in the life of a human. The grape powder used in this study was composed of fresh red, green and black grapes that were freeze-dried to retain their bioactive compounds. The researchers concluded: “These results suggest the potential of dietary grapes to modulate hepatic gene expression, prevent oxidative damage, induce fatty acid metabolism, ameliorate NAFLD (non-alcoholic fatty liver disease), and increase longevity when co-administered with a high-fat diet.” Study: Neuroprotective Effect of Virgin Coconut Oil Helps Relieve ALS  Katholieke University (Belgium), November 6, 2022   An animal study looked into the potential of coconut oil for preventing or reducing ALS symptoms. Coconut oil has already demonstrated safe efficacy for treating Alzheimer's disease symptoms, which is also a neurodegenerative disease for which mainstream medicine has no answer. 1H-magnetic resonance spectroscopy is ideal for ALS treatment diagnostics and research. It is used for many animal and human studies to isolate minute molecular changes in brain and nervous system studies without having to procure tissue and blood samples. Thus, it is non-invasive.[The study results] revealed that the coconut oil supplementation together with the regular diet delayed disease symptoms, enhanced motor performance, and prolonged survival in the SOD1G93A mouse model. Furthermore, MRS data showed stable metabolic profile at day 120 in the coconut oil diet group compared to the group receiving a standard diet without coconut oil supplementation.  In addition, a positive correlation between survival and the neuronal marker NAA was found. … this is the first study that reports metabolic changes in the brainstem using in vivo MRS and effects of coconut oil supplementation as a prophylactic treatment in SOD1G93A mice.One of the major metabolites NAA (N-acetylaspartate), has been observed as an integral part of neuron loss, which is a major factor of onset ALS when it is diminished from the central nervous system.  NAA reduction was greater in the non-coconut oil fed group of rats, indicating those on coconut oil were experiencing less neurodegeneration and neuronal destruction. Aerobic activity can reduce the risk of metastatic cancer by 72% Tel Aviv University (Israel), November 14, 2022 A new study at Tel Aviv University found that aerobic exercise can reduce the risk of metastatic cancer by 72%. According to the researchers, intensity aerobic exercise increases the glucose (sugar) consumption of internal organs, thereby reducing the availability of energy to the tumor. The study was led by two researchers from TAU's Sackler Faculty of Medicine. Prof. Levy and Dr. Gepner said, “Studies have demonstrated that physical exercise reduces the risk for some types of cancer by up to 35%. This positive effect is similar to the impact of exercise on other conditions, such as heart disease and diabetes. In this study we added new insight, showing that high-intensity aerobic exercise, which derives its energy from sugar, can reduce the risk of metastatic cancer by as much as 72%. If so far the general message to the public has been ‘be active, be healthy,' now we can explain how aerobic activity can maximize the prevention of the most aggressive and metastatic types of cancer.” The study combined an animal model in which mice were trained under a strict exercise regimen, with data from healthy human volunteers examined before and after running. The human data, obtained from an epidemiological study that monitored 3,000 individuals for about 20 years, indicated 72% less metastatic cancer in participants who reported regular aerobic activity at high intensity, compared to those who did not engage in physical exercise. They found that aerobic activity significantly reduced the development of metastatic tumors in the lymph nodes, lungs, and liver. The researchers hypothesized that in both humans and model animals, this favorable outcome is related to the enhanced rate of glucose consumption induced by exercise. Prof. Levy stated, “Our study is the first to investigate the impact of exercise on the internal organs in which metastases usually develop, like the lungs, liver, and lymph nodes. “Consequently, if cancer develops, the fierce competition over glucose reduces the availability of energy that is critical to metastasis. Moreover, when a person exercises regularly, this condition becomes permanent: the tissues of internal organs change and become similar to muscle tissue. We all know that sports and physical exercise are good for our health. Our study, examining the internal organs, discovered that exercise changes the whole body, so that the cancer cannot spread, and the primary tumor also shrinks in size.” Dr. Gepner adds, “Our results indicate that unlike fat-burning exercise, which is relatively moderate, it is a high-intensity aerobic activity that helps in cancer prevention. If the optimal intensity range for burning fat is 65–70% of the maximum pulse rate, sugar burning requires 80–85%—even if only for brief intervals. For example: a one-minute sprint followed by walking, then another sprint.  Vegan diet best for weight loss even with carbohydrate consumption, study finds University of South Carolina, November 6, 2022 The month of November often brings about a sense of dread at the thought of food filled holiday parties and gatherings, but those who consume a plant based diet have little need for concern. A newstudy by the University of South Carolina confirms one big draw of saying no to all animal products: the ability to shed weight faster than those who consume a diet that contains meat and dairy.  The study compared the amount of weight lost by those on vegan diets to those on a mostly plant-based diet, and those eating an omnivorous diet with a mix of animal products and plant based foods. At the end of six months, individuals on the vegan diet lost more weight than the other two groups by an average of 4.3%, or 16.5 pounds. The study followed participants who were randomly assigned to one of five diets on the dietary spectrum: vegan which excludes all animal products, semi-vegetarian with occasional meat intake; pesco-vegetarian which excludes all meat except seafood; vegetarian which excludes all meat and seafood but includes animal products, and omnivorous, which excludes no foods. Participants followed their assigned dietary restrictions for six months, with all groups except the omnivorous participating in weekly group meetings. Those who stuck to the vegan diet showed the greatest weight loss at the two and six month marks. The lead authornotes that the diet consumed by vegan participants was high in carbohydrates that rate low on the glycemic index. “We've gotten somewhat carb-phobic here in the U.S. when it comes to weight loss. This study might help alleviate the fears of people who enjoy pasta, rice, and other grains but want to lose weight,” she said. Weight loss was not the only positive outcome for participants in the strictly vegan group. They also showed the greatest amount of decrease in their fat and saturated fat levels at the two and six month checks, had lower BMIs, and improved macro nutrients more than other diets. Eschewing all animal products appears to be key for these positive results.  Uterine fibroid growth activated by chemicals found in everyday products Northwestern University, November 14, 2022 For the first time, scientists at Northwestern Medicine have demonstrated a causal link between environmental phthalates (toxic chemicals found in everyday consumer products) and the increased growth of uterine fibroids, the most common tumors among women. Manufacturers use environmental phthalates in numerous industrial and consumer products, and they've also been detected in medical supplies and food. Although they are known to be toxic, they are currently unbanned in the U.S.  “These toxic pollutants are everywhere, including food packaging, hair and makeup products, and more, and their usage is not banned,” said corresponding study author Dr. Serdar Bulun, chair of the department of obstetrics and gynecology at Northwestern University Feinberg School of Medicine and a Northwestern Medicine physician. “These are more than simply environmental pollutants. They can cause specific harm to human tissues.” Up to 80% of all women may develop a fibroid tumor during their lifetime, Bulun said. One-quarter of these women become symptomatic with excessive and uncontrolled uterine bleeding, anemia, miscarriages, infertility and large abdominal tumors necessitating technically difficult surgeries. The new study found women with a high exposure to certain phthalates such as DEHP (used as a plasticizer to increase the durability of products such as shower curtains, car upholstery, lunchboxes, shoes and more) and its metabolites have a high risk for having a symptomatic fibroid. The scientists discovered exposure to DEHP may activate a hormonal pathway that activates an environmentally responsive receptor (AHR) to bind to DNA and cause increased growth of fibroid tumors. Immune cells mistake heart attacks for viral infections University of California San Diego and Harvard University, November 12, 2022  A study led by Kevin King, a bioengineer and physician at the University of California San Diego, has found that the immune system plays a surprising role in the aftermath of heart attacks. The research could lead to new therapeutic strategies for heart disease. The team, which also includes researchers from the Center for Systems Biology at Massachusetts General Hospital (MGH), Brigham and Women's Hospital, Harvard Medical School, and the University of Massachusetts, presents the findings in Nature Medicine. Ischemic heart disease is the most common cause of death in the world and it begins with a heart attack. During this process, heart cells die, prompting immune cells to enter the dead tissue, clear debris and orchestrate stabilization of the heart wall. But what is it about dying cells in the heart that stimulates the immune system? To answer this, researchers looked deep inside thousands of individual cardiac immune cells and mapped their individual transcriptomes using a method called single cell RNA-Seq. This led to the discovery that after a heart attack, DNA from dying cells masquerades as a virus and activates an ancient antiviral program called the type I interferon response in specialized immune cells. The researchers named these “interferon inducible cells (IFNICs).” When investigators blocked the interferon response, either genetically or with a neutralizing antibody given after the heart attack, there was less inflammation, less heart dysfunction, and improved survival. Specifically, blocking antiviral responses in mice improved survival from 60 percent to over 95 percent. These findings reveal a new potential therapeutic opportunity to prevent heart attacks from progressing to heart failure in patients. “We are interested to learn whether interferons contribute to adverse cardiovascular outcomes after heart attacks in humans,” said King, who did most of the work on the study while he was a cardiology fellow at Brigham and Women's Hospital and at the Center for Systems Biology at MGH in Boston. Investigators found that surprisingly, the antiviral interferon response is also turned on after a heart attack despite the absence of any infection. Their results point to dying cell DNA as the cause of this confusion because the immune system interprets it as the molecular signature of a virus. Surprisingly, the immune cells participating in the interferon response were a previously unrecognized subset of cardiac macrophages. These cells could not be identified by conventional flow sorting because unique markers on the cell surface were not known. By using single cell RNA Seq, an emerging technique that combines microfluidic nanoliter droplet reactors with single cell barcoding and next generation sequencing, the researchers were able to examine expression of every gene in over 4,000 cardiac immune cells and found the specialized IFNIC population of responsible cells.

In a follow-up preview, Jörn Schattenberg, Louise Campbell, Mazen Noureddin, Ian Rowe and patient advocate Jeff McIntyre join Roger Green to discuss key presentations and posters of interest at the 73rd Annual Meeting of the American Association for the Study of Liver Diseases (AASLD). On November 4th-8th in Washington DC, as many as 10,000 attendees will convene in an effort to advance and disseminate the science and practice of hepatology, and to promote liver health and quality patient care. Ian leads with a reference to the preceding conversation on a poster that describes ways to utilize AI or other analytics of items in basic medical charts to predict NAFLD. He endorses the idea of putting as few barriers in the way of primary care as possible, speaking to FIB-4 as an excellent front-line tool for primary care initial triage. He discusses the value of BMI as being a superior predictor to more complex measures and recalls Stephen Harrison's KISS principle as a goal. He notes that patients will be referred for obesity if their BMIs are high enough regardless of whether they exhibit proven NAFLD. Next, he describes the process the NHS used in the UK to select reimbursed programs. He suggests that while there are questions regarding diet and rate of weight loss relevant to the Fatty Liver community, patients with obesity should be treated for weight loss as a simple solution. From here the other panelists provide final thoughts and closing comments on what the field can do to drive NAFLD care and screening to primary care providers. Surf on for their response, and stay tuned for more 2022 AASLD coverage.

The Lancet published a study seeking to quantify the proportion of cancer which is attributable to behavioural risk factors. Three core culprits are identified from the data which include smoking, alcohol consumption and high BMIs. We explore the study and reveal key discoveries.

