Episode 55: The Truth About Insulin Resistance & The Immune System with Dr. Vyvyane Loh

Show Notes

Muscle is not just for movement. It is a sophisticated endocrine organ that quietly determines whether you age into health or into chronic disease.

In this episode, Dr. Ravi Kumar is joined by Dr. Vyvyane Loh, a physician who has spent her career at the intersection of metabolic medicine, muscle biology, and human performance. They explore why metabolic health sits at the center of nearly every chronic disease, and why most of mainstream medicine is still measuring the wrong things, treating the wrong endpoints, and missing the real lever.

Dr. Loh reframes metabolism as the body’s energy management system. When energy supply and demand fall out of sync, the consequences ripple through every organ. The brain, kidneys, heart, and liver each fail in their own way, but they are all telling the same story. The conversation walks through why skeletal muscle is the single biggest glucose sink in the body, responsible for clearing roughly 75% of blood glucose, and why losing muscle mass with age is the quietest, most dangerous metabolic event most patients are never told about. Two people with identical body weight can have radically different metabolic destinies depending on the ratio of muscle to fat underneath the scale.

From there, the conversation moves into how Dr. Loh actually treats patients. She has taken most of her patients off insulin and oral diabetic drugs by working at the level of nutrition, movement, sleep, and stress. She explains why she writes nutrition like a prescription, with precise protein doses (25 to 30 grams of whole animal protein per meal, four to five times per day), why she avoids plant proteins and grains, and why a low-fat Mediterranean diet is functionally an oxymoron. She also lays out practical resistance training workarounds for chair-bound, bed-bound, and post-surgical patients using isometric and eccentric contractions, and why DEXA-based body composition tracking is one of the most motivating tools she has ever introduced into her practice.

The conversation then opens into the cutting edge of immuno-metabolism. Dr. Loh reframes insulin resistance not as a disease, but as a brilliant evolutionary adaptation. During illness, injury, or pregnancy, the body deliberately becomes insulin resistant in muscle and fat in order to divert glucose to the immune system, the brain, and the liver where it is needed most. It is only when this state becomes chronic, driven by relentless modern environmental stressors, that it tips into pathology.

Finally, Dr. Ravi Kumar and Dr. Loh take on the GLP-1 question head-on. They cover why GLP-1 agonists act primarily in the brain’s feeding centers rather than in the gut, how they intersect with the same immune circuits that drive sickness behavior, and how they stimulate IL-6 driven browning of white fat. This is one of the first conversations to clearly explain why GLP-1 driven weight loss can, in vulnerable populations, mimic cachectic wasting profiles and destroy 40 to 60% of lean mass. Dr. Loh issues a clear clinical warning about long-term, indefinite GLP-1 use, and discusses how she structures her six-week program to help patients wean off these drugs without rebound.

Episode Resources

Dr. Ravi Kumar on LinkedIn
Dr. Vyvyane Loh on LinkedIn
Dr. Vyvyane Loh on YouTube: Dr. Vyvyane Loh channel
Email: [email protected]
Upcoming book: The Architecture of Enough: Hunger, GLP-1, and the Immune Metabolic System

In this episode, you will discover:

Metabolism as energy management: Metabolism is not a chemistry abstraction. It is the body’s energy supply and demand system. The brain alone consumes roughly 20% of total energy, up to 25% under stress and 30% in developing children. Mismatches between energy demand and supply quietly produce fatigue, brain fog, kidney disease, cardiovascular disease, and neurodegeneration
Skeletal muscle is your largest glucose sink: Roughly 75% of circulating glucose is taken up by muscle. As muscle mass shrinks with age and inactivity, the “container” for glucose shrinks too. The excess glucose that has nowhere to go spills into the bloodstream, where it is directly toxic to vessels, kidneys, and nerves
Body weight lies, body composition tells the truth: Two people of identical weight can have radically different metabolic destinies. Visible muscle definition does not mean adequate muscle mass; a patient with a visible six-pack can still be in the bottom 1 percentile of lean mass on DEXA
80% of chronic diseases are reversible: Dr. Loh’s working clinical assumption is that the vast majority of chronic metabolic disease, including type 2 diabetes, hypertension, fatty liver, and even early liver fibrosis, is reversible with nutrition, movement, sleep, and stress management. Mainstream medicine is built around managing disease, not reversing it
The Mediterranean diet myth: A low-fat Mediterranean diet is an oxymoron. Actual Mediterranean culinary traditions are moderate to high fat. The phrase is repeated reflexively without operational definition, which is part of why patients struggle to comply with vague nutritional advice
Write nutrition like a prescription: Dr. Loh prescribes 25 to 30 grams of whole animal protein per meal, four to five meals per day, with specific dosing, frequency, and substance. She avoids plant proteins (poor bioavailability), grains (phytates that block mineral absorption), and processed carbs
Isometrics and eccentrics for the frail: For chair-bound, bed-bound, or post-surgical patients, isometric contractions (pushing against an immovable resistance) and slow eccentric phases build muscle without joint stress. A leg in a cast measurably loses lean mass within two to three weeks on DEXA
Insulin resistance is an immune strategy: Physiologic insulin resistance is a normal, adaptive response. It diverts glucose away from muscle and fat and toward immune cells, the brain, and the liver during infection, injury, surgery, or pregnancy. It only becomes pathologic when chronic environmental stress keeps the system locked on
The GLP-1 brown-fat circuit: GLP-1 agonists act primarily in the brain’s feeding centers and overlap with immune circuits that drive sickness behavior. They stimulate IL-6, which triggers stem cells in fat to become brown fat (the heat-producing, calorie-burning kind). In the right patient this drives weight loss; in the elderly or chronically ill, it can mimic cachectic wasting profiles
40 to 60% of GLP-1 weight loss is lean mass: GLP-1 agonists, weight loss surgery, and any rapid weight loss can produce 30 to 60% lean mass loss depending on the population. Dr. Loh has watched frail patients become profoundly sarcopenic on GLP-1 agonists in real time
Stop GLP-1s around surgery and illness: GLP-1 agonists cause gastroparesis, raising aspiration risk during anesthesia. They also push the body toward catabolism, which is the opposite of what is needed for wound healing and recovery. Both physicians stop GLP-1s before surgery and during hospitalization
Ten-year follow-through nobody talks about: A patient on a GLP-1 forever can go from obesity and diabetes to sarcopenia and diabetes ten years later. The A1C may have wandered back up because the muscle that was buffering glucose is now gone
Inflammation is necessary, but it has to switch off: Interleukin-6 has both an inflammatory mode and a homeostatic, repair-promoting mode. Anti-inflammatory is not always good. Chronically dampening immune tone can blunt tumor surveillance and impair wound healing. The problem is perpetual inflammation, not inflammation itself

Key Takeaways

Muscle is the single most underappreciated organ in the human body. It is the largest glucose sink, a major endocrine organ, and arguably the strongest determinant of healthy aging
Weight is the wrong endpoint. Body composition is the right endpoint. A DEXA scan that shows fat down and lean mass preserved or rising is a different story than a scale that shows pounds lost
Most chronic metabolic disease is reversible. The medical system is structured to manage it, not reverse it, which is a system problem more than a science problem
Protein should be prescribed, not suggested. Roughly 25 to 30 grams of whole animal protein per meal, four to five times per day, with vegetables, healthy fats, minimal fruit, and zero processed carbs
Resistance training does not require a gym. Isometrics and slow eccentric work can be used on chair-bound, bed-bound, and post-surgical patients to preserve and build muscle
Insulin resistance is, in many cases, the body intelligently diverting energy toward the immune system, brain, and liver during stress. The pathology is chronicity, not the response itself
GLP-1 agonists act primarily in the brain, overlap with immune sickness circuits, and stimulate IL-6 driven browning of white fat. In vulnerable populations this can produce cachectic wasting and 40 to 60% lean mass loss
GLP-1s should be paused around surgery and acute illness because of gastroparesis and aspiration risk and because of the catabolic state they reinforce
The conversation we are not having: ten years on a GLP-1 may swap obesity for sarcopenia. That is not a win
Inflammation is required for life. The dial has to switch between attack mode and repair mode. Perpetual inflammation, driven by modern diet and lifestyle, is the actual problem

