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The Curbsiders (00:03.278) Curbsiders podcast is for entertainment, education and information purposes only and the topics discussed should not be used solely to diagnose, treat, cure or prevent any diseases or conditions. For the more of the views and statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity aside from possibly cash like more hospital and affiliate outreach programs. If indeed there are any, in fact, there are not. Pretty much we are responsible if you screw up, you should always do your own homework and let us know when more. The Curbsiders (00:25.966) Did you watch Alf when you were little? I did. Are you a little bit too young for that? I did watch Alf. Do you remember what Alf, the patriarch of the family, what he did for a living? Alf was an alien and he ate cats. That's about all I remember. He was from Melmac. So as an aside, they're in the Hardee's Value Meal. I'm pretty sure it was Hardee's. At one point they were doing a promotion where they got a 45, like a record. That was the single called Melmac Girl sung by Alf. It was not good. But anyway. The father, whose name was Willie, if I remember correctly, wrote ad jingles and he wrote one for asparagus. And I could probably sing it to you if there was a gun to my head, but I'm not going to since we're actually recording. Please keep all of this in. Welcome back to the Curbsiders. I'm Dr. Matthew Watto here with America's primary care physician, Dr. Paul Nelson Williams. Paul, the audience is delighted to have heard that story, I'm sure. Sure, feeling wistful today, man. And we should mention, happy new year, Paul. Happy new year. It's not the new year yet in real time, but it will be by the time this airs to the audience. And as always, thanks to all of our patrons. Paul, this thing is really taking off and I'm excited by, we've been getting some great questions. So I really, that's a part of these episodes that I'm actually enjoying a lot. I actually enjoyed preparing for these episodes too, cause it's great space learning for me. So. We're going to talk all about, we are going to talk all about obesity medicine. This is episode number 405, where we talked about GLP -1 agonists and just weight loss counseling with Dr. Kimberly Ann Gaggioni, who is from Johns Hopkins and their weight management center there. But we also, as always, when we do these recaps, we've started to pull in some pearls from other episodes. So we'll talk a little bit of low carb on this as well. And then some of the stuff when we talked about with Dr. Cody Stanford about some of the older generic medications that can be used to treat obesity as well. So Paul, first of all, is obesity a chronic disease? And should we be considering it a chronic disease? I'm shocked that you're straying from your usual pedagogical model of saying something incorrect like, obesity is not a chronic disease. Is that right, Paul? The Curbsiders (02:46.74) Yeah, it is, according to the World Health Organization, indeed a chronic disease and it has been for a while. I think we talk a little bit about how that disease manifests and being mindful, particularly of the cardiometabolic outcomes. And we can talk a little bit, Matt, I guess, about sort of the initial testing that we do if this is the thing that we're actually focusing on. But indeed a chronic illness and probably something, not probably, something that primary care doctors should be managing by and large. Yeah, like we've talked about, clearly we know that diabetes, high blood pressure, those are within our wheelhouse, that's our lane. Addiction medicine, hopefully listeners of this show feel like it's their lane now too. I know a lot of the people on the Patreon tell us that they're practicing addiction medicine, prescribing buprenorphine. And I do really think that all internists should be comfortable at least talking to patients and doing the basics in addiction medicine. And I think it's the same with obesity medicine because it is a chronic problem. And I've heard people argue about the physiology. I've heard people argue about why everyone is gaining so much weight. I think it's just too much processed junk, like not eating enough real food, eating too much food that people have doctored up in various ways. But I'm not sure. Is this your experience that patients have a lot of weight regain and it's really hard to keep the weight off even if they've lost some weight through diet and lifestyle? Oh, for sure. Yeah, I do. I agree with you, Matt, that goes back probably to fundamentals, just the American diet in general between portion control and then also caloric density. I think we're just fighting and losing battle with food a lot of the time. But yeah, for sure, even after some initial success, it's hard to maintain for a number of reasons. We had a conversation about this idea of the metabolic set point and that's sometimes what we're fighting against. Yeah. And I tried to look into this. I mean, there are some papers saying that like when you lose weight, your if your body has a set point, let's say 250 pounds that your body is like, oh, I'm starving. So I will increase hunger so that the person eats more and I will slow my metabolic rate so that both those things get me back to the set point because it thinks you're supposed to weigh 250 pounds. Dr. Gaggioni and Dr. Yancey, who we talked about, they both mentioned that, you know, the longer you stay at a weight, it seems like The