Last time, we discussed how letting go of our sense of self can significantly impact our lives by reducing mental suffering, improving productivity, and helping us experience the benefits of awe. This week, we'll explore another question together:Can our mindsets make us healthier?Our beliefs can indeed exert surprising physiological effects. A recent randomized clinical trial discovered that educating children about the side effects of allergy immunotherapy greatly improved patient compliance and parental anxiety during treatment for peanut allergies.Oral immunotherapy is an emerging treatment for allergies in which patients are given gradually larger doses of an allergen in order to promote immune tolerance. The appearance of mild reactions to treatment like a scratchy throat or congestion can sometimes concern children and parents alike since these symptoms closely resemble those of a more severe allergic reaction like anaphylaxis. The anxiety can be so great that families may skip doses or stop treatment completely. In the study, telling children that side effects may be beneficial and even help overcome allergy in the long term allowed kids to successfully complete treatment and experience fewer side effects when exposed to actual peanuts.Why might a positive mindset change our response to something like allergens? Let's dive a little deeper to find out.Mindsets 101Our mindsets affect our perceptions of reality and are influenced by our upbringing, cultural values, and environments. Marketing, advertising, and health influencers shape our attitudes towards foods, exercise plans, and lifestyle practices.Many of our mindsets are simply the result of mimetic desire, meaning we imitate what others want. We desire what is socially desirable. Mimetic desire describes how social influences like parents, peers, teachers, media, and society impact nearly all our decisions from our career aspirations to the partners we choose.Dr. Alia Crum, Professor of Psychology at Stanford, studies how mindsets affect health and physical performance. She defines mindsets as core beliefs or assumptions about a domain. Whether we think stress is enhancing or debilitating influences the outcomes that follow. Whether we believe the nature of intelligence is fixed or malleable affects motivation and the ability to persist during academic challenges.Mindset vs. PlaceboWhile the origins of the placebo effect may have been based on insufficient evidence, science suggests that the way we feel about something does in fact impact the way it affects us. We often forget that the total effect of a medical treatment is a combination of the chemical properties of that drug plus the placebo effect, which consists of social context, beliefs or mindsets, and our body's natural physiological ability to heal.Mindset and Food MetabolismDo our beliefs change our bodies' physiological response to food?Dr. Crum conducted a well-known study, sometimes called the “milkshake study,” in which she administered identical vanilla milkshakes to the same group of people separated by a week. Participants were initially told they were drinking a calorie-rich, indulgent milkshake full of fat and sugar. The second time, volunteers were told they were drinking a healthy, sensible, nutritious meal shake.Levels of a gut hormone called ghrelin were measured before and after drinking each set of milkshakes. Sometimes called the “hunger hormone,” ghrelin signals to the hypothalamus in the brain that it's time to seek out food. After a large meal, ghrelin levels drop, telling your body that you've eaten enough.Scientists originally thought that ghrelin levels fluctuated in response to nutrient intake alone. Eat a cheeseburger, and ghrelin levels drop substantially. Eat a salad? Not so much. But Crum discovered something else entirely in her milkshake study.She found that telling people that they were drinking something indulgent caused their ghrelin levels to drop threefold more than when they thought they were drinking a low-calorie shake. In other words, simply believing that they were consuming something filling caused their bodies to respond as if they actually were.This evidence suggests that we may be able to manipulate metabolism with our mindsets. Crum argues that these findings require us to rethink our traditional metabolic model of “calories in, calories out,” which doesn't account for the influence of mindset on physiology. According to Crum,“Our beliefs matter in virtually every domain, in everything we do. How much is a mystery, but I don't think we've given enough credit to the role of our beliefs in determining our physiology, our reality.”Should we cultivate mindsets of abundance?Counterintuitively, the belief that we're eating indulgent foods rather than healthy ones seems to result in improved satiety and better health outcomes. The reason we observe this correlation may be due to the power of abundance and scarcity mindsets. Stephen Covey was the first to coin these terms in his seminal book, The 7 Habits of Highly Effective People.The scarcity mindset is grounded in destructive competition and subscribes to the idea that opportunity is a finite pie such that if one person takes a large piece, there is less available for everyone else. Individuals with an abundance mindset, on the other hand, reject the notion of zero-sum games and believe there is more than enough to go around.An abundance mindset allows us to celebrate the successes of others and share profits, power, and recognition. According to Covey, embracing an abundance mindset allows for freedom and mental clarity, which enables us to more effectively pursue our goals. Similar mechanisms may be at play when we consume food from a mindset of indulgence.The calmness that accompanies the belief that we have more than enough to eat may lead to lower levels of the stress hormone cortisol, thereby preventing excessive ghrelin stimulation and the urge to overeat. In other words, operating from a mental place of abundance or indulgence may reduce chronic stress and therefore improve our metabolic health.If an indulgence mindset can promote health, can actually consuming indulgent foods also lead to health benefits? Unfortunately, the science suggests otherwise. A 2020 review article published in the journal Nutrition Research described how satiety cues that promote a sense of fulness and satisfaction typically inhibit cravings for more food.But Western diets rich in energy, sugar, and saturated fats seem to impair these inbuilt mechanisms of appetite reduction by hijacking our brain's reward pathways and inappropriately releasing dopamine to reinforce behaviors. So how can we restore normal appetite regulation and cultivate a healthier relationship with food? Intuitive eating may provide a possible answer.Can we make eating more intuitive?Stress reduction may be one of the mechanisms by which intuitive eating improves well-being. Intuitive eating relies on a skill called interoception, which describes our ability to sense internal signals from our bodies. Interoception originates in the insular cortex of the brain and can help us register the sensation of hunger or predict our approximate heart rate.Intuitive eating relies on satiety and appetite signals to guide eating habits instead of using emotional, social, or chronological cues. Interoceptive sensitivity has been associated with healthier BMIs, higher levels of self-esteem, and reduced incidence of disordered eating patterns compared to other dieting methods.Many of us may have a reduced capacity for interoception due to chronic pain or trauma, a tendency to suppress emotions, or eating to always clean our plates instead of eating until we're full. Retraining our bodies to perceive and respond to physiological signals can help reduce cravings and improve self-regulation.Dr. Kent Berridge, a professor of psychology and neuroscience at the University of Michigan, recommends that we “allow the craving to happen; just notice it, feel it, and let it fade.” This approach is part of mindfulness-based eating awareness training (MB-EAT), which has been shown to help alleviate stress-induced cravings, improve self-control, and reduce symptoms of depression.Mindfulness-based eating awareness involves regulating emotions, consciously making food choices, developing an awareness of hunger and satiety cues, and cultivating a sense of self-acceptance. The goal is to redirect our attention to the here and now and prevent cycles of rumination. Regularly practicing mindfulness has been shown to stimulate changes in brain activity, including reduced activation of the amygdala, a brain region involved in fear and anxiety.Mindfulness can even stimulate the “relaxation response,” a term coined by Dr. Herbert Benson, founder of Harvard's Mind/Body Medical Institute. The relaxation response is the opposite of the body's adrenaline-charged “fight or flight” response and encourages our bodies to release chemicals that increase blood flow to the brain. Many different practices can elicit the relaxation response, including guided imagery, muscle relaxation, massage, prayer, meditation, tai chi, qi gong, and yoga.Mindset and Exercise MetabolismWe've already seen how mindset can impact physiological responses to food. But can mindset also affect how our bodies respond to exercise? Harvard Psychologist Ellen Langer conducted an experiment to find out. She decided to study female hotel workers who engaged in a lot of physical activity as part of their daily jobs: pushing carts, changing linens, scrubbing bathrooms, vacuuming, and climbing stairs.When surveyed about their exercise habits, one third of the women reported not getting any exercise at all. The majority of housekeepers estimated low levels of personal exercise—an average of a three on a scale of zero to ten. Even though these women were very active, they didn't perceive themselves as engaging in lots of exercise. They thought their work was just work.Researchers divided these women into two groups and told the experimental group that their work was good exercise and met the guidelines for an active lifestyle. Subjects in the control group weren't given any information. Throughout the study, Langer tracked metrics like weight, body fat, and blood pressure.Four weeks later, the group that had received positive counseling about the benefits of work-associated exercise lost two pounds on average and decreased their systolic blood pressure by about ten points. The control group didn't experience weight loss benefits and only droppped systolic blood pressure by an average of two points.Women who were informed about the benefits of exercise also exhibited improvements in body fat, waist-to-hip ratio, and BMI, none of which were observed in the control group. No other detectable behavioral changes such as increased physical activity or dietary changes seemed to be at play.These findings mean that objective health benefits like cardiovascular disease risk and weight maintenance depend not only on what we're doing but also on what we think about what we're doing.To recap, mindsets have a profound impact on our metabolism by affecting our physiological responses to diet, exercise, and medication. What you believe about the nutritional content of your food considerably affects the way it impacts your brain and body. Adopting a mindset of indulgence, satisfaction, and enjoyment can help us feel more satiated after meals by manipulating levels of hormones like cortisol and ghrelin.Eating nutritious foods with an indulgent mindset may provide the best of both worlds. Retraining ourselves to eat when hungry instead of eating due to stress or boredom can help reduce cravings and prevent overeating. Intuitive eating and mindfulness practice can help you inhibit your body's stress response, identify your underlying feelings, and choose alternatives to comfort food, like a soothing cup of tea.Thinking more positively about our daily activity levels can help us more effectively leverage the benefits of work-related exercise. Mindsets may even affect the severity of immune reactions by modulating our stress response, inhibiting cortisol release, stabilizing mast cells, and preventing the formation of downstream inflammatory compounds like histamine.Listen to “Evolving with Nita Jain” on Spotify, Apple Podcasts, Amazon Music, Audible, Google Podcasts, Soundcloud, Deezer, TuneIn, RadioPublic, Stitcher, Castbox, Pocket Casts, Player FM, Podcast Index, Castro, Overcast, Listen Notes, Podchaser, Goodpods, or iHeart Radio!Music for this episode, “New Beginnings” by Joshua Kaye, was provided courtesy of Syfonix. Some links are affiliate and help support my mission to share actionable health insights with the general public. Thank you! This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit nitajain.substack.com

Over the years, I've worked with countless numbers of women who'd previously followed Weight Watchers or who'd been members at Curves. If you've been looking for a good weight loss program, you've no doubt come across one, or both of these. While there are much better approaches to weight loss than either one, a recent study compared the effects of the two, which led to some interesting findings. In this blog post, I'll review the study and tease out some of the valuable findings. At the end, I'll give you my advice about whether either one is a good option, and if not, what would be better. Two Different Approaches to Weight Loss Weight Watchers Momentum™ is a social support-based diet program that encourages exercise. Curves® Complete is a program offered at Curves, a gym exclusively for women. Members at Curves start with exercise as a foundation and add a diet program, whereas Weight Watchers is a diet program that just suggests people exercise. That's a distinct difference. It's this difference that led a research group to study the effects of the two programs with 24 women who followed Curves Complete, and 27 who followed Weight Watchers Momentum. All women were overweight, with BMIs over 25 kg/m², and ages 18-50 years old. Curves Complete Those in the Curves Complete program followed a three-phase diet, as follows: Phase I: 1200 calories/day coming from 30% carbohydrates, 45% protein, 25% fat for 7 daysPhase II: 1500 calories/day coming from 30% carbohydrates, 45% protein, 25% fat for 21 daysPhase III: 2000-2500 calories per day coming from 45% carbohydrates, 30% protein, 25% fat for 14 days. During this phase, if a woman gained three pounds or more, they went back to 1200 calories per day for 2-3 days. The phases were cycled, with the women completing Phase 1 and Phase 2 three times, and Phase 3 twice. Read also: More Research Support for a High-Protein Diet for Weight Loss. Weight Watchers Momentum Though Weight Watchers has moved on from Momentum to Personal Points, many similarities still exist, making the new study relevant today. Participants had to attend one weekly meeting, on-site at a franchise location. There, they weighed in, participated in coaching sessions and group discussions, and received their support materials and recommended points by which to measure their food intake. Workout Program Curves is a gym first, a diet program second. The gyms have a variety of hydraulic resistance machines, which are to be used in a circuit style. Each set last 30 seconds, during which participants complete as many reps as possible, then rest for 30 seconds during which they perform calisthenics, in-place aerobic exercise, or Zumba, to maintain an elevated heart rate. Each circuit consists of 26 exercises and the women did this exercise format three times per week. Again, the Weight Watchers group was encouraged to exercise, just as they are in all other Weight Watchers programs. But there's no gym at a Weight Watchers facility unless that facility sits within a gym setting. Read also: 9 Reasons Strength Training is Critical for Long-Term Health, Fitness, and Longevity. Results: Weight Watchers vs. Curves Both groups lost the same amount of body weight. So, that means both programs are equally effective, right? No. Not at all. The following table details the differences in results between the two groups. Average ChangeWeight WatchersCurvesBody Weight-13.42 lbs-10.78 lbsFat Mass-6.38 lbs-14.08Lean Mass-5.5 lbs+2.86 lbsBody Fat %-1.4%-4.7% Those in the Curves group also experienced a drop in insulin, whereas the Weight Watchers group did not, and the Curves group saw a rise in HDL cholesterol (good cholesterol), whereas the Weight Watchers group saw a slight decrease. According to the study's authors: Results revealed that over time, both groups lost a similar amount of body weight. However, the CV (Curves) intervention led to a greater de...