Transcript

[00:00:00 –> 00:02:27] Dr. Ravi Kumar: Welcome to the Dr Kumar Discovery podcast. My name is Dr. Ravi Kumar. Today, we’re talking about something that touches every single chronic disease that you can think of. Metabolic health. My guest today is Dr. Vyvyane Loh. She’s a physician who has spent her career at the intersection of metabolic medicine, muscle biology, and human performance. And I have to tell you. This conversation genuinely surprised me. We covered things that I hadn’t even heard of before. So believe me, you’re in for a special treat today. By the end of this episode, you’re gonna understand why muscle is the most underappreciated organ in your body, and what happens when you lose it. You’re gonna learn why 80% of chronic diseases are actually reversible, and why your doctor probably has never told you any of this. And we get into GLP-1 drugs, where Dr. Loh talks about what these drugs are actually doing to your immune system, and your brown fat. This is stuff you’re not gonna hear anywhere else folks. Honestly, it’s gonna be a real eye opener. It was for me. But before we get into it, a quick disclaimer. Dr. Loh and I are both physicians, but we’re not your doctors. This podcast is for informational purposes only. Our goal is to give you real knowledge, backed by real science so that you can have a better, more informed conversation with your own healthcare provider. And ultimately, take greater ownership of your own health. Also, this podcast is completely separate from my role as assistant professor at UNC. Alright. Let’s get into it. My name is Dr. Ravi Kumar. I’m a neurosurgeon in search of the causes of human illness and the solutions that help us heal and thrive. I want you to join me on a journey of discovery as I turn over every stone in search of the roots of disease and the mysteries of our resilience. The human body is a mysterious and miraculous machine with an amazing ability to self heal. Let us question everything and discover our true potentials. Welcome to the Dr Kumar Discovery. Dr. Loh, thanks so much for joining us today. We hear a lot about metabolic health and how it might be the center of all chronic disease. Can you tell us what metabolic health is and how you look at it in regards to human health and wellness?

[00:02:27 –> 00:04:35] Dr. Vyvyane Loh: I guess the best place to start, Dr. Kumar, is I like to define what metabolism is for most of my patients first. Because, you know, metabolic health obviously is circling around metabolism and what exactly is metabolism. And I think the best way to think about it is that it is the energy management system in your body. Okay? How we regulate and manage energy and why is that important? Because if we want to be alive, we need energy. That’s the basis of everything. And if we mismanage the energy and we have mismatches in our energy demands and what we can supply, then we’re gonna have disastrous consequences in different parts of the body. So for example, the brain has a very heavy energy demand, right? It’s a tiny organ, maybe two pounds, uh, a little bit more in some people, but it’s gonna easily take up 20% of your total energy intake. And if you’re stressed, it may go as high as 25% and in the developing brain in young children, it may be as high as 30%. Okay? So it’s consuming a lot of energy, but if there’s a drop in the energy supply to the brain, then obviously, misfunction is going to happen. We’re gonna have the brain rerouting, you know, supply to different areas, the survival areas and maybe other areas are not as well prioritized. So that’s just the brain, but it happens in any other organ in the body. So metabolic health really is the system in our body that manages and regulates energy flow and if there’s a mismatch, it should be able to adapt. But over time, if we chronically burden it through our environment, through maybe our nutrition, our sleep patterns and so forth, you know, there comes a point where it really can’t keep up with the mismatch. And that’s where we start to see dysfunction happening, and that’s when we notice the symptoms and people start getting sick.

[00:04:35 –> 00:04:43] Dr. Ravi Kumar: Yeah. Okay. So what does metabolic disease look like clinically? If you have a patient with metabolic disease, what are they experiencing?

[00:04:43 –> 00:05:40] Dr. Vyvyane Loh: So the classic metabolic disease you could think about is, let’s say, diabetes. Right? High blood pressure, also another metabolic disease and along with that goes, kidney failure and heart disease. So a lot of times it’s termed cardiometabolic health and the general common symptoms are that people start feeling unwell, fatigue is a big one, brain fog, again, because when there is some issue with energy management in your body, then obviously your brain suffers because a lot of times it doesn’t get what it needs, so brain fog is very common as well. And then depending on different organ systems, if your kidney is experiencing more of that stress, then you might end up with kidney disease, right? If, let’s say, your heart is experiencing that stress and you have more cardiovascular disease, and if your brain is having more of that, then we might go into the neurodegenerative diseases and so on.

[00:05:40 –> 00:06:00] Dr. Ravi Kumar: So metabolic disease is this poor utilization of energy, essentially, in all the cells. And you you highlighted all these diseases that basically are manifestations of metabolic disease. Yeah. I would say that there’s really no tissue in your body that’s not touched by metabolic insufficiency or metabolic disease.

[00:06:00 –> 00:06:10] Dr. Vyvyane Loh: 100%. Yeah. You know, we are everything needs energy to survive. Right? And there’s not one cell in your body that is exempt from that wound.

[00:06:10 –> 00:06:19] Dr. Ravi Kumar: Right. So what causes it? Why do we develop metabolic disease? Why don’t we just live like we’re supposed to and operate like we’re supposed to?

[00:06:19 –> 00:07:24] Dr. Vyvyane Loh: I think our bodies, human species developed under certain environmental conditions and those conditions have changed rapidly, right? Compared to the evolutionary scale, it’s changed to a much quicker extent than our bodies can actually adapt. And so now there’s a mismatch between what we’re built for and what the environment is around us. Now, what do we do when there’s a mismatch? You would think that we would try to make the environment fit our bodies, but our solution seems to be, let us force our bodies to fit the environment. Okay? We’ll force it one way or the other. Either you white knuckle it through or we’ll put drugs on board. We’ll do something to force your body to fit the environment. And when we talk about making the environment fit us, well, nobody’s that interested. Yeah. Yeah. Whatever. Right? So it’s kind of a weird way to think about it. And for me, it doesn’t seem like the most useful or helpful way to think about it, but I feel like that’s how it is, especially in the medical system that we inherit.

[00:07:24 –> 00:08:10] Dr. Ravi Kumar: Yeah. Yeah. This whole concept of evolutionary mismatch is really fascinating to me because, like you said, there are these ancestral conditions or evolutionary conditions that our biology literally took millions of years to synchronize itself with, to live in harmony in that specific set of environmental factors like nutrition, sunlight, sleep, all these things that we were designed to do. And now, we have this different environment, and we are trying to take, you know, million year old evolutionary biology and fit it into something that’s relatively new Right. As far as new nutrition and and environmental stressors and all that. So, tell me what these specific mismatches are that are causing metabolic disease.

[00:08:10 –> 00:10:13] Dr. Vyvyane Loh: A big one is nutrition, obviously. Right? Because we need faster, we need more convenient, we need things that will stay on the shelf longer. And so we have a lot of processed foods for example, and of course cost comes into it as well. Sadly, sometimes getting real foods is more expensive than the highly processed food. So depending on where you’re living, sometimes a mother may be able to afford a bag of chips better than eggs, you know, or dairy or any real protein, for example, for their kids. So, nutrition is one one piece. Another piece is movement or lack of movement because now you don’t have to move. Maybe you just move your little finger, you know, tapping on the, on the keyboard, right? A nod here and there, right? Put on your headphones, that’s like a whole workout. You don’t even need to go to work if you’re, you know, working remotely, right? You don’t even have to walk to your car now. You can get things delivered to your door. So we were designed to move, really designed to move and the brain is designed for movement and brain health is really dependent on how well and how much we move, right? And the minute we start, you know, cutting down our movement is when our brain health also starts to suffer. My father passed away a few years ago, but I knew he was getting into trouble when I saw that he became more and more sedentary. So he used to be very active. He used to go for long walks and so on. Then in the last, like, two years of his life, he just basically sat in front of a screen all day. He hardly walked. And I told my brothers at that point in time, try to get him to move more because he’s gonna decline in terms of cognition, and that’s exactly what happened. I mean, his cognition really dropped significantly as he just became more and more sedentary. So I think those things are linked and then, you know, within the two years he was gone. So I did expect it. I could see it, uh, coming.

[00:10:13 –> 00:10:20] Dr. Ravi Kumar: I always tell my patients, as soon as you stop moving, you start dying. Yeah. It doesn’t matter what age you are.

[00:10:20 –> 00:10:21] Dr. Vyvyane Loh: Yeah.

[00:10:21 –> 00:10:52] Dr. Ravi Kumar: Even after surgery, I do a lot of spine and brain surgeries. I want my patients up and walking immediately after surgery if it’s possible. Yep. Because if they do that, their whole biology lines up and they heal better. Yes. If they don’t move, they get pneumonias. They get atelectasis of their lungs where the lungs kinda just close down. They get blood clots in their legs. They get urinary tract infections. Their wounds just don’t heal. I mean, you would think, you know, the intuitive thought would be, oh, if you move around, you’re putting stress on that wound and it’s gonna come apart.

[00:10:52 –> 00:10:53] Dr. Vyvyane Loh: Yeah. Body needs

[00:10:53 –> 00:10:54] Dr. Ravi Kumar: the opposite.