Curbsiders (05:10.126) the easier it is to maintain that weight. So for good or for bad. So if you maintain a desirable weight for you for a longer time, it makes it easier to maintain that weight. So just maybe the set point can be reset, although I'm just not sure. It seems like most patients kind of yo -yo up and down. I do worry that it's probably an oversimplification. I think a lot of... The fact of the matter is that we... for decades had talked about weight like a math problem. We've talked about this before. It's just sort of, if you are calories, then what you need, then you lose weight, more calories, then you gain weight, and blah, blah, blah, it's that simple. And it turns out it's not, and I don't think any of it's that straightforward. And even though this idea of a set point is attractive because it makes straightforward sense, and the idea of calorie deficits and calorie overshoots also makes it straightforward. I don't think any of it's quite that simple. Which is, I know not a helpful thing to say, but the more I think about it, the more I realize we just don't, I think, fully understand what we're dealing with. Yeah. I do feel like one of the best gifts we can give our young people in this country is preventing them from becoming, uh, you know, developing a problem with their weight. Because if you don't have a problem with your weight, it's, it's easy to maintain the weight that you're at, you know? And, but once you develop this chronic disease called obesity, it, it becomes an issue that you're going to have to deal with long -term, just like high blood pressure, just like type two diabetes and other things. And, you know, I. I hope that's not a controversial statement. I just, I feel like we could do better from preventing it. And we had done better at other times throughout human history and other countries do better. So it is possible still. That's all I'll say about that, but this is a major soapbox of mine, Paul, as you know. So Dr. Gaggioni, she mentioned that some of the barriers to care and Paul, I don't know if you're feeling some of these, but I think a lot of people just lack training, which we sort of mentioned up top that there wasn't, there's, we had to own this, but we didn't get a lot of training in this. So this is a lot of, this learning has just been done on the show. And what other barriers, Paul, do you think people come up with when they're talking about, uh, why they don't talk about obesity? Time I think is always the thing that's going to be brought up. No matter is it makes everything kind of hard to talk about, but it's such a delicate conversation and what requires a lot of education and sort of, um, pre -gaming and sort of revisiting that it's in a. The Curbsiders (07:35.502) 20 minute visit, which I, you know, we'll talk about one of those questions. It's really hard to get everything done. And unfortunately this one might get sort of triaged to the bottom, um, just because it's harder to talk about, just takes up so much time. Um, I, and I personally have really been struggling with availability of medications and the fight to actually get the medications that actually work, which I know is not an emphasis of this episode and is, you know, hopefully we'll evolve with time. But right now I think there is, there's a, not to timestamp is too much, but a manufacturer shortage on a lot of the agents that are commonly used and the ones that are left are. less appealing as maybe their daily dose or they're not as efficacious. So it's, I think just even getting the medications and putting the fight for them also takes time and it's just kind of defeating in itself. Yeah. Usually at a first visit, I will, I will give them just some general advice. I will give them some kind of handout on maybe Mediterranean eating style. Uh, you know, it may be low carb if they're interested in that and just some general guidance on exercise targets. But, uh, Dr. Gaggioni said that she, will often just like say, I'm glad you want to talk about this. You know, we're going to handle all your preventive stuff today and your knee pain, whatever else, and I'm going to bring you back for a full visit and we're just going to talk about the medication options for you. And I think—so I think that's one way people can do it. And I have done that as well for people too. It's funny. Analogous in my addiction medicine practice, when I see patients for say opioid use disorder, I'm like— I see here that you smoke cigarettes. I'm going to tell you, you should not do that today. And I promise you, this is going to come up. We're going talk about more detail next time. So I do kind of prime the pump a little bit. In the same way with conversations about weight loss, I will sometimes say, we have a lot to address today. But I think something for us to think about moving forward, because the joy of longitudinalities that you can do that. You can sort of preset an agenda for your next visit and be like, all right, next time we're actually going go through these things. Because you have time to deal with it. So it's time that's going be split over multiple visits, which I think is how you have to do it anyway. Now, Paul, when you're talking to your patients about obesity, you just pick a number and you tell them this is what you should weigh, right? That's the best way to approach it. Yep, I do the old school calculate ideal body weight based on height and inches. Everyone comes out to about 120 pounds and everyone's