Much attention has been paid recently in both scientific circles and in the media to a drug for weight loss newly approved by the FDA. A flurry of articles in the media hailed this drug as a breakthrough. This was prompted by the publication of a landmark article in the New England Journal of Medicine addressing the impact of this medication in a large clinical trial. Today's guest is one of the authors of that paper. Another flurry of media attention occurred as the drug became available, with news that supply couldn't keep up with demand. Dr. Thomas Wadden is the Albert J. Stunkard Professor and former Director of the Center for Weight and Eating Disorders at the University of Pennsylvania School of Medicine. He is one of the most highly regarded experts on treatments for obesity, having done some of the most important research on very low-calorie diets, a variety of medications, bariatric surgery, intervention in primary care settings, and more. Interview Summary   You and I grew up together in this profession, having spent some early years together working on treatments for obesity. You're one of the people in the field I admire most, both for the quality of your work and the breadth of your knowledge across various treatments for obesity. So let me begin by asking something regarding our former mentor, Albert Stunkard. So one of the most famous quotes of all time in our field came from Mickey Stunkard in 1959, no less, way before the field was really paying attention to obesity. He wrote that "most obese persons will not stay in treatment. Most will not lose weight. And of those who do lose weight most will regain it." There was a stark honesty to this, and it motivated Stunkard to help overweight people. So if we fast forward to today, do you think this is essentially still true?   Well, first, let me say that Dr. Stunkard's statement sounds somewhat critical. Today, we might say stigmatizing people with obesity. You know, they won't stay in treatment, they won't lose weight, they'll regain it. And Stunkard, as you know perhaps better than anybody, was an extremely compassionate, empathic person. To clarify that, he knew that the limitations to success were with the treatments available and not with the people who had obesity. So to answer your question, the first two parts of Stunkard's statement that people won't stay in treatment and people won't lose weight were probably no longer true by the early to mid-1980s. And pioneers like yourself showed that if you gave people a structured program of diet and physical activity, and most importantly, if you gave them behavioral strategies to improve their treatment adherence, then 80% of people would stay in treatment for 16 to 26 weeks. They'd lose an average of 6% to 10% of their weight. So what remained, however, and remains today, was that people have trouble maintaining the weight loss. And that's something that still challenges us.   Well, it's nice to start on that optimistic note with the hope that people will go into treatment. Let's talk about the drug. So what is the new drug, and how does it work?   Well, the new drug is called semaglutide. It comes in a dose of 2.4 milligrams and is injected subcutaneously once per week. The drug at the retail level is known as Wegovy. Some people will know about semaglutide for the management of type 2 diabetes. It is used at a dose of 1.0 milligrams and it's called Ozempic. So Ozempic was approved first many years ago. Now, semaglutide is a glucagon-like peptide 1 receptor agonist, and that's a mouthful. But glucagon-like peptide 1, GLP-1 for short, is a naturally occurring hormone that is released by the body when food, particularly carbohydrates, hits the stomach. GPL-1 is released by cells in the small intestine, and it does several important things. First, it signals the pancreas to release insulin to pick up the glucose that's coming in. And then it also slows gastric emptying, which as you know, leads to greater feelings of fullness. And then finally, these GLP-1 receptor agonists are hitting a part of the hypothalamus that stimulates fullness or what's known as satiation receptors, so people feel full earlier when they're eating and don't eat as much food. I think you may remember, Kelly, that naturally occurring GLP-1 has a very short life when it's released. It's active for about two to three minutes, so you have a temporary feeling of fullness. But these new drugs, semaglutide 2.4 milligrams, have a seven-day half-life. So people are feeling greater fullness and less hunger sort of around the clock, and as a result, they are just eating less. And to use your terms, they are less responsive to all the cues in the toxic food environment that are saying come on, it's time to eat more. It's time to have a large serving of ice cream or sugar-sweetened beverages, whatever it is. People don't seem to be as vulnerable to the toxic food environment.   I really appreciate that you've taken a pretty complex subject, namely the physiology of this drug, and made it come alive in terms that most of us can understand. So thanks for that. So before you talk about the weight losses that the drug produces, you mentioned that some treatments are producing weight loss of 5-6% of body weight. Can you place that in context for us? I mean, is that enough to produce medical benefits? Are the people losing weight happy with that degree of weight loss?   Sure, most individuals who go through a behavioral treatment program will lose about 7% to 8% of their weight on average. And those weight losses are associated with significant improvements in health. The landmark study in this area is the Diabetes Prevention Program published in 2002. People with pre-diabetes lost seven kilograms, about 7% of their weight, and they exercised 150 minutes per week. And those individuals with pre-diabetes reduced their risk of developing diabetes over 2.8 years by 58% compared to the control group. So that's a really important finding that modest weight loss, and modest physical activity prevents the development of type 2 diabetes. And weight loss is also going to improve blood pressure, and it can improve sleep apnea, so modest weight losses have benefits. But two things. First, larger weight losses have greater improvements in health. That's important to know. It's in a linear relationship there. The more you lose usually, the better the health improvements. And two, most people seeking to lose weight want to lose about 20% of their body weight. So if you're a 200-pound female, a 250-pound male, you want to lose 40 to 50 pounds, respectively. And so, larger weight losses are highly desired.   So how do you deal with that psychologically when somebody's goal is far beyond what treatment typically produces? Can people come around to the fact that the smaller weight losses are really good for me, and I've accomplished a lot even though I may not get to my goal?   Well, I always tell people, I know you want to lose 40 pounds. So let's start with the first 15 to 20. Let's focus on that because you have to go through 15 to 20 to get to 40, and let's see how you feel after you've lost the initial weight. And I can't promise you you're going to get to 40 pounds for potential genetic or biological reasons, but let's try to achieve what we can achieve and focus on larger weight loss. And many people are more satisfied than they'd imagined with a more modest or moderate weight loss, even though the dream is to lose more than that.   Okay, so back to the drug then. This big clinical trial you were involved with, published in the New England Journal of Medicine, can you quickly explain the trial and tell us what you found?   There were four big clinical trials of this medication that were presented to FDA for approval, but the seminal paper published in New England Journal treated about 1,961 participants. And everybody got lifestyle modification every month with a dietician for 15 to 20-minute visits. And then on top of that, half the participants got assigned semaglutide 2.4 milligrams, and the other half got a placebo. And they were followed for 16 months. And the reason it's a 16-month trial is that you have to introduce the drug slowly over four months to control gastrointestinal side effects. So as you start to take this drug, you're likely to experience a little bit of nausea. About 45% to 50% of people do so. So some patients, about 20%, will experience vomiting. Constipation and diarrhea also occur in response to the drug. So if you slowly introduce the drug, you can prevent some of those symptoms. And so it's not till four months that you're on the full dose of the drug, and that's why they run the trial for 16 months, so people have been on the drug for one year. And so what happens at the end of these 16 months is that the participants who get lifestyle light with placebo lose 2 1/2 percent of their weight. That's about what we'd expect. Those who get semaglutide, lose 15% of their body weight. So a remarkably robust weight loss. And when you break it down a little bit further, what happens is that 69% of the people on semaglutide are losing 10% or more of their weight. And then 50% are losing 15% or more of their weight. So that's a substantial loss. And this is something that I'd never seen in this kind of a trial. One-third have lost 20% of their body weight. And those weight losses are cumulative. So the 69% who lost 10% of their weight include the people who lost the 15% and 20% of their weight. But as you well know, those are substantial losses where the average loss is 15%, and that's achieved by 50% of the people. That is double what we get with our best behavioral treatment, and it's about double what you get with most weight loss drugs.   Yeah, that's pretty darn impressive to double the impact. I mean, most people will be excited with a a little bit of improvement. That's a lot of improvement. So certainly, we have to take note based on that. When you talked about the side effects, you were talking about the fairly immediate side effects of beginning to take the drug. And then it takes four months for people to get up to the full dose. Are there side effects that exist beyond those four months?   Well, most people will be through those gastrointestinal side effects within the four months. But, if you go out to 16 months, there will be a small percentage of people who have nausea, diarrhea, et cetera, throughout the trial. And you try to help those people with their side effects by doing things like chewing their food more thoroughly, eating smaller meals but more of them, and drinking more water. All of that can help them control their nausea if it's persistent. I think that the most serious side effect, Kelly, is that about 4% of people will develop gallstones or need to have a gallbladder removed. That is just a consequence of the large weight loss. Anytime you have large weight loss, whether it's from a very low calorie diet, from bariatric surgery, or these medications, you will find that a small percentage of people have gallstones and will need attention.   And what about the fact that people need to get this by injection? Are people able to do that okay, or is that a deterrent for people using it on a broad scale?   It's an excellent question. I can tell you that I have injected myself on several occasions just to see what it's like. You find a fat fold in the stomach and inject yourself. The needle is so small that you can't feel it. So once people try it, there's really very little hesitancy. I think certainly some people would think, "I don't want to be injecting myself with this thing," They may not even come in, but once you try it, there's no problem. And right now, there is an oral version of Ozempic. It's called Rybelsus. So it's the same medication for type 2 diabetes but in oral form rather than sub-q injection. And a trial is currently underway to see if we can make an oral version of semaglutide injectable drug, and I think that's going to prove acceptable. So that barrier should be eliminated over time.   So what happens if people stop taking the drug?   I think you know the answer. People who stop taking the medication are vulnerable to regaining their weight. And some people would say, well, that illustrates the drugs a failure because you take it and you lose weight, and you regain it, and you're no better off. But I am on a medication for high blood pressure and on a medication for high cholesterol. I can assure you that if I stop taking those medications, my cholesterol and blood pressure would go up. So this speaks to a very important issue which we have to look at obesity is probably a majority of persons as being a chronic health condition for which they're going to need long-term ongoing care and you would need to take these medications indefinitely just like I take my hypertensive or cholesterol medication indefinitely.   You know, the description of the cholesterol and blood pressure drugs is a great example. And I think this really speaks to the issue of obesity stigma, doesn't it? Because if you have these blood pressure, cholesterol drugs, and lots of others, if people are taking them and they're effective and then they stop taking them and then the medical condition comes back, it's even more evidence that a drug works. But in the case of some of these obesity drugs, people say, well, if you stop taking it and you regain the weight, it's proof the drug doesn't work. So how do you think that might be bound up with kind of general social attitudes about people with obesity?   It's such an important point. So persons with obesity are still stigmatized, as you, Rebecca Puhl, and many people have shown. And there's just so much unrelenting stigmatization of people saying, you know you should be able to control your weight by exercising more, cutting down on what you eat, push back from the table. You see, it's your problem, your shortcomings in self-control. So people with obesity are stigmatized. Similarly, obesity medications are stigmatized. Anytime I give a talk to physicians, I'll ask how many would consider prescribing an obesity medication? And only about 10% of hands go up at most. Then I'll ask, would you prescribe a drug for hypertension or cholesterol? Everybody's hand goes up, and I say, what's the difference here? And people invariably say, well, people should be able to control their eating and exercise with their willpower. And I say, well, it's an illness, it's a disease partly caused by this toxic food environment, so why are you treating that differently? You allow diabetes medications. That's caused by eating behavior to some extent. So I think you're correct. There's this profound stigmatization of people with obesity and of the medications. And I think that view is beginning to change. One of the most important things about this new medication semaglutide, and there'll be a new drug from Eli Lilly called tirzepatide, is that doctors, endocrinologists, and primary care physicians, are comfortable with these glucagon-like receptors because these are diabetes drugs that they prescribe. They're willing to prescribe that long-term. Now they may be willing to recognize obesity disease, which requires long-term treatment. They feel comfortable with the drug and that it's not going to have adverse side effects. So I hope this is a turning point in stigmatizing persons with obesity and obesity drugs.   Tom, how much does the drug cost, and is it covered by insurance? And what about people on Medicare and Medicaid?   This medication, if you go to your pharmacy and ask for it, I think is currently priced at about $1,300 per month. And so that is a very high barrier to the vast majority of people who would want to take this drug. It's possible, and I hope that the price will come down, but I haven't seen any indication of that. Some insurers and some employers cover the medication so that some people will benefit from it. But I think, as you know, Medicare and Medicaid do not cover any obesity medications at this time. There's a very important piece of legislation in the Senate and in the House called the Treat and Reduce Obesity Act, and part of that bill is to get Medicare to cover obesity medication. So even though they've got a terrific new medication, most people who would benefit from it, and particularly people of color who have higher rates of obesity, minority members, will have a very difficult time getting this drug to use it appropriately.   