[00:10:54 –> 00:11:09] Dr. Vyvyane Loh: Needs to detect that stress and then it knows how to heal properly. It knows up from down. It can lay down tissue and the collagen in an organized mat, uh, manner. And that depends on you moving. You’re absolutely right. Yeah. It’s fascinating, isn’t it?

[00:11:09 –> 00:11:30] Dr. Ravi Kumar: Yeah. It’s totally fascinating. And so, I think movement is essential to to life for this species that we are humans, because we are a species that move around since the beginning of time. So tell us how maybe that is linked to muscle and how muscle is linked to metabolic health, because I think this is something you talk a lot about.

[00:11:30 –> 00:15:42] Dr. Vyvyane Loh: Yeah. Uh, so obviously, you know, people realize that whatever you do, you need muscles, right? You need to have that musculature to be able to support you doing anything, getting out of bed, making your bed, going to work, shopping and so forth. And as we age, we tend to lose muscle and we tend to become less and less active, right? What happens is over time, if we’re not being aware of this and actively trying to mitigate that, you lose more and more muscle. Now muscle is your biggest glucose sink in the body. This is something I wish people would talk about more because 75% of the glucose in your bloodstream would be taken up by muscle. Now imagine you have, let’s say, a huge, um, you know, dumpster. Okay? A big dumpster size to contain the glucose and you can just dump the glucose into that dumpster. But over time, you know, the dumpster gets smaller and smaller. And just to make it more dramatic, imagine now, instead of the dumpster, you have a trash can, a tiny little trash can, and you’re supposed to fit that same volume of glucose into the trash can. It’s not gonna fit. And what will happen is the trash or the glucose is gonna spill out and spill out where? Into your bloodstream. Right? So in terms of your metabolic health, that muscle is the biggest container for that glucose. And we need it to go in there, feed the muscle. It may even be stored in a safe form so that the muscle can use it when necessary and so in that sense, it would be stored as glycogen, but you can’t have this vast volume of, of glucose floating around in the bloodstream without causing damage because glucose is very toxic and if you’re not, uh, careful as your muscle mass shrinks with age, then you’re losing that natural reservoir that you have and that is like a very dramatic change. So people will often say, you know, Dr. Loh, I’m not doing anything different. I’m eating exactly the same, right? The weight may stay the same. And that might be because you’re gaining more you, you know, you have more fat and you have less muscle. So if you look on the scale, if you lose five pounds of muscle and you put on five pounds of fat, congratulations, you’re the same weight. And that’s what a lot of times, you know, you go to your medical practitioner and that’s what they measure. They measure your weight and they measure your BMI, but they never think about your body composition. So one time, tell the story because it’s particularly frustrating for me, I was at a cardio metabolic conference, right, and the presenter got up there and she told the story. Uh, she’s an endocrinologist and she told the story about how at the age of 60, she got diabetes but it’s not type 2 and she called it autoimmune diabetes. Now, she also pointed out that all the antibodies were negative. The workup was negative for any autoimmune diabetes and so she labeled it this new unknown autoimmune diabetes. She also pointed out that she knew for a fact it wasn’t type 2 regular type 2 diabetes because she says, I’m actually underweight. Okay? She made that a point. She says, most people with diabetes have obesity or are overweight, but I’m not like that and therefore, I am different because I am underweight. And her BMI she shared was actually under 19. Okay? And just looking on the screen, she looked frail. And I was thinking to myself, before we go to a new mysterious autoimmune type of diabetes and she might well be right. I’m not saying she’s wrong, but before we jump there, I’d like to know what her muscle mass is and I would have liked to see a trend and see her blood sugars go up as her muscle mass Frank. You know what I’m saying? But we don’t track those things. So I guess we’ll never know.

[00:15:42 –> 00:15:54] Dr. Ravi Kumar: Yeah. You know, that’s something I commonly see is people who you wouldn’t look at and say you’re overweight or you’re obese, but you look at them and you see that their muscle mass is Yeah. Not good.

[00:15:54 –> 00:15:54] Dr. Vyvyane Loh: Yeah.

[00:15:54 –> 00:16:05] Dr. Ravi Kumar: They are just soft Yes. In general. Yes. And they often have type 2 diabetes. Yep. Because they don’t have, like you talked about, this sink for glucose.

[00:16:05 –> 00:16:05] Dr. Vyvyane Loh: Yes.

[00:16:05 –> 00:16:28] Dr. Ravi Kumar: They don’t have this energy consumptive organ all over their body, which is muscle, basically absorbing the excess glucose that happens after eating processed food or even, you know, healthy foods. And so they’re basically having high levels of glucose floating through their bloodstream much of the time, causing all these complications that diabetes is known for. Yeah. And they don’t look obese.

[00:16:28 –> 00:17:41] Dr. Vyvyane Loh: That’s right. And one other thing I always like to point out, uh, to my patients is just because you can see the muscle or see the muscle definition does not mean you have a lot of muscle. So for example, I had a patient and he had, you know, inflammatory bowel disease and you can see his muscle definition very clearly. You can see the six pack or eight pack or whatever. Right? It looks very impressive. But when you look at the DXA and look at the body composition, he’s in the bottom 1 percentile, you know. So he has very low mass for people in his demographic. Right? The point is that if you look at it, you see you think, I can see the muscle and that’s because he also has very little fat. So we’ve removed the fat so you can visually see the muscle. Doesn’t mean you have enough muscle. So that’s a common mistake because people go, but look at him, her, whatever. Look at look at the six pack. That just means we took away the overlying fat under the skin and you can now see the muscle. Doesn’t mean that person has enough muscle and to your point, that person might still be very frail and could still be at risk for developing, you know, diabetes or insulin resistance.

[00:17:41 –> 00:18:03] Dr. Ravi Kumar: That that’s very interesting, and I think this is like a good point to start talking about your approach to metabolic disease. Because if someone in the audience has metabolic disease or one of their family members has metabolic disease, they’ll go to the doctor and they’ll get a prescription for metformin or they’ll get put on a GLP-1 agonist. And that’s the treatment, essentially. Yeah.

[00:18:03 –> 00:18:03] Dr. Vyvyane Loh: That’s right.

[00:18:03 –> 00:18:04] Dr. Ravi Kumar: What do you think about that?

[00:18:04 –> 00:23:12] Dr. Vyvyane Loh: So that’s not my approach. Obviously, I think you and I, we share a lot of the same way of thinking about health. Um, 80% of chronic diseases are really reversible. Okay. But we never talk about that and we just, you know, when when someone goes to see their doctor with new onset diabetes or high blood pressure, they just hear it’s genetic or it’s because you’re aging. Yeah. That’s usually the most common things that the patient will report back to me and there’s never any talk about what you might be doing to make your blood sugar go out of control or your blood pressure and so forth, right? So my approach is that when I see a patient, my aim is to help reverse the disease because I know that 80% of chronic diseases are reversible So when I see a patient, that’s my goal for the patient, right, is to try and reverse it. What the current medical industry does is manage disease. Okay. I’m gonna tell this story. I had an old house, I still have that old house in in in the Boston area. There’s a lot it’s made of wood and so forth. One year, there was termites around it. So I got all these quotes from different termite companies, right? But if you look at the contract, doesn’t matter which termite company, you know, they quote you a price and the contract says they’re gonna manage the termites. They’re not gonna remove the termites, God forbid, right? Let’s just manage the termites because then next year we still continue to manage the termites, right? So this is our approach in medicine. We don’t want to get rid or reverse the disease. There’s no focus on that, we never even talk about that. Okay? The aim is to manage it. Now think of all the medications we have with the exception of antibiotics. All medications are to manage symptom. They’re not to reverse the disease. Antibiotics, you take it, you kill the bug, done. Okay? Okay. You could call it curative. But almost everything else is to manage the disease, kick the can down the road, kick it down the road. Now, we need more drugs to manage. Now, we need that drug for the side effects of this drug and then, you know, it keeps rolling down the hill. Right? And now, we have an avalanche at the bottom. So, that’s the general approach and that’s not my approach. So, when I first see, uh, a patient, my approach is, okay, let’s talk about how we can reverse it as much as we can. And sometimes there’s already damage to the organs, but by and large, there’s still so much that we can do because you and I just talked about this, yeah, how wonderful the body is and just how amazing it is in terms of regeneration and repair. We just never give it a chance, right? So to this day, I still have doctors telling their patients, yeah, you have liver fibrosis and, yeah, we can’t reverse that. That is not true. The data is very clear that you can reverse liver fibrosis. Okay? And in some cases, even cirrhosis, though that is much harder and it’s iffy, plus minus, you know, with cirrhosis. But with fibrosis, yes, you can, but we never tell people that. We never even tell them that fatty liver, which is an even earlier stage, we never even tell them that fatty liver is reversible. Okay? So we start there and you have a patient and they’re diagnosed with metabolic fatty liver disease and you say, well, your genetics, aging, there’s nothing we can do, we’ll just watch it. We’ll just watch you get sicker and sicker and sicker. That’s not my approach. My approach is immediately thinking about, let’s talk about how we can reverse this as much as possible. Okay? The basics have to be in place and the basics, no one wants to hear this, you know, the basics are your nutrition, right? Your movement, exercise movement, sleep, yeah, and how you handle stress, all of that is basic. No one wants to hear it. Now I always say Dr. Kumar that, um, our full time jobs as physicians, our full time job is to tell people things they don’t wanna hear. That’s the full time job, right? But then the job is to present it in a way that it’s safe for them to hear. They don’t feel judged and they can hear it and then after they’ve heard it to give them a plan. And I always said to my patients and they know this, I said, you know, I can be tough, I’m never mean. Here’s why, because when I bring something to you, there’s always something you can do about it. Because telling you something and not giving you a way to to do something about it, that’s kinda mean. Right? Because it’s like Yeah. Causing a lot of stress and anxiety and, um, that’s not my goal. My goal is to give the news and to have a plan. Right? And it’s not 100% that we can reverse everything, but there’s a lot we can still do and we never talk about that enough, I feel.