happy with that number. No, I think there's lots of ways to think about sort of what your weight loss goals are. Rather than having... The Curbsiders (09:56.398) a set goal like by the time we're all done here, you should be at this weight is probably not the best way to do it. So interval goals can be helpful, like maybe between now and the next visit, we can try for five pounds or, you know, our target is to get you a place where your blood pressure is a little better controlled or we actually see your A1C go down. Like I think having tangible metrics, but not necessarily a set weight is probably the most effective way to do it. What is your practice, Matt? How do you, when patients like, what should I weigh? What do you tell them? Yeah, I always tell them, The short answer is I don't know. I can tell you that if you lose 10 pounds or 10 % of your body weight from a maximum weight, we do know that there are some metabolic benefits from that. But I mean, we're trying to get you to feel better. So, and we want to get you healthier. And like you said, you mentioned some of the metabolic parameters, blood pressure, maybe they have a functional goal to, you know, to jog or to... you know, to be more active with their kids or grandkids, whatever, then maybe that's lumped in there too. But it shouldn't just be a number. And I think that's the main point. So patients do often ask, what should I weigh? But I think just sort of reframing it into a more realistic goal that we can actually achieve rather than just say, I want to weigh 150 pounds because that's what I weighed when I graduated high school. I think just, you know, framing it the way you suggest it is a better way to go. Let's say that I'm seeing a patient for the first time, physical exam, give me a physical exam, Pearl, how can I measure someone's waist circumference, which I'm told is a better way to assess obesity? So how can we do that? Right, yeah, because as Dr. I think Yancey mentioned, BMI can be not so reliable in certain circumstances, say for instance, someone who is very muscular. So if you're... And also, it's sometimes more satisfying to sort of lose inches off the waist. So the way he suggests doing it is actually at the level of the umbilicus, which is a little bit different than what's done in research studies, but at least probably more reproducible in the office setting. So he mentioned two big things. One is having a really long tape measure, just so that the last thing you want is for someone to feel defeated because you can't get the tape measure around their abdomen. That would be counterproductive for sure. And then the other thing is it's hard to do it as a one person show. So if you're trying to measure someone's waist and you're like wrapping your The Curbsiders (12:15.022) arms around them, like that's just awkward and kind of weird, especially if you're meeting them for the first time. So instead, have them hold the tape measure at the level of their belly button and kind of do a pirouette. And then you sort of hold the other end of the tape measure and then just kind of meet them at the other side and get their waist measurement that way as opposed to trying to give them a bear hug, which is just an awkward way to have a first patient visit. Yep. It's elegant. It's practical. And it sounds kind of fun too. So it's like a romance almost. All right. So Dr. Gugini did mention that telemedicine is a good way to just fit in visits with your patients because managing this condition, at least early on, before you're in the maintenance phase, does require frequent check -ins. And so that just is a good way to be flexible and be able to get your patients in. Paul, what about tracking apps? Any cautions there? Yeah, it's a good point that I don't think I'd consider before, but you don't want to be doing super intense calorie tracking or food tracking if someone has disorder eating or a history of disorder eating. So one of the things Dr. Gugini will do actually screen for that before making the recommendation. There is some utility in doing it for certain patients, but in patients who have had complicated histories with food in the past, it's probably not the best thing for them. So I think she uses something called the SCOF questionnaire, which is something I honestly always have to look up every single time. I think one of the... What are the criteria? Have you lost more than like one stone or something like some weight? It's like a British measurement of weight that I have to look up what a stone equals to in the first place. But it's worth at least asking about a history of disorder eating before making a heart recommendation to track your calories. And this kind of brings up the fact that she did mention that she does often refer to psychologists who have experience with eating disorders. And, you know, there's all sorts. There's binge eating disorder. obviously anorexia, bulimia, but binge eating disorder and there's like a night eating disorder. So I think a lot of patients have emotional eating. So I've had actually had patients ask me if I could connect them with a psychologist because they think they need help with their binge eating. And I thought that was very insightful of the patient to realize that they needed that help. Maybe a medication could help that, but I think there's some other self work that they could do to hopefully improve that. The Curbsiders (14:40.43) Paul, she did briefly just mention that we should be familiar with counseling