You mentioned that Eli Lilly may be coming out soon with a competitor drug. Do you think the competition will reduce the cost?   I would hope it would reduce the cost, but I can't say that I have any advanced knowledge of that or any assurance that that will happen. Eli Lilly has put a lot of money into producing their medication. Their medication tirzepatide looks like it will be as effective as semaglutide if not more effective by two or three percentage points. So I think probably the best bet for having a cost reduction is that another medication very similar in its mechanisms of action to semaglutide, it's called liraglutide 3.0 for obesity. It is a GLP-1 receptor agonist, it's just not as effective, it produces an 8% weight loss, it's going off patent, I believe in 2023 or '24 and when it goes off patent, I think that there will be generics to at least make that drug available at a very reasonable cost. I believe that that drug currently is at about $600 to $700 per month, but it should come down dramatically when it goes off-patent, and there are generics.   And for people who have health insurance, are insurers covering the drug?   A smattering of people are covering the drug. I don't think there's universal coverage. If you're under Blue Cross Blue Shield or whatever your company may be, remarkably, the University of Pennsylvania is covering some of these medications, which I'm delighted to see. But you would have to check your insurance plan carefully. For people who do have coverage, there are coupons to get your costs down to as little as $25 a week. So it's really worth looking into. And I know that Novo Nordisk, which manufactures semaglutide, is trying to work with insurers to get more to pick up the coverage of the drug. Let's hope that they reach some insight that'd be important to reduce the cost of this drug to make it more available to people who really need it.   Let me ask a big picture question to end our conversation. So where does this drug fit in the broad scheme of various options for treatments for obesity and how would someone or their physician know if this medication would be a good option to pursue?   Sure, if we follow just the FDA guidance and the guidance of expert panels, this drug is appropriate for people who have a body mass index of 30. So you can go, and your doctor will measure your weight, calculate your height, and tell you what your BMI is. So at a BMI of 30, you're eligible for this drug if you've tried diet and exercise, which just about everybody will have, and you haven't been successful with that alone. I think that the drug is most appropriate for people with a body mass index of 30 or greater who have significant health complications, meaning they have type 2 diabetes or hypertension, or sleep apnea. If the drug's going to be limited in availability because of it's cost, I would try to get it to the people who have the most benefit in terms of improving their health. That's the primary reason to seek weight reduction, I think. Technically, to address your question, the drug's available to people with a body mass index of 27 who have a comorbid condition such as hypertension or type 2 diabetes. And if you've got a BMI of 30, you would like to get this drug to people who have the highest BMIs and have the greatest benefit to health. Those individuals with higher BMIs at 35 who have a comorbid condition are eligible for bariatric surgery, which is the most effective obesity treatment. If you look at the most popular surgical treatment right now, it's called sleeve gastrectomy, where you remove 75% of the stomach so you can't eat as much food, and it does have improvements in appetite-related hormones such as ghrelin, the hunger hormone. That is dramatically suppressed by the operation so people are less hungry, have less desire to eat. And so that operation produces about a 25% reduction in body weight in one year. And at three to five years, people still have 20% off. So a person who's got a BMI of 35 or more with a comorbid condition such as type 2 diabetes wants to talk with his or her physician and see if they might benefit from bariatric surgery. If the doctor and patient don't think that's the option, you would like to consider an obesity medication to help you just control your feelings of appetite, hunger, and satiation, to make it easier to eat a lower calorie diet, to make it easier to want to get out there in physical activity. So that is the big picture of the options: Diet and physical activity for people who have overweight and obesity without health conditions. And then you add medications for people at a BMI of 27, 30, or greater who have health complications. And then you add bariatric surgery when medications don't work.   Bio   Thomas A. Wadden, Ph.D. is Professor of Psychology in Psychiatry at the Perelman School of Medicine at the University of Pennsylvania. He served as director of the Center for Weight and Eating Disorders from 1993 to 2017 and was appointed in 2011 (through 2021) as the inaugural Albert J. Stunkard Professor in Psychiatry. He received his A.B. in 1975 from Brown University and his doctorate in clinical psychology in 1981 from the University of North Carolina at Chapel Hill. Wadden's principal research is on the treatment of obesity by methods that have included lifestyle modification, very-low-calorie diets, physical activity, medication, and surgery. He has also investigated the metabolic and psychosocial consequences of obesity and of intentional weight loss, the latter as represented by findings from the 16-year long Look AHEAD study. He has published over 500 scientific papers and book chapters and has co-edited seven books, the most recent of which is the Handbook of Obesity Treatment (with George A. Bray). His research has been supported for more than 35 years by grants from the National Institutes of Health.  

Episode 2088 - On this Sunday School episode, Gina Grad joins Vinnie Tortorich and the two talk misleading BMI, cholesterol numbers, heart disease, smoking, and more. Https://www.vinnietortorich.com/2022/04/misleading-bmi-episode-2088 PLEASE SUPPORT OUR SPONSORS MISLEADING BMI Body mass index is generally a pretty inaccurate measure. The calipers don't really work. And often, the information can just be misleading. Those who are muscly might have a higher BMI. Vinnie has seen so many silly BMIs because of this. And just because you have a lower BMI does not necessarily mean you are healthy. Gina was told she was very overweight based upon her BMI. She felt dejected and terrible. Vinnie says: this is not an accurate or meaningful measure. He KNOWS she is not overweight like she was told based upon her BMI! It doesn't take into account so many important variables. PURCHASE BEYOND IMPOSSIBLE The documentary launched this week on January 11! Order it TODAY! This is Vinnie's third documentary in just over three years. Get it now on Apple TV (iTunes) and/or Amazon Video! Link to the film on Apple TV (iTunes):  Share this link with friends, too! Link to the film on Amazon Video: It's also now available on Amazon (USA only for now)!  Visit my new Documentaries HQ to find my films everywhere: REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter! FAT: A DOCUMENTARY 2 (2021) Visit my new Documentaries HQ to find my films everywhere: Please share my fact-based, health-focused documentary series with your friends and family. The more views, the better it ranks, so please watch it again with a new friend! REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter! FAT: A DOCUMENTARY (2019) Visit my new Documentaries HQ to find my films everywhere: Please share my fact-based, health-focused documentary series with your friends and family. The more views, the better it ranks, so please watch it again with a new friend! REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter!

It was just this overnight conversion. Like, oh, okay, yep, the way I've been doing things my entire career is super wrong, and super harmful, and has hurt a lot of people. And that's terrible. And I'm very done with that.Welcome to Burnt Toast! This is the podcast where we talk about diet, culture, fatphobia, parenting, and health. Today I'm chatting with Anna Maltby. Anna is a longtime magazine and digital editor and someone I've worked with many times over the years, including at Medium’s Elemental Magazine, where I wrote features on diet culture and fatphobia that she edited. And right here on the Burnt Toast newsletter, Anna is often the person who does a top edit for me on particularly tricky reported essays. Another cool thing about Anna is that she’s a certified personal trainer and Pilates instructor. In addition to her editorial work, she does a lot of fitness consulting and training. That gives her this pretty unique perspective on the world of fitness journalism and the fitness industry —and on the harm that these industries have caused to folks in marginalized bodies, what changes are happening, and where we still need to make these spaces better and safer for all kinds of marginalized folks. But Anna is really here to talk to us about the myth of visible ab muscles.I want to say really clearly before we start the show: Health and fitness are not moral obligations. Core strength is certainly not a moral obligation, although it is practically useful. We are talking about core strength in a very different and much more functional and accessible way. But if even that feels triggering to you, I get it. There was a long time where I just couldn't engage in abs talk at all. One more disclaimer that Anna is a thin white lady. We both have a lot of thin and able-bodied privilege in this conversation. I'm seeing this episode very much as the start of a conversation about fitness I want to have on Burnt Toast. There are lots of folks in marginalized bodies doing really amazing work in the fitness space that we also need to center and hear from and we talked about some of them on the show. I'm hoping some of them will be joining me in future episodes. PS. Friends! The Burnt Toast Giving Circle is over $8,000! We are so close to our goal. And if you’ve been thinking about joining, we still need you! Here’s the Burnt Toast episode where I announced it, ICYMI, and the link to donate.Episode 37 TranscriptVirginiaHi Anna! Why don't we start by having you tell us a little bit about yourself and your work?AnnaI started my career as a magazine editor. I worked mostly in the service space, so magazines that tell you how to do things: Men's Health and Self and Marie Claire and Real Simple. I've worked in the digital space as well for a while: Refinery29 and one of the in house publications at Medium. I've done a lot of things, but but health has been a main thread for me. I've also been a certified personal trainer for about seven years. I'm a pre- and postnatal certified exercise specialist, and I received my mat Pilates certification about a year ago. I now do a bunch of freelance editorial and fitness-y things, like fitness programming, fitness performance coaching, and then I also train a few clients every week. I do a mix of Pilates and weight training.VirginiaDid you start out as a journalist and then go into the health and fitness stuff? AnnaI definitely was not into sports or exercise or movement at all, as a kid. I always loved reading magazines and that was what I focused on in school. I sort of fell into this internship at Men's Health when I was in college, and my manager there was like, “Okay, if you're going to write stories for us, you're going to need to know some of the basics of scientific reporting.” Like how to read a study, how to talk to a researcher, how to interview a medical expert. I loved that process. I suddenly had at my fingertips just being able to pull a study and understand what it said. Then, through a random series of magazine world misfortunes—which I'm sure you're very familiar with—I ended up going freelance. I got a job as the fitness editor at Fit Pregnancy magazine and I really loved that work. I found more flow in it, honestly, than more hardcore health reporting. One of the things that I did for that job was to be on set during workout photoshoots. We would always have to hire a personal trainer to be on set as well, to oversee the form for the models to make sure everything was safe and accurate. I was just so interested in it and I felt like I kind of had the basics of what these people were doing. So I was like, “For the cost of this person's day rate, my company could just pay for me to become a personal trainer.” Which was like a lot easier said than done, because it's really hard. All of the studying that you have to do and the reading and the test is really intense. I recently made kind of a big career change and went freelance again and started building my own business and training clients has become part of my week to week work, which has been so cool—just working with real people and seeing how their bodies work and how they respond to movement and how they learn things and seeing them get stronger and more motivated and more confident in the way they move. It has also really informed the sort of content work that I do. Like, how do I explain this to my client? I've seen in practice, that this concept is difficult for people or that this movement is not actually that accessible to people.VirginiaThat makes sense because so often people who are naturally good at certain types of exercise are not necessarily the greatest at explaining them to other people.AnnaHaving an editor brain is really helpful for training clients, as well, because I'm so in tune with what language people understand and how to break things down in a way that's accessible. I think the two things really do complement each other. VirginiaI want to go back to you being not athletic as a kid because I completely relate. I was a very un-athletic child. I think I played one season of Little League and just sat down in the outfield for several months and was like, why are we doing this? I think I tried one season of field hockey in middle school. Oh, no, I did not try a season, I tried one practice of field hockey in middle school. I got there and they didn't wear the cute skirts to practice and they had to run a lot of laps. And I was like, “Nope. Peace out. Not for me.” I should also say, I was a skinny kid and I was really given a free pass to not be athletic because of that thin privilege. People didn't think I needed to be athletic because my body was already the acceptable body. My then my understanding of exercise was definitely in this category of either you're some kind of hardcore jock or you do this because you're making yourself thinner. And if I'm already thin, I don't have to worry about it. AnnaTotally, I find that very relatable. I was a very skinny kid and very inactive. I remember in maybe in fifth or sixth grade, we played this game called mat ball, which was sort of like kickball, except they put big gymnastics mats out for the bases and for some reason as many people could be on the base as could fit. And I was like, great! I'm going to kick the ball. I'm going to run to the mat, and then I'm going to sit down. My teachers loved me. I have to say, I think I might have been sheltered from the fatphobia of it all. It wasn't really on my radar at that point, that exercise was for weight loss. I just didn't understand what it was for. But then in my early 20s, a couple of things happened. For a few years, I had been throwing my back out. I was a young, relatively healthy person and I was just throwing my back out. I would sneeze and not be able to turn my head for three days—that kind of thing. My first job out of college, I worked at Men's Health. I was the assistant to the editor in chief. They gave us all really cheap gym memberships, so I got a fancy gym membership for like 10 bucks a month. And I was surrounded by this Men's Health gym bro culture thing. I was like, okay, I've been working on some of this content, I'm starting to understand it a little bit more, I feel like I can stand to get stronger. That sounds interesting. I had a couple of sessions with a free personal trainer. I joined the gym and started doing some of the exercises that person taught me and I was like, Wait a second, I don't have back pain anymore. My back does not hurt. I'm not throwing it out. Although if I skip the gym for a couple of weeks, I throw it out again. It was just a really clear connection between pain and to my ability to function and live my life comfortably. And that became this incredible motivator for me. I need to work out because if I don't, I will feel terrible.VirginiaYou talking about your back pain leads me perfectly into what I want to talk about next, which is the real reason I was like, “Anna you have to come on the podcast.” It was this great Twitter thread you did recently about the myth of visible abs. AnnaI got this mat Pilates certification a year ago and a lot of my work is focused on sort of the prenatal and postpartum period. I think a lot about the core, the pelvic floor, the diaphragm—all of the things that we work on in Pilates, all of the things that change and are affected by pregnancy and the postpartum period. I think the core is so amazing, especially for the pelvic floor, and is not talked about enough. It's something I think about from a very functional perspective. So, a few weeks ago I got a message from a friend of mine, who is a few months postpartum after having her second kid. She sent me this message and she said something along the lines of like, “Can You please help me get my abs back? I am doing everything I can think of. I'm doing Pilates a few times a week, I'm doing HIIT workouts a few times a week.” She said, “I'm restricting. I'm doing Whole 30 about like, 80% of the time, I'm not drinking alcohol. I feel really strong and feel really toned but I can't get to my lower belly pooch. Like, what's your secret? What do you do?” It really took me by surprise and made me feel sad. For someone who has two children and a really busy professional life to like, be spending so much time—VirginiaSo much time in pursuit of this one thing.AnnaExactly. And of course, hearing that she was restricting was pretty disturbing to me. I tried to respond in a very kind and non-judgmental way while also being like, “Please don't do this. Please eat bread, please take care of yourself, please feed yourself please do movement that feels good to you. It's great that you're building your core, but…” I actually, I sent her a mirror selfie. I was like, “I want you to see my stomach right now. It's not flat. It’s not ‘toned.’ It's bloated and round and cushiony.”VirginiaBecause that’s what bodies look like when they’re not fitness models on photoshoot.AnnaThat's what a belly looks like. So I was thinking about that and this is the time of year when a lot of us start getting advertisements on the internet about workout plans and supplements and workout clothes, and all of those things. I noticed a couple of them popped up in my feeds that had people with very visible, cut abdomens. And I was really surprised, by my initial gut reaction to those ads, which was, “Oooh!” I was so drawn to those images of people with really defined, visible abdominal muscles. Of course, immediately, it was like, What are you doing Anna? You know that's not achievable. You know they're trying to sell you this thing. Move on. But those two experiences started me thinking, what is this pull that abs have on us? I'm sure you remember from your magazine years the many cover lines that we had to write about “get a toned, taut, tummy” or whatever. Or when I was at Men's Health, like “get shredded in six weeks” and stuff. You always had to have some kind of abs cover line. VirginiaIt sells magazines, it sells media. You have to talk about abs.AnnaAbs just have this pull on us and marketers know this. Companies know this. It's such a central point of insecurity for so many people. So it inspired me to write this thread that you're talking about on Twitter. Because the way that our culture deals with abs is so messed up. Look, abs are so amazing! They do so many things for you. They're this like miraculous muscle group that we don't really show the right kind of love to because we're so focused on how they look. But how abs look is the one thing that you're never really going to be able to affect unless you engage in potentially disordered eating patterns or pretty toxic exercise habits. VirginiaI just want to say this really clearly: The ability to do ab workouts and develop really visible abs is primarily genetic, right?AnnaIt's primarily genetic, because it's really about the way that you carry weight and fat, like how much subcutaneous fat you have on top of your abdominal region. Fitness models and people who compete in fitness competitions, there are things that those people do to change their nutritional intake to really minimize the amount of fat that's showing so that the muscle definition can show through. But even those people only do that some of the time because they know it's not sustainable. It's not actually good for their for their muscles. It's not safe. They eat to build muscle a lot of the time, and then for a very short period of time they eat to cut down on visible fat.VirginiaI'm so glad that is not how I spend my life. That just sounds exhausting. It's powerful to think that you, who has all this knowledge, are still looking at a photo of visible abs and feeling that pull towards them. Even people who know that it’s all fake are still caught up in what we're seeing. We can't say often enough that this isn't real, this isn't realistic, this is unsustainable. My reaction to a lot of this has been to stop doing ab exercises, to be very honest. Exercise for a long time was only about weight loss for me. As I divested from that and stopped dieting, stopped pursuing thinness, it was really important for my mental wellbeing not to do abs exercises because I knew they would trigger a whole set of body aspirations that were not good for me. So I didn't do the ab exercises for a long time—including during the period when I had two children and my abs had to work real hard. I've been through some stuff, they've seen some things. As all my listeners know, in January, I threw my back out and couldn't walk for five days. That is probably the 10th time in two years that has happened. That was when I emailed you in a panic and was like, “What is happening?” So talk about what abs do, and why they matter, in the non-aesthetic sense.AnnaIt frustrates me so much, as someone who personally has benefited from this kind of exercise, who's seen my clients feel so much better after strengthening their core. It’s so fraught, it's so tied to these feelings for so many people. But in reality, your core is the most important area of your body to build strength, because it supports your spine that supports your pelvis. It supports these centers of the way your body functions and moves. Your abdomen is where all your organs are too. It's also important for the health of your back, your posture, the way that you breathe, the way you walk, if you're a runner, the way that you run, protecting yourself against injury—even things that seem like totally far away and unrelated, like people who have wrist issues or ankle issues or foot issues, some of that can really be tied back to the core and the pelvic floor. Another part of all of this that gets me is that fitness is so fraught for so many people for lots of reasons. But, getting into a really like healthy and positive movement practice—I think we can agree that that's a really lovely thing for people. It really makes you feel good. It's good for your mood and your sleep and your health, by and large, if it's something that's available to you. When you look at the science around motivation, like what gets people to start and stick with a new habit, there's good evidence that things like reducing pain, feeling good, moving more smoothly, feeling more energetic—all the things that can come from a movement pattern like Pilates or focusing on core and strength—those kinds of things are way stronger motivators. You're much more likely to stick with that kind of practice, if that's what's driving you, than external motivators like pounds lost or visible abs, partly because those things are really hard to attain. Even if you ‘achieve’ a certain visible goal, you're probably not going to be able to sustain it. We all know the research about that. So that's another area about this that frustrates me. Visible abs is such a bad motivator. Strong abs, functional abs—that's a great motivator.VirginiaIt's a fascinating disconnect. We've really been taught to focus on the aesthetics. It helps you find the lie in the “We're worried about people's health” b******t. If we were really worried about people's health, we would be focusing much more on how to motivate people to exercise for all those reasons that really work. You and I both started on the dark side, in women's media and Men's Health, these creators of the pro-ab agenda. You've had this evolution and so have I. I would love to hear your evolution story and what got you into a different place with fitness. Anna Looking back, I was 100% one of the bad guys. To forgive myself a little for that, I think it was pure cluelessness, not anything malicious. I wanted to be a journalist. I wanted to work at magazines. Here's the magazine where I got my job, this is what they do. Sure, like, I will do it. Like I said, I started my career at Men's Health and I was specifically spending almost all of my time helping write and edit this series called “Eat This, Not That.” It started off as a little column in the magazine. It was like, if you're at McDonald's, get the this thing instead of this other thing because it has fewer calories and less saturated fat. So they turned that into a book. They turned it into its own website, my boss went on the Today show all the time to talk about it. I was like helping write and edit those books, writing and editing blog posts, and Today show appearance scripts. All of those were all entirely focused on weight, all entirely focused on calorie counts, which I didn't enjoy. It wasn't the diving into science that had drawn me to that field. So I did move away from that, although unfortunately not like for “the right reasons.” A few years later, I was at Self Magazine—I was not like editing the drop 10 plan or anything each each year, but I was very adjacent to it.  Then when I was fitness editor at Fit Pregnancy, our postpartum fitness story every issue was called “Bye Bye, Baby Weight.”Virginia Oh, that is so cringe-y. I wrote for Fit Pregnancy a lot in my early freelancing days and I had blocked out that part of it. AnnaIt sucks. It was actually such a great magazine. Then I started talking to Refinery29, in about 2015, about an opportunity there to be the health director. The person I was interviewing with, Kelly Bourdet, gave me some links and some things to look at as I did the interview process. One of the things was the first year of their Take Back the Beach project. I don't know if you remember the project, but it was sort of in response to all of the like “bikini body” stuff. I think there were those big ads that year in Times Square with the really skinny person in a bikini and like maybe it was for some kind of weight loss supplement or something. I'd been seeing things around the internet about body positivity. This was like really the first large scale, very thorough takedown I'd ever really ingested about diet culture and all the messages the media sends to people, especially women, about what makes an acceptable body and how harmful those messages are. It was so eye opening for me. It was this overnight conversion, like, oh, okay. The way I've been doing things my entire career is super wrong and super harmful and has hurt a lot of people probably. And that's terrible. I'm very done with that.VirginiaSo that's what led you into, as you were doing your own work becoming a trainer, taking a really different approach. AnnaI think all of those building blocks that were set for me at Refinery29 really changed the way that I edit. It changed the way that I work on content. Even after Refinery29, I continued to work in health coverage for several years, taking the reins at different publications and saying, “Okay, this is the stance that we're gonna take on this.” I fought those battles, I brought in fat voices, I made sure that we were doing right by that subject matter. That has all really deeply informed the way that I approach fitness with my clients. I think also, continuing that education process by following other thinkers in this space, especially people who aren't thin or white or straight or cis, like Mikey Mercedes is just amazing. She's been with you before on the show.VirginiaYeah. Someone I learn so much from all the time,AnnaShe's just brilliant and she's really helped push my thinking. I think I owe her a lot. I try to support her as much as I can. And then people more specifically in the fitness space, Ilya Parker of Decolonizing Fitness is someone. I'm a supporter of their Patreon, and they just have amazing resources for fitness professionals, making sure that the spaces that we're creating are trauma informed and welcoming to people of all body sizes and abilities. Especially as a thin white lady, how can I make sure I'm creating a safe and positive relationship to movement for my clients and in whatever content that I'm helping create.VirginiaI felt like the fitness industry for a long time was really lagging behind the anti-diet conversation. There has been this sort of steady growth of Health at Every Size, anti-diet, weight-inclusive dietitians trying to get away from the weight loss focus that most dietetics is based on, but there wasn't a parallel shift happening in fitness for a long time. I think in mainstream fitness brands, it's still really in its infancy. I look at what brands like Peloton are doing, and there's certainly lip service and use of rhetoric, but I am not yet convinced it is backed up by a full rejection of intentional weight loss. I think that they're still trying to have both. Like, for the folks who want weight loss, we do that and then for the folks who want something else, of course we want you to love your body. But I think there is more creeping progress in fitness now. The folks you mentioned like Ilya and other people who have just been doing the labor for so long. We owe them so much for starting to shift these conversations. AnnaWhat I'm finding now in my consulting work is that people are really open to it. When I come in and I say, “Okay, if you want to create this body of editorial work or this fitness program, it's going to be it's going to be body neutral. We're not going to talk about visible results. We're not going to talk about calorie burn. We're not going to talk about weight loss. Here's how we're going to approach this.” They're actually surprisingly really open to it. I don't get pushback on that. But it's things like sizing. What are we going to put people in for a shoot? It's things like casting. Like, “Oh, it's, it's kind of hard to find somebody in the larger sizes. I hope this like size 12 person is good enough.” There are all these process hurdles which are ultimately pretty b******t. If people cared enough about it to invest the time and money, they would. VirginiaAll fixable problems. AnnaAll fixable problems, but when you're in the room and you're trying to make it happen, it is hard. It isn't as easy as waving a wand and magically a size 20 model appears. Like, are they working with a casting agency that offers those options? It's those little cogs in the machine where each one has to be set up for success. If that kind of representation and accessibility and inclusivity isn't centered in the process, it's just going to end up being not a priority.VirginiaWe've been kind of bashing women's media and I'm comfortable with that, but brands like Self have done a real 180 on these issues. It's not a print magazine anymore, but self.com is very committed to an anti-diet, weight-inclusive, pro diversity perspective. That's just a world away from what it was, ten years ago. Man, if you had told me I would live to see the day that women's magazines would care about fat people. AnnaSelf has gone through such an interesting process now. When I started there, there was no fat representation. Of course, it was talking about weight loss and all of that stuff, but the vibe overall of the magazine was about being kind to yourself and about exercising and participating in sports