[00:23:12 –> 00:23:45] Dr. Ravi Kumar: Yeah. I mean, the body is this amazing machine that wants to heal. Yes. If you get out of its way. That’s right. Honestly. And most of the time we’re getting in its way with poor eating, no exercise, smoking. You know, there’s a number of things that you do, not getting enough sleep. You know, just those things hurt you. And the body is trying to heal, but you’re blocking it. So what happens and, like, if you optimize nutrition and you optimize sleep and exercise, what happens to these chronic diseases that are related to metabolic syndrome?

[00:23:45 –> 00:24:42] Dr. Vyvyane Loh: So I will say that in all my years of treating patients, I have taken most people off their insulin and their diabetic drugs and even their primary cares are shocked. They’re like, Oh, I never thought you could take a patient off insulin. I’ve never seen that happen, right? And I’m like, yeah, we’re really good at prescribing, we’re never really taught to deprescribe, you know, I even taught a course on deprescribing ones just because, yeah, we don’t, we don’t talk about that. But I have seen their diseases reverse so that their blood sugar is normalized, they are off their medications. Their lab tests normalize, um, and they feel so much better, they can function better, they feel good about themselves and a lot of times they get discharged by their specialist. So the kidney doctor will say, I don’t need to see you anymore. The endocrinologist will say, I guess I don’t need to see you anymore, you know, and that’s the best news for me.

[00:24:42 –> 00:25:38] Dr. Ravi Kumar: That is great. I I think most people know that diet and lifestyle is curative in most of these conditions, even if your doctor doesn’t tell you. It’s common sense that if you’re healthier, if you feel better, if you’re moving and you’re eating well, you’re going to be a better person and optimize your health and wellness. But saying that is much easier than actually doing it. How do you get your patients to accomplish these goals through diet and lifestyle? Hey guys, I need a quick favor. If you’re getting value from this show, would you please take thirty seconds to rate and review us on Apple Podcasts? I know it seems like nothing, but it genuinely changes how many people the algorithm puts the show in front of And if an episode hits home for you send it to someone who you think needs to hear it I’m doing this to cut through the noise and bring you clear honest information on health topics that actually matter to all of us So please help me get the show to more people who need it. Cheers.

[00:25:38 –> 00:30:45] Dr. Vyvyane Loh: There are a couple of issues there. Right? We know generally that lifestyle modification can do most of the heavy lifting in our in our health. However, a lot of the information on what is a healthy lifestyle may not be actually good evidence based information. Right? And it’s just what has been regurgitated over the ages, uh, and it’s very culturally dependent as well. So one example I will give you is this Mediterranean diet. Every dietitian you go to, every doctor that you go to usually will say, Oh, you should be on a heart healthy low fat Mediterranean diet. Now, when I ask for actual, like, criteria for that, nobody tells you because they don’t know. We have never quantified what that is. So now, when I say Mediterranean diet, in my head, I’m thinking one thing, in your head, you’re thinking something else. Someone’s thinking Greek salad, right? Someone is thinking, you know, sausages. All of it is valid because Mediterranean is a huge area, a huge region, right? We’ve never really quantified it. In addition, pretty much across the board, if you look at the culinary habits across the Mediterranean, at the very least, they are moderate fat and in some cases, high fat diets. So a low fat Mediterranean diet is an oxymoron, does not exist. Okay? Maybe in a separate universe that I am not inhabiting, but whenever people go, a low fat Mediterranean diet, I’m like, okay, I’m having a hard time already. So imagine what the patient is going through, right? So we have such poor criteria and we have such poor evidence for these, uh, these recommendations that we just dole out. And give you another example. So, you know, you know that if you have diarrhea, you know, BRAT diet and also one of the things you should have is apple or banana. Yeah? And they are the reason is that the pectin in these fruits, the pectin is what helps bind you. Okay? But actually, if we’re accurate about it and we are precise and you really want to help the patient, it’s a green banana and a green apple. Because as the fruit ripens, the pectin is converted to sugar. And you pretty much have no pectin left. Okay? But, what do we tell patients? Have banana, have apple. Okay? And what do we do? We go to the supermarket, we buy the juiciest, reddest apple. Right? Or the, uh, the bananas that are ripe. Because who wants to eat a green banana? No one. Right. Right? But, again, we don’t never think about that. We just say, oh, yeah. Yeah, just have a banana, have an apple, right? So yes, we can talk about nutrition and lifestyle modification, but across the board, you know, there’s not a lot of good evidence and many times the advice that’s given even in medical circles is not evidence based or imprecise to say the least, okay? So that’s one category and then even with good evidence, how do we make it happen? And you’re absolutely right, You know, how do you help the patient? Now, I always say that, you know, we can make the plan, we can communicate the plan. The only person that can do anything about the plan is the patient and that person has the least support and, you know, resources. Right? We just kind of deliver the plan and good luck, wish you well, right? God speed, right? So I find that working with coaches, you know, having a lot of accountability, making sure that you have a frequent check ins. So, you know, I had a practice that focused on obesity medicine and when someone was struggling with their weight, I never had them follow-up in three months. Three months! That’s a whole lifetime. Uh, a lot can go very wrong. You know, I tried to see them within the week, the next week or within two weeks. At very least, phone call. At the very least, you need to check-in way sooner, way more often. You can’t let people drift for three months on their own and then they come back and go, Oh, how come you didn’t do? That’s just not how it works, right? It’s not gonna be helpful. So I think the the close supervision, the coaching aspect, the accountability is very, very helpful and then giving the right instructions in a granular way. So I’m very precise, I do not tell people go eat protein, I tell them how much, I want them to schedule it. So when I prescribe nutrition to my patients, it’s like writing a prescription, there is a dose, there’s the substance, the protein, right? And there’s the dose and there’s the frequency, okay? So I do all of my nutrition like I do a prescription. It’s very precise and there’s no guesswork. You don’t want and it’s not the patient’s job to guess. That’s not the patient’s job. It’s my job to be clear and give the correct information then to help the patient comply with that.

[00:30:45 –> 00:30:58] Dr. Ravi Kumar: Yeah. So you’re prescribing the macronutrients in this person’s diet, and are you giving them a certain basically, eat this much, uh, polyphenol rich vegetables and this much grass fed beef? Is that what you’re doing, or are you

[00:30:58 –> 00:32:37] Dr. Vyvyane Loh: So I don’t specifically eat what you want? I don’t know. I never say do what you want. That never happens. Never. Um, I I pretty much tell them how much protein. So for me, it’s 25 to 30 grams of whole animal protein per meal, per meal. Okay? And that’s a cooked weight, so it translates to about four depending on the patient, four to six ounces, bit more with fish because it’s not as protein dense. Right? And I don’t necessarily say it has to be grass fed beef and because that’s gonna be very dependent on what the patient, a, can afford and also personal taste, right, cultural preferences and things like that. But I make sure it’s whole animal protein, I do not use plant proteins at all in my approach and people are often shocked, why not and so forth. The reason is that I want to make sure that I can get adequate bioavailability and absorption and even with animal protein, it is hard. So with plant protein, forget about it, and with grains, there’s a lot of phytates that will basically absorb the nutrients like the minerals and so the patient then gets micronutrient deficiencies. So, yeah, I don’t even play around. I I feel like when it comes to preserving muscle, it’s important to make sure my patient has the best shot at it and nutritionally, I wanna make sure that protein has the best shot at helping them at least maintain muscle. And I just wanna point out too, I was a vegetarian for eighteen years so I pretty much existed on yogurt and eggs, you know, and some cheese, you know. So that’s not to say you can’t be vegetarian, but vegan is definitely not gonna be, you know, healthy enough.

[00:32:37 –> 00:32:38] Dr. Ravi Kumar: Okay.

[00:32:38 –> 00:32:38] Dr. Vyvyane Loh: Yeah.

[00:32:38 –> 00:32:48] Dr. Ravi Kumar: So you’re prescribing animal based proteins, you’re avoiding plant proteins, and you’re avoiding grains in your dietary prescriptions essentially. Is that right?

[00:32:48 –> 00:33:29] Dr. Vyvyane Loh: Yes. I don’t make them stick to a carb count only because I don’t want them to spend all day calculating. Okay? Because what I find is that they’ll do it for a while and then it drops off. So basically, I just give them, this is what you eat for the protein and then we select the proteins that they are comfortable with and then I give them the list of vegetables and I try to minimize or avoid the starchy vegetables. Okay? And then there is minimal fruit and zero processed carbs if possible. So I I try to keep away from the processed foods obviously and then making sure that they also get in their fluids, that’s important as well.

[00:33:29 –> 00:33:31] Dr. Ravi Kumar: Yeah. And what about fats? Where are you?

[00:33:31 –> 00:35:14] Dr. Vyvyane Loh: Yeah. Healthy fats, You know, healthy fats. So I like using the olive oil and avocado, things like that. And people always worry with me. I don’t know why. They’re like, oh, my chicken. I should remove the skin. And I’m like, that’s the yummiest part. Why are you removing it? Cow down. Right? You know, and they always I think, you know, when when I I have dinner with with people, I think they are aware that I do this kind of work that I’m an obesity, uh, medicine physician too and so they’re all very self conscious and they’re like, you’re eating the skin? And I’m like, yeah, why wouldn’t I? That’s the yummy part, right? So no, I don’t avoid, uh, the fat and I think that that helps with satiety as well. Most times, when people have a good decent meal, you eat eggs for example, and you know, if you’re doing eggs like I was doing for x number of years, you know, it’s four to six eggs per meal, you will be full. I promise you will be full, you know, and most times people don’t wanna they don’t wanna eat anything else after that, right? So they’re not grazing through the day, which is which is something that I think is a good habit to avoid any snacking or grazing. So I prescribe the meals and I often get, what about snacks? I’m like, uh, what about them? You know, uh, where can I fit in snacks? Now, most of my patients are eating four times a day, four meals, four protein rich meals and and a good proportion are eating five protein rich meals, okay, spaced out. So when someone asks me about snacks, I say, what about them? Well, uh, can I substitute no, no, no? There’s no substituting. We’re having a meal, we’re having nutrition and fuel, Right? And at five meals a day, most people don’t need or want a snack.

[00:35:14 –> 00:35:16] Dr. Ravi Kumar: Okay. Four or five meals a day.

[00:35:16 –> 00:35:30] Dr. Vyvyane Loh: It depends on the patient. The older they are, the more I push towards five. Okay. And people are shocked that my patients that I’m seeing for obesity, that they are having five meals a day and losing weight. Okay.

[00:35:30 –> 00:35:31] Dr. Ravi Kumar: Yeah.

[00:35:31 –> 00:37:28] Dr. Vyvyane Loh: And losing weight without compromising too much within muscle mass. Okay? So people are shocked and they go, how’s that happening? And patients will tell me, how is this possible? So I had a patient and she had lost a good amount of weight in the first three months of my program and then she went on to do the next three months, right? So at the next three months, I looked and I realized that, okay, I don’t want her to lose too much mass, okay? So she was going through week by week and weighing in and she said to me, you know, Dr. Loh is not working now, it was working great the first three months I lost a lot of weight but now it’s not working, what should I do? And at that time she was on four meals a day and I said, we’re gonna add a meal and she like almost flipped out. She’s like, add a meal. I just told you I’m not losing weight and you’re telling me to I was like, look, you’ve been with me this three months, right? And you followed just what I said, you did great. Just trust me on this, right? She’s like, okay. Okay. But she gave me that side eye. I know she gave me that side eye. Right? But she did it. She did everything I told her to do. At the end of the second three months, so now six months out, she only lost five pounds. Okay? But when we did her DEXA, she had lost most of it in fat and she actually gained a little bit of lean mass. She gained some muscle. She looked, felt different, clothes were different, I mean, everything and she felt great and she was so exuberant and she said, Oh my God, I cannot believe that you added a meal and I got this kind of result, right? Because people are very resistant, they’re try most people I see with obesity are actually under eating, you know. And and that’s something that we don’t often talk about. A lot of times, they are under eating, especially their nutrients, and they are malnourished in many ways.

[00:37:28 –> 00:37:46] Dr. Ravi Kumar: Yeah. I think that’s very common and that’s missed um, basic medical exams. They say, for instance, if you prescribe someone a GLP-1, they just stop eating they stop eating at the same quantity, and now Yeah. They’re already in a malnourished state. Now they’re just eating less of the wrong thing, and it just perpetuates this cycle

[00:37:46 –> 00:37:49] Dr. Vyvyane Loh: of Yes. Yes. Undernourishment. Yes.

[00:37:49 –> 00:37:59] Dr. Ravi Kumar: But, um, okay. So let’s say okay. So we’ve kind of got a good idea of how you do your nourishment prescription. What about movement and the other lifestyle factors?

[00:37:59 –> 00:40:07] Dr. Vyvyane Loh: Yeah. So, obviously, I am very much for resistance training, but, you know, with a mixed population, you have the elderly, I have people who are just, you know, recovering from hip surgery or need a replacement so they can’t weight bear the same way. So I try to modify things, a lot of times I will use isometrics. I think it is so underused, you know, in building strength. So the isometrics are great because it’s very safe because there’s no movement so you are not gonna hurt any joint because you’re not moving, right? And that is working against the resistance like pushing against a wall, for example, you’re not moving anything. You’re not going anywhere. The wall isn’t going anywhere, but you are actually straining and loading that muscle. So that’s an isometric, actually straining and loading that muscle. So that’s an isometric, uh, contraction and so for my patients who are chair bound, bed bound, a lot of times I will use isometrics and then I also use eccentrics, especially for those who are new to exercise. So that’s the lengthening phase. So if we do a biceps curl, right, lifting the weight is going to be the concentric phase, but when I lower the weight down again, that’s the eccentric phase. That usually is the easier phase in terms of sensation, right, and effort. So if you slow that down, eccentric contractions are very helpful in helping you build muscle. So I like to use those tricks, you know, and I start small and sometimes, you know, most people are very, very prone to doing cardio, they wanna get on the treadmill, they wanna get on the bike, but they don’t want to do resistance training. So sometimes I try to work around, so if someone will get on a stair climber, I ask that they crank up that resistance or if they’re on their stationary bike, crank up the resistance so that your at least your legs are working, you know, steadily, consistently against a load. So we can start there and then slowly build them up. There are many ways to to make it fun and, uh, to make it doable for everyone. I think we just have to be more creative when it comes to different patient population.

[00:40:07 –> 00:40:21] Dr. Ravi Kumar: Right. And so with the high protein intake that you’re prescribing and this isometric and gradual increases in loading with these exercises that you’re talking about, people are not losing mass No. Muscle mass during their weight loss journey.

[00:40:21 –> 00:41:35] Dr. Vyvyane Loh: That’s right. And that’s the most gratifying thing and now I have my own DEXA machine. So I could pop them in the DEXA, right? And there’s very low, almost zero radiation really. So you can even do body composition on babies, which they have done and so, uh, really there’s no contraindication. I mean, technically if they’re pregnant but I didn’t have patients who were pregnant come and see me actively, right? So most of my patients, I can just pop into the DXA and check their mass and especially check for, you know, it’s interesting, any casted patients, if they had a leg cast or something, ankle cast, right? And we would dex them and you would see literally over a couple of weeks, three weeks, you can see the mass go down compared to the other leg. So dramatic, right? And so just any kind of decrease in movement, in loading will result in loss of mass, especially as you age. So that’s and and having the DEXA was very, very motivating for the patient because they can actually see it. They go, oh my god. My yeah. And they can see the numbers, but they can visually even, in some cases, see, oh my god. My left leg is smaller than my right, you know. That’s just a reminder and it’s very motivating for them to go on and do their resistance training.

[00:41:35 –> 00:42:01] Dr. Ravi Kumar: Right. So the DEXA scan is basically like a low dose radiation that can tell you body composition. Yeah. It’s an x-ray, yeah, that can tell you body composition. Most people know it by having a bone density scan to see what their bone density is, but you can use it to look at fat composition, muscle composition, bone. And this is something that you can get objective data and track people as they go through their healing journey. Is that right?