because it made you feel good and felt fulfilling and felt like putting yourself first and taking care of yourself, which is a pretty positive message, if you take out the weight stuff. VirginiaAnd if you ignore the fact that they're only showing skinny white people.AnnaAbsolutely, absolutely. I remember while I was there, we went through this rebranding, like they brought in some outside consulting agency. And the determination was we need to go younger. The way to reach a younger audience is to focus entirely on aesthetics. So any recommendation we were giving, even if it was in a freaking like breast cancer story, “Make sure you get at least 150 minutes of moderate exercise a week. As a bonus, you'll get toned for the summer!” Every single story had to take it back to being hot which just like, I hated that. A lot of people that work there hated that. We started getting letters from readers who were like, this isn't why I read Self. So it just kind of sucked. Then a few years later, the magazine folded and they went digital only. I know Carolyn Kylstra, the prior editor in chief, did so much work to bring that brand to where it needs to be from the lens through which they cover health and bodies and from the visual representation standpoint. VirginiaOh, man, I feel like we could talk about different women's media brands all day. But I do want to go back to abs. So, as I was saying, like, I have had this experience of throwing my back out. I finally started physical therapy, in large part because you encouraged me to—thank you very much. It is amazing how well it works. Maybe because I took a fairly long hiatus from doing any kind of ab exercises, this is the first time in my life I'm noticing when I do ab exercises how much better I feel the rest of the day. I have to admit, as someone who has this whole other experience with fitness being really toxic, I almost feel like a traitor to myself being like, Wait, doing core exercises makes me feel good. It's like this weird, disconnect. But if I do five minutes of core exercises in the morning, my back doesn't hurt. I'm sleeping better. I'm feeling better walking up a flight of stairs in my house and picking up my four year old who I really felt like I'd gotten to the point where I couldn't pick her up that much anymore. And now I'm like, oh, I can pick you up again. I feel like I've been lied to for a long time. But I also just want to hear more about like, is that the deep core? What is that that just doing a few minutes of ab exercises can actually produce that. I feel like I'm in an infomercial now.AnnaThe visible abs, if you were to able to see them are the rectus abdominus, which is sometimes called the “six pack muscle,” unfortunately. It's those muscles that are right on the front of your stomach. Basically, when you're bending at the waist those are the muscles that are working. They certainly serve a purpose—abdominal flexion is a functional movement, like you use it to get out of bed and off of the sofa and things like that. The deep core muscles that that you mentioned—specifically the transverse abdominus, the multifidus, which is like a really small, deep muscle on the back of the deep core, and then the diaphragm at the top, and the pelvic floor muscles at the bottom. That’s the deep core. That's what really has to expand to accommodate a pregnancy. Obviously, the rectus abdominus has to expand for that as well, but working the deep core during pregnancy really helps protect you from the activities of daily life putting too much pressure on the pelvic floor and potentially leading to a pelvic floor dysfunction. They really are what supports the spine and the pelvis. Strengthening those deep core muscles—the TA especially—really supports any other kind of movement that you want to do, whether it's picking up a kid or walking up and down the stairs or standing. Bringing strength and bringing activity to that area is so good for you. It feels amazing. It's a different. Sometimes working the TA, working the deep core can be as simple as a deep breath—breath work essentially. I like to teach this: if you place your hands either on your ribcage or on your belly—you could even do one hand on your ribs, one hand on your belly. You take a really deep inhale and really send the air down into your belly. Instead of just letting your chest rise, you're really breathing, you're sending the air as deep as you possibly can. And you're feeling your belly get bigger on the inhale, like there's a balloon inside your stomach. And that inhale fills it up with air so the balloon gets bigger, your belly relaxes and expands. Hopefully your pelvic floor is also relaxing and expanding on that inhale. And then on the exhale, it kind of zips back up into more of a neutral position. If you really use a strong exhale like a “ssss” or like a “hah” you could actually feel those deep core muscles kind of tightening and turning on underneath your hand. It should move in just a little bit. VirginiaFor listeners at home, I'm doing it and I'm feeling it.AnnaYeah, so that kind of breath work. Both the inhale and the exhale are really important. Because being able to relax and release the tension in that area is almost as important as like building the strength. It's so functional, because your breath and your deep core are so connected. You could do this kind of breath work any time of day. You can do it before bed. It'll help you get stronger, it'll help you get more relaxed. Your deep core, your pelvic floor in particular, holds a lot of stress and tension. If you have a really stressful day, sometimes your pelvic floor tightens up a little. So deep breathing at the end of the day will both release that tension in the pelvic floor and also help you relax a little bit emotionally.VirginiaI love that. The idea of relaxing and letting your belly expand runs so counter to the diet culture version of abs. Like, that's all about sucking in and keeping everything tight. Whereas what you're saying is actually much more beneficial and also lets you relax. That seems great. Anna A healthy pelvic floor can do both—can be strong and engaged when it needs to and can be relaxed and released when it needs to. So many of us are just by habit, since we were kids probably, going around trying to suck in our gut all day. It is so bad for your pelvic floor to do that. It puts so much pressure on that part of your body, it can end up causing more discomfort and bloating and all that stuff.It's really hard if you're used to walking around that way and you feel self conscious about your stomach, but: Anytime you can, let your stomach go.VirginiaI love this. This is the new Burnt Toast mission. AnnaLet it go. The other thing that's ironic to me about sucking it in is it actually doesn't like align with anatomy. Exhaling brings your stomach in. You can't suck it in. When you suck air in, your belly gets bigger.VirginiaAll of this stuff you're talking about isn't going to give you a visible ab definition. That's not the mission. So another misconception I want to have you speak to is the misconception that fat people can't have strong cores and that if you're fat, all of this is out of reach for you. Can you help us debunk that? AnnaYeah, I think it is so similar to health misconceptions about body size. Just like you can't look at someone's body and tell whether they're healthy or unhealthy—whatever definition of that you subscribe to—you can't look at someone's body and tell whether they're strong or weak. I mean, obviously, there are people—The Rock, of course he's strong. VirginiaI'm willing for us all to make a snap judgment about The Rock.AnnaAlthough, I don't know what's going on with his pelvic floor. I hope it's okay. You know, you never know.VirginiaHe's not keeping us updated on that.AnnaThere's certainly research out there about—I hate to say the word BMI—people with higher BMI sometimes have more muscle strength than those with lower BMIs. It's on an individual level, there's no correlation.VirginiaWeight is not predictive. They may be finding research showing that people in larger bodies have less abdominal strength, but it doesn't mean that's their weight that's the deciding factor there right? Like there could be other things at play AnnaI follow all kinds of like amazing like fat fitness influencers on Instagram and they post their workout routines and they do like ab exercises that would have me panting on the floor. I am definitely not as strong as they are. It's so important for everyone to feel like this is something that that is accessible to them and that they can work on and that they can feel the benefits of. That's such a good thing for everybody.VirginiaI love that. You know, health is not a moral obligation. Fitness is not a moral obligation. Nobody needs to do these exercises. But if you're listening to this, and you're thinking, huh I am interested in a weight neutral approach to abs, here is what Anna recommended. You can take it or leave it, but it's stuff I've been personally finding really useful. AnnaYeah, and on that note, I do want to say I am a thin white person. I did used to write this column where I posted a move of the week on Medium. That's what I sent you, a few exercises that I really recommend for abs strength and back strength. I stopped writing that column because I just started to feel uncomfortable with being a thin white lady putting more images of thin white bodies performing fitness on the internet. It just didn't feel useful or additive. So I want to caveat those resources by saying, “Hey, you're gonna see a thin white lady doing ab exercises.” If that feels like something that would be fine for you, great. If not, don't look at it, it's fine. I agree that it's not the most necessary perspective to have out there.VirginiaI so appreciate that. And we will also link to the other folks of color, fat fitness folks you talked about. We'll put some resources in so people can see what they're doing. I think that was a tough, but kind of important conclusion to come to. But also your take on fitness is really helpful. You do write exercise moves very clearly. And I appreciate that. So thank you for that. Butter For Your Burnt ToastAnnaWell, we are talking in late March and I have been—I'm sure you'll appreciate this—daydreaming about gardening, and just plotting. I haven't had time to do any seedlings or anything like that, but we had kind of a warm day yesterday in New York and I went out on my balcony and started clearing things out. I noticed my little strawberry plants are starting to regenerate. I was on hold or something and I just spent three minutes clearing out old, dead branches and taking a look at what was going on in the beds that I haven't touched for a few months. It was such a wonderful, restorative feeling and just held so much promise. So I would recommend spending a little time with some dirt.VirginiaI love that. I mean, I am a well known plant lady so I've given a couple gardening recommendations lately. I think getting out with some dirt is so calming. My recommendation is the movie “Turning Red,” which I'm hoping everyone has already seen. If you haven't and if you have kids in your life of any age and any gender—and I really want to emphasize that part—Turning Red is such an important movie to watch with your family. It is the story of this 13-year-old Chinese-Canadian girl who is going into puberty. It turns out in her family when girls go into puberty, when they have big feelings, they turn into a big red panda. It is obviously a metaphor for periods. There's also some great normalization talk of periods and bodies and teenage girls having crushes and sexual desire. I love it so much. The backlash is hilarious and very irritating and outrageous. Particularly the older white men who say that they can't relate to the movie because I guess they were never a child or a person with emotions because that's all you really need to have to relate to this movie. So Turning Red, we love it so much. So Anna, thank you so much for being here. Tell people where they can follow you and find more of your work.AnnaThey can follow me on Twitter at @amalt.VirginiaAwesome. Thank you for being here.The Burnt Toast Podcast is produced and hosted by me, Virginia Sole-Smith. You can follow me on Instagram or Twitter.Burnt Toast transcripts and essays are edited and formatted by Corinne Fay, who runs @SellTradePlus, an Instagram account where you can buy and sell plus size clothing.The Burnt Toast logo is by Deanna Lowe.Our theme music is by Jeff Bailey and Chris Maxwell.Tommy Harron is our audio engineer.Thanks for listening and for supporting independent anti-diet journalism. This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit virginiasolesmith.substack.com/subscribe

On this episode of That's Rad, host Anastasia sits down with Kelsey McCullough, Registered Dietitian and owner of the 21st Century R.D., to have an honest conversation about how our relationship with food and our bodies is not always as positive as we project it to be on our social media feeds. The truth is many people struggle with being comfortable in their body–and Anastasia and Kelsey dive into some of the reasons why. They discuss how diet culture has now become almost inseparable from American culture, and how that affects our perceptions of ourselves, each other, and the food we eat. They also discuss the prominence of disordered eating and some of the different forms eating disorders can take. **Listener discretion is advised as the content of this episode discusses diet culture, fad diets, obesity, BMIs, weight loss, eating disorders, and other sensitive subjects.** If you or someone you know is struggling, please call the NEDA Hotline (800) 931-2237 or visit https://www.nationaleatingdisorders.org/. The following topics are discussed in depth during these time frames: Diet Culture 11:12-19:19 ; 28:08-28:28 ; 30:51-35:10 Fad Diets 11:50-11:58 ; 35:11-40:30 ; 42:35-42:56 ; 1:03:10-1:03:44 Eating Disorders 3:57-4:59 ; 25:25-25:50 ; 43:28-57:24 Obesity 20:45-21:45 ; 22:34-23:22 ; 24:15-24:32 BMIs 18:35-18:43 ; 19:35-24:32 Weight Loss 31:49-32:12 ; 34:05-34:44 ; 35:11-40:30 ; 41:14-42:56 However you choose to nourish your body, the Littleton Food Co-op is here to support you. We have a variety of fresh produce, bulk items, meat and seafood, artisan cheese, craft beverages and more, plus a full deli counter with take-away prepared foods. Located conveniently off of Exit 41, we are Littleton's only 100% community owned grocery store. Stop by today– no membership required! – or visit us online at littletoncoop.com. Dedicated to M.E.S

This week at Grey Sloan  we are devided by good intentions. Morality and Morbidity conferences are the worst-but who is on trial Webber or Levi?   Bailey needs at least 6 extra hands, 4 surgeons, 3 interns and a massage.  We find out the big fat truth about BMIs. They're about as useful as Link's opinions. Will Owen's good intentions back fire on him and his relationship with Teddy?  Amelia, Deluca and Jo work together to shed light on the dark side of womens medicine. We get an answer to the question that has the internet on edge- Is Nick a Ghost?  Contact us at email - scalpelsandtequila@gmail.comInstagam - @scalpelsandtequilapodcast@missthayes and @ms_ayla_azureTamzen and  Ayla xHosted by Tamzen Hayes and Ayla AzureGreys Anatomy CreditsCreated by Shonda RhimesStarringEllen Pompeo - Meredith GreyChandra Wilson - Miranda BaileyJames Pickens Jr - Richard WebberKevin McKidd - Owen HuntKim Raver - Teddy AltmanCamilla Luddington - Jo WilsonCaterina Scorcone - Amelia ShepardKelly McCreary - Maggie PierceChris Carmac - Atticus LincolnRichard Flood - Cormac HayesJake Borelli - Levi SchmittAnthony Hill - Winston NduguJaicy Elliot - Taryn HelmAbigale Spencer - Megan HuntScott Speedman - Nick MarshE.R Fightmaster - Kai BartleyGreg Germann - Tom Koracick

Robotic surgery at MUSC Health is making life changing procedures, such as the most complex bariatric surgeries, accessible to more people than ever before. In this episode of Advance with MUSC Health, https://muschealth.org/MUSCApps/ProviderDirectory/Pullat-Rana (Rana Pullatt, MD), explains how these transformational surgeries are changing the lives of patients with BMIs from 35 to the upper 90s. Pullatt is a Professor of Surgery and serves as the Clinical Director of Bariatric and Robotic Surgery.