[00:42:01 –> 00:42:51] Dr. Vyvyane Loh: Yeah. Absolutely. So it is not covered by insurance. So bone density, depending on the population, insurance may cover it. Body composition, DEXAs, by and large are not going to be covered by insurance, but over time, it has become more and more affordable. So you can find some commercial places that will do these DEXA scans. Now there’s some limitations to that. So for me, because my focus is on metabolic health and my expertise is on body composition, I don’t like how they report the visceral fat because they report it in pounding. And what we need to see clinically, right, to correlate to risk, what we need to see is actually, um, the visceral adipose tissue area between l three l four. Okay? Between, you know, the spinal levels l three

[00:42:51 –> 00:42:53] Dr. Ravi Kumar: l four. Yeah. Yeah.

[00:42:53 –> 00:43:11] Dr. Vyvyane Loh: And without that, just a number of, like, six pounds of visceral fat, it doesn’t mean anything to me. Clinically, I don’t know what to do with that. So all the commercial Dexus report it that way, but they will report the muscle mass in terms of how much mass, the actual weight, and that can be helpful if you’re tracking your mass.

[00:43:11 –> 00:43:35] Dr. Ravi Kumar: Yeah. Okay. And because I think that’s very interesting. If you look at most weight loss programs, there is a certain amount of muscle loss that happens when you lose weight. What is really striking to me, and maybe this is something you can comment on because I know you’re actually writing a book on this, is that with GLP-1s, which are, you know, the biggest craze for weight loss right now, about 40% of the weight that you lose is actually muscle mass.

[00:43:35 –> 00:43:36] Dr. Vyvyane Loh: Lean mass.

[00:43:36 –> 00:44:16] Dr. Ravi Kumar: And so now, this organ that’s keeping you metabolically healthy is rapidly being lost. And actually, in my practice, I’ve seen elderly patients go on GLP-1 agonists and were totally destroyed, essentially. I mean, they became so sarcopenic, which is this rapid loss of muscle and cachectic, which is, you know, frailty, that they were not able to thrive anymore because of a GLP-1 agonist. Now, that’s not an argument against GLP-1s, but I’m curious what your thought is on this, because you’re doing this weight loss and metabolic health program that’s preserving and even increasing muscle. Whereas a lot of patients are tackling this from a totally different approach with a pharmaceutical.

[00:44:16 –> 00:49:04] Dr. Vyvyane Loh: Yes. And I will say, uh, to be fair, with GLP-1s or with medication approach or even diet and lifestyle generally and with weight loss surgery, you do see about anywhere 30 to it’s been reported up to fifty, sometimes even 60% depending on the patient population of lean mass loss. So it’s not unique to the GLP-1s themselves and just even dieting on your own or even under supervision, but not maybe informed supervision, right, that you could have that. But the GLP-1s are actually very potent in terms of how they override your appetite and a lot of people believe that they actually act in the gut. Actually, the main action is in the brain, in the feeding centers of the brain and they intersect with immune circuits in the brain. So in one sense, it will directly affect your feeding patterns and make you not want to eat. But since it also intersects with the immune circuit, it intersects with the circuit that brings on sickness behaviors. So when you’re sick, and I had the flu earlier this year, right, I didn’t wanna eat, I didn’t want to drink, I didn’t wanna move, I kinda felt down, right? That is what we term sickness behaviors and a big part of it is not wanting to eat. Most of us remember when we’re sick and we’re like, I don’t have an appetite, right? So part of that not wanting to eat also comes from sickness behavior and it has profound implications in terms of the rest of the hormones in your body because there’s usually a synchronized effort, it’s a system, right? And GLP-1 exists within the system of hormones. What you did was take one hormone within the system and ram it down your throat. You explode the signal and you blast it, okay? And you drown out other signals. And now, what you’ve done is distort the architecture in your body, okay. So this can prompt profound anorexia, not wanting to eat and you’re not getting enough, uh, intake. The other thing that is interesting about GLP-1 is that GLP-1, uh, causes you to release interleukin-6, which is an inflammatory molecule. It’s a signaling molecule. Talked about the link with the immune system. This signal is going to direct your stem cells in the fat, what we call the pre adipocytes. It’s gonna direct them to become brown fat. And brown fat is a specific type of fat that actually burns a lot of calories to make heat. Okay? And so a lot of people put themselves through, like, cryotherapy or they go for cold swims or cold baths or they stand out in the cold because they’re trying to make their body make more brown fat so that they can just, you know, produce more heat and lose weight that way, use up calories that way Now, what people don’t understand is that cachexia, which is profound muscle loss, people think there’s a muscle problem, people studying cachexia, whether it’s in pharmaceutical circles or in research circles, they are studying the muscle cells. But we also know that in most cases, you know, of cachexia, there’s increased browning In cancer, for example, 20% of cancer patients die from the wasting or the cachexia alone They’re not dying from the cancer, they’re not dying from the treatment, just the wasting that comes about with the cancer, right? Now, that wasting is often associated with increased browning and so now we have brown fat activation all over the body and you keep wasting all those calories in terms of heat so that no matter I I mean, their appetite goes down but even if you slam them with nutrition, they actually cannot keep up, you know, because they’re just wasting away this heat. So, because GLP-1 medications do promote browning, it’s not the main effect for weight loss. But in the population that you described, the elderly, they’re already compromised, they’re maybe more frail already, right? Those are the ones I worry about because the minute we activate that and they get into a tactic profile, a wasting profile, it’s very hard to turn off. Okay? Right. And they have profound wasting. So that’s just one way that that might be having the effect. Okay? And so, yeah, I think that we are so focused on weight, we don’t think about what we’re losing, okay? Right. And what we’re losing is more important than just a number of how many pounds we’re losing. But that discussion, it still doesn’t get discussed very much.

[00:49:04 –> 00:49:04] Dr. Ravi Kumar: Yeah.

[00:49:04 –> 00:49:31] Dr. Vyvyane Loh: If you look at criteria for keeping someone on the medication, it’s how much you lost, right? It’s a number on the scale. Nobody’s talking about, hey, maybe she’s losing a lot of weight, but actually a lot of muscle because I see her really getting weak and frail and, you know, we should be stopping or at least like, hey, going down on dose or something. But, you know, we’re going by only the number. It’s working. She’s losing weight. Right?

[00:49:31 –> 00:49:32] Dr. Ravi Kumar: Mhmm.

[00:49:32 –> 00:50:38] Dr. Vyvyane Loh: And you could be doing more harm than good. But here, I’m gonna bring something else on board. So let’s say, you took this patient and they came to you, they had some obesity and diabetes. Right? And the doctor says, Okay, you know what? You should start on a GLP-1. Okay? Because they came to you and now the A1C was 9 or 10 or something like that. No, no, you think it’s a great idea. You start, then they lose weight, the blood sugar gets under control. Raw, everybody is so happy, okay? And then, they keep this patient on, okay? And let’s say it’s a 58 year old, 55 year old, doesn’t matter. Ten years later, because now they’re talking about keeping these people on these medications forever. Right? So ten years later, the patient comes in and you do, you know, their usual panel of labs and now the A1C is wait a minute, it was 5.4 and now it’s 7.8. Let’s just say. Okay? The patient swears, I’m not doing anything different. I eat the same. I’m still doing my exercises, but the muscle mass has shrunk.

[00:50:38 –> 00:50:38] Dr. Ravi Kumar: Right.

[00:50:38 –> 00:50:54] Dr. Vyvyane Loh: Okay? And so we started with obesity and diabetes. And ten years later, we have sarcopenia and diabetes. I don’t know what we did for the patient, but that is not a conversation that we are having because no one thinks that far.

[00:50:54 –> 00:51:10] Dr. Ravi Kumar: Yeah. So let’s talk a little bit more about that brown fat hypothesis that you have. These GLP-1s are causing a release of interleukin-6, which is converting white fat to brown fat. Brown fat is highly metabolically active and heat producing. It’s a lot of kids

[00:51:10 –> 00:51:47] Dr. Vyvyane Loh: Yeah. It is not a a hypothesis because there’s a paper, Gutierrez in 2022 actually showed this, and they showed that the antidiabetic effects of liraglutide, which is a GLP-1, If they’ve blocked the interleukin-6, you didn’t have the anti diabetic effects. So we know that it is actually using that circuit and that there is a browning effect. We see that in agents in weight loss agents, uh, like GLP-1 and glucagon when they add the glucagon on board too. That’s through a different mechanism, but we also see it with with the agents that add on glucagon. So we actually know this, but nobody links it.

[00:51:47 –> 00:51:48] Dr. Ravi Kumar: Cool, actually.

[00:51:48 –> 00:51:48] Dr. Vyvyane Loh: Yeah.