On this week's 51%, we stop by the swearing in ceremony for Mary Ritayik, the first female police commissioner of the State University of New York. We also check in with Chelly Hegan of Upper Hudson Planned Parenthood following the Supreme Court's hearing on Dobbs v. Jackson Women's Health Organization. Guests: Mary Ritayik, Commissioner of SUNY University Police Department Commissioner; Chelly Hegan, president and CEO of Upper Hudson Planned Parenthood 51% is a national production of WAMC Northeast Public Radio. It's hosted by Jesse King. Our executive producer is Dr. Alan Chartock, and our theme is "Lolita" by the Albany-based artist Girl Blue. Follow Along You're listening to 51%, a WAMC production dedicated to women's issues and experiences. Thanks for tuning in, I'm Jesse King. This week was a big week in terms of women's issues — we'll discuss the Supreme Court's hearing on Dobbs v. Jackson Women's Health Organization later on in the show. But first, we're stopping by the Albany offices of the State University of New York, or SUNY, which recently swore in its first female police commissioner. SUNY has roughly 500 police officers across 64 colleges and universities. Mary Ritayik started out as a campus police officer at SUNY Purchase, and later became the first female police chief at SUNY New Paltz in 2019 — so the milestone is not exactly new to her.  Ritayik was particularly recognized at SUNY New Paltz for her efforts on community policing and “bridging the gap” between college students and law enforcement. It should come as no surprise that, just as police departments across the country have faced outcry and debates over police brutality, racial bias, defunding, and labor shortages, so have campus police. At the time of Ritayik's swearing in, SUNY Plattsburgh was in the process of facilitating discussions between the student body and law enforcement amid fallout from a Black student's arrest at what started as a routine traffic stop. At New Paltz, Ritayik was no stranger to these discussions through the creation of her University Police Department Advisory Committee, which brought together students, faculty, alumni, and officers to discuss police interactions with Black communities and other minority groups. Following her ceremony, I got the chance to sit down with Ritayik to get an idea of what students can expect, learn about her career so far, and ask about her goals for the university system as a whole. What does your job look like on a day to day basis? When do you get called to deal with a situation? Usually it's any issue on a specific campus. But it's also the good – I know [at the ceremony] they talked about [how] usually when you get called, there's a negative thing going on. But it's any kind of high-priority issue, or a staffing issue or something going on within that specific UPD that could affect everybody else, too. And I'm also the point of contact for if they need something, and they're trying to do something, you know, policy wise, in Oneonta [for example]. I need to know what that looks like, and have the best practices in place for them. But also, [if] another campus [is] doing what they're trying to get done at Oneonta, [I] point them in that right direction to kind of, “Hey, talk to this person. This is what they rolled out for like, a UPD Committee. We all kind of talked about our different ones and what's working, what's not working, kind of the best practice as well.” But I'm kind of that that liaison here at SUNY that manages all the different things going on. One of the things that they were talking about during the ceremony is how policing on campus is different than policing in a municipality. What are some of the differences? What are some of the similarities? What are the kind of issues that you guys are dealing with on a day-to-day basis? I mean, it's a different group of individuals on campus. So you really have your focus on that educational foundation. You have your employees, who work with students or work for the college; you have your students, who are there to get their education. And then also, it's like a little microcosm of society where you have things that do occur on campus – where you have, you know, 10,000 individuals living on campus -= you do have some crime or areas of safety concerns where you need a police department to help assist in that. What's unique also is the fact that it's a group of individuals that are just learning, or just becoming responsible adults. So they're kind of just getting out of living at home and experiencing life events. And it also lends itself to community: you have your residence hall communities, you have your student groups, your organizations, your fraternity, your Greek life. So there's a lot of different communities. It lends itself to those great opportunities, where [in a municipality] you really have to really work hard to meet with community groups, and establish that relationship. So it lends itself to a very good opportunity for relationships to occur. What are your priorities as commissioner? It really is to go back to that backbone of community policing – we've done it forever, and we did it before they even dubbed it “community policing” – and really connect with the community. I think there is that mistrust between the police and community as an institution overall. Our role is, yes, we're police officers. So individuals see us as an NYPD officer, or a Minneapolis police officer. And we really have to go back to what our foundation is – [that] we're different. We're university police officers. Yes, we will handle those situations where it's a safety risk or concern, but what we're doing is different here. And we're really building that community trust and coming to the table with this as the community: “This is your police department, we need to hear the feedback. Is there an issue? Is there a problem? What can we do to make it better?” When I first saw that you had gotten the position, the release said that you are focused on a student-focused approach. Can you go into a little bit about what that means? It's really what the students needs are: do they want to feel safe? Do they want to be able to go to class and feel comfortable, and feel that they can see a police car and have a good feeling about that? You know, not like, “Oh my gosh, the police. It's a negative thing.” So really looking at how we can better that relationship with students and that younger generation as it comes, as they go through their years of college, to really build a better student approach. What the students feel is a safety need we police officers may not realize that's a concern. So really getting that feedback from students is really important. I know [in New York] municipalities were tasked with looking at their police departments and seeing how they could reimagine policing. Is that something that happened in SUNY? It was the executive order that Governor [Andrew] Cuomo did, where he put it on municipalities and towns and villages to really look at their police departments and how to better improve and reform what their policies were, and how to make it better. The actual executive order didn't apply to state agencies. So technically, no, we didn't have to finish something by April 1 and have it delivered to the governor's office – but you can't just sit back and say, “Well, that doesn't apply to us.” And you know, it's such a bad image when you think of that. So really, it's doing something parallel – but keeping it consistent and keep it ongoing. You know, some departments, some sheriffs or [counties/municipalities], they had to have that report, and then it was given, and then they say they're going to do that. But like, is it reviewed all the time? I wanted something consistent. I wanted our department to consistently look at our policies, what we're doing, and are we doing the best practices that are out there. So for that reason, we did something parallel to it, to make everyone understand that we're not going to just shut down and say, “Well, that doesn't apply to us.” And this was while you're at SUNY New Paltz. Yes. The University Police Department Advisory Committee, was that a part of it? Yeah. And, you know, we were finding that individuals, whether they were students, or staff, or visitors that were on campus – they didn't have an outlet to go to if there was an issue that they had with an interaction with an officer. They didn't feel comfortable going to the police department, and saying, “Officer, so-and-so pulled me over, I have an issue with how he treated me.” So it really was a group of individuals who were experienced in law enforcement in some way, or they were studying it (students who were studying it), or they had a role on campus that they were a voice for students. So it was a group of individuals that we put together to say, “Hey, look at UPD, look at what we're doing. Are we doing a good job?” It also was an avenue for me to use saying, “This is why we do these things. You know, it's not to persecute an individual or group of people. This is the safety concern we have. And this is why we do it.” So it was a good platform to have, like a neutral platform for us to give our feedback on policies, use of force, things like that – where they can then know it's coming from this group of people, to explain it like, “This is why the police did A, B, C, and D on that traffic stop.” [To] kind of have a more neutral voice explain what we do. And they also then do the opposite [for us] with incoming feedback from the community. Do you see something like that happening on a broader, SUNY-wide scope? Perhaps? I know each individual campus has some form, or they're in the process of doing it, and some campuses have had it for years. And it's a little different, it's come together when there's major issues going on, and then the group also changes as well. You know, you have different individuals that retire, or they go to a different campus for their employment. So the group of people kind of fluctuates as well, I suppose, especially with students. Just looking at some of the other issues that people deal with on campus. I went to SUNY Oneonta, personally, and a lot of things that you would see campus police called for would be either like on-campus parties or marijuana use, stuff like that. With the state's new stance on marijuana, how does that impact things at campuses? Or does it impact the way you guys have to deal with things at all? It does a little bit, because campuses still have to adhere to federal law. Cannabis is still illegal federally, so for any kind of higher ed institution, it's still not allowed, it's prohibited. So the use, having it, the paraphernalia – it's still not allowed on campus. It's a different role of who handles it now on campus. There's no criminal component anymore to it. So the roles of UPD have changed, and the roles of other professional staff or paraprofessional staff in the residence halls, their rules are now looking at it differently as well. It's still prohibited. It's just not criminalized anymore. Another thing that has been a pretty big topic in colleges across the country is how schools are responding to reports of sexual assault or sexual harassment, and Title IX issues. Is there anything you'd like to see changed in New York state on that front? I mean, I think we're on a great path for dealing with sexual harassment and sexual assault. You know, in my career, I've seen a definite change of how it's viewed from students, and how they deal with it, and from staff and Title IX. I mean, when I first started, there was really no Title IX investigator or office, so the transition going across my career is really putting that at the forefront of what can happen on campus. And you have the “Enough's Enough” legislation…you need to address sexual assaults on any campus, whether it's SUNY, or any private institution. So it's headed in the right direction, but unfortunately, it still occurs on campuses. Now, I know some police departments have had either staffing shortages or trouble recruiting during the past few years. Is that something that's been happening in SUNY? It's difficult. We have to go through New York State Civil Service to hire our officers, and the way that system is set up, it's testing, and if you want to be a police officer, you wait for the test to happen. And sometimes they only happen [every] three or four years. So you have to hit at the right time, when you're interested. And then score well, and then wait for a campus to canvass you, interview and go through that process. So there's a lot of steps. It would be nice to see it a little bit easier, and reach out to more communities that can take the test and be qualified candidates for it. But right now, we struggle with that, and that's a big hurdle with trying to get hiring. And it's also a field that is evolving into…you know, those who wanted to be police officers are now kind of going away from the field just because of where we currently are with the focus on law enforcement. So people's career choices aren't geared towards law enforcement. For the past year and a half, going on two years now, what has it been like working in campus law enforcement, when classes have either been completely disrupted, or things have been very unstable? It's been interesting. For us, we are dedicated to the actual campus proper, so when you pick up your total on-campus population and you send them all home, we're left with an empty campus. You still need to be here, you still have to make sure there's nothing going on on-campus that involves criminality, but the population is gone. And it's not only students, but all your community members and your staffers are gone as well. So for the everyday UPD officer, they still came to work, and they still had to adhere by the COVID regulations. So there was a little bit of juggling with making sure our officers were in a safe environment when they were approaching or doing their day-to-day things like you know, just walking through a residence hall was something they did.  