[00:51:48 –> 00:52:18] Dr. Ravi Kumar: Yeah. It’s very and no one no one talks about it. Right? I I mean, I just did a whole episode on GLP-1, and I didn’t come across that, this browning of white fat, which normally we would think, hey, that’s a good thing. You’re creating more energy, metabolically hungry tissue in your body, burn more calories, lose weight. But like you talked about, there’s a certain contingent in the population who can’t afford to have this metabolically hungry tissue sucking away their nutrients while they’re trying to thrive and be metabolically healthy.

[00:52:18 –> 00:53:52] Dr. Vyvyane Loh: 100%. So number one, let’s say you have a 50 year old healthy. You know, she put on the GLP-1, she lost weight and great and everybody’s rah rah, and then she gets a diagnosis of breast cancer. If it were me, I’d look at that GLP-1 and say, you know what, let’s have a discussion. I am worried at this point. Now, you’re a surgeon. So someone in the hospital for surgery, post surgery, wound healing, right, any hospitalized patient. This came up in the q and a, and I did that talk at the OPC conference just last weekend. Oh, what happens if a patient gets sick? Yeah. Me, I would, at the very least, decrease the dose. If they are hospitalized, I would stop. Because by definition, if you are sick enough, especially these days, to be admitted to the hospital, you’re pretty sick, right? And you’re also more sedentary, you’re gonna have, you know, be bed bound more and so you’re at risk for muscle loss, very high risk and you’re in a catabolic state post surgery and post, uh, or during illness. Yeah? So these are the states that I would be like, yeah, I think we should like stop that. Right? But that never gets discussed either. So, you know, and a lot of clinicians, a lot of doctors were asking me, oh, we never thought about that. So again, we’re so eager to jump on board, you know, oh, yay, look, look, but it’s losing weight. Yeah, it’s helping. But what are we actually doing? Nobody stops to think. And it’s, you know, we we had this discussion too. Right? We work, unfortunately, in a system that doesn’t prioritize or reward thinking.

[00:53:52 –> 00:54:47] Dr. Ravi Kumar: Or creativity. Yeah. Or deeper understanding. Yeah. That mean, it’s what’s on the glossy pamphlet that you’re handed to in the clinic, you know. Yeah. That’s that’s what the world essentially wants us as doctors to know. So let me ask you this, and I’ll just add here. I stopped GLP-1s in all my patients before I operated on them. Actually, three days before I do an operation, I stop their GLP-1s. And the reasons are a couple fold. One is they all cause gastroparesis. Yes. So, your stomach doesn’t empty. Yeah. And, you know, after surgery, before surgery, during anesthesia, these aspiration events can happen where people are not emptying their stomach. They’re maybe sedated or they’re taking pain meds and the stuff comes up. And if you aspirate into your lungs, it is a bad day and a bad week and can even be fatal in some circumstances. So I I do it in that situation. Also, I need people to be in anabolic mode after surgery.

[00:54:47 –> 00:54:48] Dr. Vyvyane Loh: I need them to be dealt

[00:54:48 –> 00:55:14] Dr. Ravi Kumar: with tissue. And these GLP-1s are I mean, they’re blocking that, essentially. They’re sending people down the road of catabolism, which is, you know, towards cachexia and and sarcopenia. So they’re definitely, if you’re gonna have a surgery and you’re on a GLP-1, talk to your doctor about start stopping it before you have the surgery and how long to be off of it. Tell me about this immunological, neurological pattern that GLP-1 stimulate. Uh, that’s something that’s new to me.

[00:55:14 –> 00:59:15] Dr. Vyvyane Loh: So we’ve known for a long time that when you have a rise of toleukin six in your body, that actually is going to bring about a rise in GLP-1. So the interleukin-6 directly stimulates colonic cells and the areas of the brain to produce more GLP-1. The flip can happen that when you have high GLP-1, you’re gonna stimulate the immune cells to produce IL-6. So there is a clear link and crosstalk between the metabolic system and the immune system. Now, I put this in my book and I said this at my lecture at the conference. This is something I want people to understand. And a metabolic intervention is always an immune intervention. An immune intervention is always a metabolic intervention. Why? Because we need energy, okay? I just kind of had randomly brought up this example, but recent events have highlighted it. When there is any conflict or war or excursions that happen in the world, Armies need what? Supplies, resources, energy. So without that, there’s no defense. Correct? So your immune cells, if they are ramping up for defense against a germ, a bacteria, or they’re trying to deal with some area of damage in your body, they’re gonna need energy. So what happens, and a lot of times people misunderstand insulin resistance. Insulin resistance is a normal physiologic adaptation. I have this in my book and I said this and it kinda like a lot of people were like, what? Because look, when you get sick, alright, what happens is you become naturally insulin resistant, which means that your GLUT four tissues, your muscle, and your fat are not gonna take in the glucose as well or as easily. And so since they’re not taking in the glucose, there’s more glucose floating around in the bloodstream. For what? For your immune cells, for the brain, for the liver, to make all the, you know, uh, inflammatory proteins and so forth, signaling proteins and so forth. We have to find a way to divert energy, you understand? That’s why metabolism is so fascinating to me, uh, and my main interest is in immuno metabolism because I don’t see a separation. Okay? So now, if we need to, uh, defend against something or or against either a pathogen or damage in our body, right, then you’re gonna have to give those cells the energy and you’re gonna have to shut off the divert from muscle and fat and say, guys, sorry, we’re closed for today. We gotta get all this to the immune cells. We gotta get this to the brain. We gotta get this to the liver. Okay? So we think of insulin resistance as a bad thing that we have to work against. This is a signal from your body trying to adapt to changing circumstances. Again, to our point earlier, to changes in the environment that are not natural for us. And our body says, uh, this is causing a lot of damage and our immune cells need to work harder and we gotta give them energy and we’re insulin resistant. And we’re like, it’s bad, it’s genetic. Right? It’s because you’re aging. And nobody understands this is pure basic physiology and it’s your body keeping you alive and doing the best it can. Okay? Yeah. Now another naturally insulin resistant state is when you’re pregnant. Pregnancy is the same. You wanna prioritize nutrients for for the fetus, the growing fetus, right? So again, this is not like, oh, what happened here? The bad guy showed up suddenly. No. This is an adaptive response And over time, if we keep pushing the system, you know, then the level at which the system can adapt and respond, you know, becomes less and less. And then we topple over into disease state.

[00:59:15 –> 00:59:29] Dr. Ravi Kumar: That concept of basically any energy preservation in the setting of stress, I mean, we see it all across the board. So I mean, if you’re psychologically stressed at work, if you’re sleep deprived, if you’re injured

[00:59:29 –> 00:59:33] Dr. Vyvyane Loh: Sleep. Sleep is big. It’s not a little thing. It’s a huge thing.

[00:59:33 –> 00:59:49] Dr. Ravi Kumar: And we’ve shown this. I mean, this is clinically evident that insulin resistance is high, blood glucose is high during these periods of stress. And let me ask you this, is taking a GLP-1 agonist putting you in a state of stress?

[00:59:49 –> 01:01:41] Dr. Vyvyane Loh: So it does definitely change the immune tone in your body. The problem is we don’t quite know a lot about how it changes the immune tone because guess what? We didn’t bother to study it. In fact, most people don’t even know about this connection so why would they even study something they don’t know about, right? But what we do know is that it definitely changes the immune tone And the main thing I wanna point out here and that I pointed out in my lecture and in the book, I think most people think of inflammation as a bad thing and anti inflammation is the antidote. Right? So the bad guy is inflammation, anti inflammatory is the good guy. And if you see a high inflammatory number in interleukin-6, which is a marker for inflammation, then that’s bad. And if we get that number lower, that’s good. Okay? That is way too simplistic. And it’s because something like interleukin-6 has different signaling modes. There is an inflammatory mode and there is a homeostatic, quote unquote, anti inflammatory mode. So let’s say you just did surgery on someone and that wound is still fresh, right? So there’s an inflammation process going on around the wound and the tissues that you just worked around, okay? Over time though, as the wound starts to heal, you may still have high levels of, let’s say, interleukin-6 or other cytokines, but it changes its signaling pattern. And now we turn on the repair mode. You are going to need that part of inflammation to repair the tissue. Wound healing will not happen without your immune system turning on that repair system. So your immune system does a lot of things. It’s not just bad or good. It has a range of roles that are dependent on context and the tissue and timing. Right?

[01:01:41 –> 01:01:42] Dr. Ravi Kumar: Mhmm.

[01:01:42 –> 01:02:44] Dr. Vyvyane Loh: So now, we know that we changed the tone with the GLP-1, the immune tone. We don’t quite know how. Right? What we do is we have a very big consistent signal because we slam in this GLP-1 signal, and it’s very loud and it’s consistent. Now the way our body produces GLP-1, it’s very short and it’s pulsed, and it works with the other hormones. We’ve taken all of that away. We just have one very loud signal on all the time. And we’re definitely changing the immune tone, which actually in a normal human being, changes over time and adapts to different conditions. Now, we kind of flatten everything and hard lock everything. So your level of adaptability is actually going to be dampened as well. Right? And this is what we’re not talking about, and this is what we need to have more research on, but you wanna bet that we’re not going to. I put money on the fact that we would never touch that with a nine foot pole, you know?

[01:02:44 –> 01:03:46] Dr. Ravi Kumar: No. I mean, if there was some money to be made off of it, maybe. But I think the results only would, like, would drive us towards less GLP-1 usage, honestly. And it’s already a multibillion dollar industry, so that’s probably not gonna happen. This concept of inflammation being bad, that’s something I talk about all the time as well. I mean, inflammation is necessary for life. I mean, every minute of every day, you are developing micro injuries, little stresses that need repair. Inflammation is the repair process of your body. And so, it mobilizes the immune system and the nutrients that are needed for repair. And without inflammation, you would fall apart. So, what needs to happen is inflammation has to be turned on and then turned off. But we find ourselves in this state of perpetual inflammation due to diet and lifestyle choices, environmental toxins, you know, and that ends up what takes us down is this perpetual inflammation. But inflammation is necessary for life.

[01:03:46 –> 01:04:28] Dr. Vyvyane Loh: Inflammation dial needs to switch from repair mode to attack mode to defense mode. Right? For example, if you were in anti inflammatory all the time, you’re more predisposed to cancer, right? You need your immune system for tumor surveillance. So at night, actually, we have a little bit more inflammatory action at night, okay? And that’s because that’s when those killer t cells are out there and they’re looking for these cancer cells. All of us have cancer cells in our bodies at any point in time. And the fact that you’re not sick from cancer is because of how well your immune system is being activated to get rid of those cells, Right?

[01:04:28 –> 01:04:29] Dr. Ravi Kumar: Yeah.

[01:04:29 –> 01:04:57] Dr. Vyvyane Loh: If you switch that off, right, and you basically eradicate that, then, you know, you lose your tumor surveillance, for example. In fact, in cancer, what they’re finding is that the t cells, for example, are not as aggressive. They’re really not very inflammatory. They’re just sitting around and they let the cancer cells walk all over them. And all the therapies that they’re trying to develop is to wake up that more aggressive side of the t cells. Right? And other other immune cells.

[01:04:57 –> 01:05:30] Dr. Ravi Kumar: No. I that was something I researched during my residency was how glioblastoma, which is a cancer in the brain, actually mobilizes the immune system to suppress it through these myeloid, uh, derived suppressor cells. You know, there’s a certain part of the immune system, like you said, it turns it off, it turns it on, it goes in defense, offense. And cancer develops these strategies to, one, evade the immune system, which is its biggest enemy, and to use the arm of the immune system that churns it off to its advantage. Like the board. You’re right.

[01:05:30 –> 01:05:33] Dr. Vyvyane Loh: You know, if you’re a trickier There’s these

[01:05:33 –> 01:05:59] Dr. Ravi Kumar: checkpoint inhibitor drugs now that basically are being used to try to churn off that suppressive side of the immune system and then in combination with vaccines, get the immune system, they kill cancer. Because I’m telling you right now, the chemotherapy and radiation we use right now, someday will look back on that and say, how barbaric. Yeah. Oh, and surgery, too. I mean, I do surgery on brain tumors all the time. And they’ll look back on that, and they’ll say

[01:05:59 –> 01:06:01] Dr. Vyvyane Loh: My God. Back in the cave

[01:06:01 –> 01:06:20] Dr. Ravi Kumar: days they cut open their head, and they cut out these tumors, and they’ll think, what barbarians. Because now, we just tell the immune system what to do and it goes and removes the cancer cell by cell until it’s all gone and there’s no residual carnage. And anyway, that’s something someday we’ll see.

[01:06:20 –> 01:06:47] Dr. Vyvyane Loh: Again, you know, this is all happening very exciting at the research level in the bench and and translate it a lot of times in therapeutics and pharma and stuff like that. I think the sad thing is it doesn’t get to mainstream medicine, you know. And, you know, I I just feel like in terms of the medical curriculum, we’re like forty, fifty years behind. What they teach today is what they taught forty, fifty years ago by and large.

[01:06:47 –> 01:06:48] Dr. Ravi Kumar: The world doesn’t like change.

[01:06:48 –> 01:06:48] Dr. Vyvyane Loh: Right.

[01:06:48 –> 01:07:10] Dr. Ravi Kumar: You know, change is for the change stresses the mind, especially for people who are already stuck in ruts of dogma, which is very common in the medical community, honestly. So Dr. Loh, what are you doing actively right now in your research and in your patient care that’s kind of exciting you or is something that people can look forward to?

[01:07:10 –> 01:08:48] Dr. Vyvyane Loh: So my book is coming out. It’s called The Architecture of Enough, Hunger, GLP-1, and the Immune Metabolic System. So that’s the book and I’ve been giving talks. I’ll be off to India next month to give a talk in Goa at the obesity conference there, so I’m very excited. The other thing that I do is metabolic health coaching, so I do that online and I help people do all the things we talk about, get their nutrition in place, get their exercise, but with the best evidence based knowledge, the latest science and also practical ways to make sure that we can bring that knowledge into actual application in life. Specifically now I’ve been focusing on people who started on GLP-1s or are trying to get off GLP-1s. So in that category, I’m sure you’ve noticed people who got on GLP-1s, they’re struggling to get off if they want to get off. Many of them say, I don’t wanna be on this for life doll, But whenever they try to wean down, the weight comes back up. They panic. They don’t know what to do, and they get in a tizzy, and it’s a very lonely place to be. So I do a six week coaching program to help them get that structure and wean in a very structured way. I don’t handle the medications, I’m not their doctor, but I’m really augmenting the lifestyle part and giving them the knowledge base and the practical tips to be able to accomplish that. So that’s the main thing that I’ve been working on these days. And obviously, doing like you sharing as much of this knowledge as possible to people who are open enough to listen because not everyone is open. Yeah.

[01:08:48 –> 01:09:08] Dr. Ravi Kumar: Yeah. Well, I think that’s really cool. I really admire that you’re out there stepping out of the mold that medicine tries to push us into because it does. It tries to fit us all into a certain shape that sticks within that dogma that drives medicine. And I I think it’s really cool when you have the courage, you have the creativity, and you have the curiosity.

[01:09:08 –> 01:09:10] Dr. Vyvyane Loh: Or maybe, Dr. Kumar.

[01:09:10 –> 01:09:11] Dr. Ravi Kumar: Step outside that.

[01:09:11 –> 01:09:17] Dr. Vyvyane Loh: Maybe we’re just fools, you and I both. I don’t know.

[01:09:17 –> 01:09:25] Dr. Ravi Kumar: To some of our medical colleagues, we might be. But to my audience that’s listening right now, they’re very grateful. I guarantee that. So how can people get ahold of you?

[01:09:25 –> 01:09:44] Dr. Vyvyane Loh: Well, they can I’ll just give up my email because I go through it. It’s [email protected]. On YouTube, I have a channel, Dr. Vyvyane Loh, and I’m on Instagram as well, so they can also message me there. But email is best, [email protected].

[01:09:44 –> 01:09:51] Dr. Ravi Kumar: Okay. Great. I’ll put that in the show notes, and thank you so much for joining us. This was an awesome conversation.

[01:09:51 –> 01:10:01] Dr. Vyvyane Loh: Uh, it was a lot of fun for me, and it’s always nice to have, you know, a conversation with a kindred spirit really. Gets lonely out there on our own. Right?

[01:10:01 –> 01:10:03] Dr. Ravi Kumar: It is. Alright. Cheers, Vyvyane.

[01:10:03 –> 01:10:06] Dr. Vyvyane Loh: Thanks so much. Thank you. Bye.

[01:10:06 –> 01:11:11] Dr. Ravi Kumar: Okay. So I hope you enjoyed that conversation with Dr. Loh. She has a truly creative and curious approach to metabolic disease. I learned a lot of new things today and I hope you did too. If anything in today’s episode sparked something for you whether it’s rethinking your body composition questioning what a GLP drug might be doing long term or just starting to look at chronic disease different I hope you take that curiosity and run with it. That is exactly what this show is for. You can find Dr. Loh at [email protected], on YouTube, and on Instagram. Links are in the show notes. And her new book, The Architecture of Enough, is also coming out soon. And based on today’s conversation, I already know that it’s gonna be a must read for me. So, until next time. Stay curious, stay skeptical, and stay healthy. Cheers.