Everybody has dealt with COVID in some way or another, it was difficult, but we're getting through it. You mentioned something during your speech that I thought was interesting, too, about the focus on both officer health but also mental health. I mean, people are burned out in fields across the U.S. But is there burnout in policing? Yes,it was even before COVID. It's an ongoing thing [with the] taboo of mental health, and it applies to officers as well. You're that strong individual that needs to approach a scene, no matter how gruesome or how horrifying or upsetting it is, and you have to be that person that's level-headed, and gets it squared away. And you have to take in what you're looking at, and shove it back to the back of your head and deal with it and process it later. That catches up to officers. It's like, how do you cope? And we need to do a better job with getting our officers to decompress in a healthy manner. Not, you know, going home and having a drink or, you know, doing something else or just tuning it out. Because you really you have to deal with that to move on. And that's why you'll see there's a lot of suicides in law enforcement, and it's really [about] taking care of our own. We expect them to go through all these things, see all these horrible things at times, or deal with like a victim and hearing that story, and trying to get them help – and sometimes you can't help them, and then having that rest on you. We're doing a disservice to officers if we're not getting that mental health that they need. And it's also, you know, a cultural change in law enforcement, where officers didn't want to say, “I need help, I'm struggling.” It made them look weak, like they can't handle the job. And then some officers quit, but you have really good officers that, if they can recognize that they need help, you want to keep those officers, because they're trying to deal with what they're going through. You're the first female police commissioner here at SUNY, and you were the first female chief of police at SUNY New Paltz as well. What do those milestones mean to you? I mean, it's different for me. I kind of downplay it, when people say, “Oh, you should be up-playing it.” But when I think back and look at it, I'm very proud that I was able to make my way through this group of individuals and kind of rise up that way, amongst mostly male peers, and that they saw something in me. I continued to push through each promotion and realized it's my merit. It's not my you know, [my gender]. After a while, I felt like, as an officer and an investigator, my gender, or how I was a female versus male – that got lost. You were just investigator at the time, or you were an officer. The group of individuals I was able to work with were really welcoming in that, and they did not really give me much issues with the fact that I was female. But there is a different way you actually have to…unfortunately have to prove yourself, whereas your male counterpart and officer doesn't necessarily have to do that. Whereas a female will come in and they're going to judge that female and see how well they perform, and then accept the fact that they're a female officer and one of one of the group. Thank you so much for taking the time to speak with me. Is there anything that I'm missing that you'd like me to know? You know, I think I want to get a more standardized policies and the way we do things across SUNY – which is difficult, because there's so many different ways people are doing things. Not that they're the wrong ways. It's just kind of getting us on a level playing [field], where you have an officer from one place can go to another SUNY and everything's done the same way. So it's really kind of getting the group of departments on the same level, standardize policies and practices, and doing those best practices in the best way we can. Now to perhaps the biggest story this week: on December 1, a divided Supreme Court discussed the future of Roe v. Wade as it appeared ready to uphold a Mississippi law banning abortion after 15 weeks. In Dobbs v. Jackson Women's Health Organization, the state of Mississippi is asking the Court to overturn Roe, the 1973 landmark decision legalizing abortion during the first two trimesters of pregnancy, and return the issue to the states. While New York codified abortion rights into state law in 2019, the case has had local providers concerned. Back in August, I spoke with Chelly Hegan, the president and CEO of Upper Hudson Planned Parenthood, about a different (and more restrictive) abortion ban in Texas — but she says she's been dreading the Dobbs case for months. I checked back in with Hegan briefly after the hearing for her reaction.  What did you make of today's hearing? I think it's a really sad day for the Court and for the country. I think it was Justice Kagan who pointed out that making politics out of Roe is playing right into the hands of saying that the Court is a political body. You know, we had other cases that were essentially identical cases (to Dobbs v. Jackson Women's Health Organization) that the Court did not hear because of the precedent of Roe v. Wade. This case was taken up with the sole purpose of a direct assault on Roe, so that feels pretty sad. The state of Mississippi in this case is essentially asking to overturn Roe and Planned Parenthood v. Casey, and return the issue of abortion to states. What would that mean for Planned Parenthood and other abortion providers across the country? I think it means two things, in a broad sense. For starters, we have 16 states that have trigger laws on the books right now. Boom, those states will have no access to abortion for people who live there. Which means, depending upon your ability to pay to get out of there, your freedoms are going to be limited if you live in those states. And 24 states in total are really poised to severely limit access to abortion. So we're looking at half of our country having no access, or very little access, to basic health care. And that is discriminatory at its core. There is always a way for a wealthy white woman to get an abortion if she needs one. It is not always possible for an immigrant person, or a Black or brown person, or a person who's living paycheck to paycheck to be able to access abortion if they want to. So that's one thing. But I think it's also important to know that these are all places where abortion has been under attack for decades. And so we do have rights in some states, but it doesn't mean that we have access in other states. Mississippi is talking about closing its only abortion clinic. It's hard for us in New York to imagine what that's like — there is no abortion access in several states in the country right now. Many more have one, maybe two providers. Here in the northeast, we have this experience of more dense populations, we have more access and more freedom. And we all live in the same country. And it doesn't seem right to me that we have more freedoms than our brothers or sisters in Texas or in Nebraska. Today, there was a lot of discussion around fetal viability, and that mark where a law might say abortion is no longer allowed. Like, "Why shouldn't Mississippi put that line at 15 weeks?" Or, "Why is the current line at like 22 to 24 weeks set by Roe more appropriate?" What do you make of the conversation around that? I think that's been a problem with Roe since Roe was written. Roe says that the state has a vested interest in the pregnancy after the point of viability. Viability has always been a sort of quasi-science, quasi-religious conversation. Some religions see conception as the moment there's a life. Other religions say it's at birth — there is no real line. It's an artificial conversation, and science has a different approach to it. So Roe's always been sort of faulty on that point. And so that's part of what has continued to cause this churning fight. It's, "Well, what do you mean by viability?" I think one of the arguments today was that science has changed so much, so viability is earlier than it ever was. But the reality is, viability is not 15 weeks. And so even if you want to make a purely viability argument, could this pregnancy exist outside of the parent's body as well as inside? That's not 15 weeks. Aside from the conversation about viability, there's the matter of whether it's possible to seek care and an abortion in 15 weeks. I mean, that is always a conversation. I think, for people who have struggled with their fertility, so really worked hard to become pregnant, they probably have a hard time understanding that. Or people who who have never been [pregnant] or could never become pregnant, like Justice Kavanaugh, for example. 15 weeks seems like, "Oh, of course, you're gonna know long before then." But for young people who may not yet have regular periods, for people with certain BMIs whose periods may be non-regular, you're really only talking about three periods. So the first one may have come, you know, you're eight weeks before you know it, and you can get to 12 weeks and still maybe have spotting. So it's entirely possible that people who are not seeking pregnancy, who are on contraception, find themselves pregnant and don't know it. It is not typical, but it is certainly not impossible. In New York state, abortion rights are pretty well protected by the laws here. But what are you hearing from abortion providers in other areas of the country? People are really brokenhearted about what this means for our patients. And I think it's so easy to have politicized this discussion. Our country's always been very good at demonizing women and judging women for the choices that they're making. And for providers in states across the country where they're going to have their hands tied and be unable to provide their patients with the care that they're coming to them for, is absolutely heartbreaking. A decision on the case isn't expected until the summer, but what do you see as being next? Are there any steps that abortion providers can take in the meantime? I think that's a fantastic question, Jesse, because I am asking myself, like, "What can I do?" Really quick, to remind anybody who will listen: if you're in the Capital Region and you need services, our doors are open, and they're not closing. And yet, my heart is just broken for people across the country who are looking at this dramatic limitation on people's basic right to freedom. I think all we can do is raise our voices. All we can do is keep the gas pedal down and say, "This is not OK." Be loud, be aggressive about it. At any turn, vote in your primaries, hold politicians accountable for what's happened. Be prepared and start preparing. How are we going to get medication, abortion drugs to people who need them? There are not-for-profit organizations that have been working with countries that have severe access issues for people in those countries. We can do that here in this country. We're going to have to treat part of our nation as a third-world health care access space. I just want to call out one of the things Justice [Sonia] Sotomayor said. She said, "Will this institution survive the stench that it creates in public perception that the Constitution, and its reading, are just political acts? I don't see how we survive that." You know, and then you think about our institutions across the board — we've got people who are still debating whether or not the election was won. We have people who are debating basic facts. And now we have the Court being thrown into this very political space. So do we, collectively as Americans, believe that the Supreme Court speaks for us, and that we need to be held to the standard that they hold up for us, if it is so clearly politicized? I think those are incredibly dangerous things for our democracy. You've been listening to 51%. 51% is a national production of WAMC Northeast Public Radio. It's produced by me, Jesse King. Our executive producer is Dr. Alan Chartock, and our theme is “Lolita” by the Albany-based artist Girl Blue. Thanks to Commissioner Mary Ritayik, Chelly Hegan, and you for participating in this week's episode. Until next week, I'm Jesse King for 51%. 

Host: Dr. Jamie Murphy, Student Affairs DirectorGuest: Dave Hopkins, Director of the LECOM Medical Fitness and Wellness Center Dave Hopkins is the Director of the LECOM Medical Fitness and Wellness Center and shares his insight on setting goals and determining fitness goals. He discusses the most efficient way to exercise, the different types of calories, eating regimens, body fat percentages, optimal BMIs, and the social-cultural aspect of physical fitness as he works to keep healthy the next generation of LECOM healthcare heroes.________Please visit LECOM.edu for to learn more about the educational opportunities available at our institution.

Former President of South Africa, Nelson Mandela, made an important observation when he said, “There can be no keener revelation of a society's soul than the way in which it treats its children.” Our children are wholly dependent upon us, their parents, teachers, and society for their education, their safety and their health. It is with this mindset that we proclaim, high-value pediatric care is critical for winning the race to value. Our guests this week are Ginger Hines, Executive Director, Seattle Children's Care Network and Dr. Sheryl Morelli, Medical Director for Seattle Children's Care Network, and Clinical Professor of Pediatrics, University of Washington School of Medicine. Seattle Children's Care Network (SCCN) is a pediatric clinically integrated network comprised of Seattle Children's Hospital, 600 specialists in Children's University Medical Group, and 20 primary care pediatric practices comprising more than 200 providers and 6 specialty clinics. Member practices in the CIN support the health of 50,000 pediatric lives in value-based contracts. Episode Bookmarks: 03:20 Background on Seattle Children's Care Network (SCCN) and Seattle Children's Hospital 04:45 Pediatric value-based care being driven by employers and how SCCN formed direct-to-employer contracts 05:30 The movement to value-based care in Washington State's Medicaid program 06:00 How SCCN engages with physicians to build trusting relationships and a shared vision 09:00 The long-term societal benefits to investing in children's health 10:30 Children with high BMIs that become adults with diabetes, CHF, and depression 12:00 Parents missing work to take care of unhealthy children and how employers investing in children's health care lead to productive employees 12:40 Leveraging data and analytics in the CIN and how vaccinations and well child visits are key to disease prevention 15:00 How pediatric value-based care is different than adult value-based care 15:30 Data integration within SCCN and how the HIT infrastructure is foundation to success in population health 17:20 The validation of data accuracy as a critical success factor to building trust and supporting evidence-based quality improvement 19:30 Operational efficiencies within the CIN as a more effective way to provide actionable insights to providers 21:00 Developing consistent pediatric quality metrics and standardizing care within the CIN 24:00 Benchmarking quality performance at both the regional and national level 25:00 Recognizing the opportunity in pediatric value-based care and how you have to look for cost savings and improvements in different areas 27:30 Establishing a secure intranet to provide resources and reports to providers in the CIN 29:30 Focusing on the full panel of patients in the presentation of data and how that leads to success in population health 30:00 Transitioning to telemedicine during the pandemic and how that will impact pediatric care delivery in the future 34:00 Financial results from value-based contracts by focusing on ED utilization, asthma management, well visit completion rates, transitions of care, and quality measures 36:00 Capitalizing on quality improvement projects to decrease exacerbations within asthmatic pediatric population 42:00 Expanding value-based contracts with payers, employers, and Medicaid to prepare for full capitation 44:00 Mental health of children nationally is more important than grades in school (mental health-related pediatric emergency department visits on the rise) 45:00 Integrating behavioral health within primary care and addressing social determinants of health through innovative partnerships 49:30 Food insecurity with children as a national problem (14 million children living with food insecurity, almost 6 times as many as in all of 2018) 50:00 How SCCN is looking to build a scalable, community-based approach to addressing SDOH and food insecurity