patients or giving them handouts on either like Mediterranean or DASH diet, maybe low carb. And that's how I want to segue into talking a little bit about low carb, which we did with Dr. Yancey, who was from Duke, and this was episode number 412. And of course, the fantastic Dr. Fatima Syed. who is one of us, Paul, but she works there with Dr. Yancy as well. And Paul, do you think this diet would be right for you? This 20 to 50 grams of carbs a day? I would struggle with it. I did some self -confession on the episode, Matt, as you recall, because I'm mostly vegetarian. And so as a result, instead of eating vegetables, I eat garbage. So it would be a big adjustment for me. but not necessarily a bad one. So at some point I may need it, but it would be a struggle. And I think a struggle for a lot of our patients to be honest. Yeah. So just for the audience, 15 grams is about a slice of bread, right? So a low carb diet that Dr. Yancey uses for people who medically need more of a drastic measure to help treat weight loss is 20 to 50 grams of carbs total per day. So like if you have one slice of bread, that might be... like your whole carbs. So these people on— on his diet and— and I'll include this table number three from one of his papers in the— in the show notes for this but he's— examples of foods that are allowed. Basically, you can eat as much like meat, poultry, fish or eggs as you want. You— you eat until you're satiated because that is no carbs. And then you can eat a limited amount of leafy greens and non -starchy vegetables. and then a little bit of like cheese, cream, butter, oils. And basically you're getting all your carbs from vegetables and like, cause like a cup of kale, Paul has like five to seven grams of carbs. So that you have to factor that into your 20 gram allotment for the day. So half a kale sandwich and you are done. And then, you know, you could eat some cheese, cream, that, that sort of thing. So. The Curbsiders (16:52.686) But this diet, I mean, for the right, maybe some people would not mind eating this way. I mean, for me, I do like to eat berries and fruit. And this is just too strict for me. But even eating lower carb than the average American, he said probably the average American gets between 200 and 300 grams of carbs per day. So this is like 10 times less or more. So it's pretty strict. And then the crazy thing about this, Paul, I mean, patients come off, like day one, they are halving their insulin, where they're, if they're on like glipizide, they're halving the dose of insulin, halving the dose of glipizide, and maybe coming off blood pressure medications. Like this, this happens in a matter of weeks that just drastically alters things for them. And patients are coming off medications. So, you know, if you're on a bunch of medications, you know, drastic, something like this might be, yeah, an easier pill to swallow, so to speak. So I want to move on a little bit, Paul, and talk about the medication. And just ask, check in. You mentioned the GLP ones. We'll get to those in a second. Since we did the episode with Dr. Stanford, are you using any of the other meds, like either in combination or by themselves, like Fentermine and those ones? Yeah. I don't know if you remember, Matt, and this is a little bit off topic, but there was that. that looked at actually tailoring your medication therapy to particular obesity phenotypes. Yes. So there was the sort of the impulsive or emotional eating. I'm not going to get them exactly right. So versus hypo metabolic, I think was one versus sort of, but so I have been using sort of those broad principles and actually have been sort of branching out. So the GLP ones are generally the ones that I reached for first just because of convenience with one's weekly dosing and the efficacy and some of the cardiovascular benefits. But if someone does have... particularly impulsivity as part of their eating. Then I, and I have another indication and I might reach the root program a little bit earlier. I'm not above, I shouldn't say not above. That makes it sound like it's a lesser medication, but I think there are certain patients for whom I will prescribe Ventermine and who do really well on it. I think we talked about during the episode, even though it was studied as a short -term medication, I think even some professional societies recognize it as an off -label management that can be used longer term. The Curbsiders (19:09.582) So I do, and metformin, I think is one that, again, if I have a reason to use it, I feel like that should almost be in the water. So metformin I will also use, even though I think that the weight loss is not quite as robust with that as it is with some of other medications that we talked about. Yeah. Dr. Stanford said metformin is one of those ones. It's kind of unpredictable. It should be weight neutral, but some patients will lose weight on it. But part of the reason I prescribe metformin is, especially if someone has diabetes, They, you pretty much need to try metformin sometimes before they'll unlock a GLP -1 agonist on their formulary. So I'm often just at least trying it to say whether or not they tolerate it. And then, uh, yeah, I do talk to patients about phentermine topiramate. I do talk to them about bupropion naltrexone. Uh, and usually I'm not starting naltrexone by itself. Like usually I'm adding that on if someone's already on bupropion and we've had like a little bit of response, but not as much as we wanted. And Fentermine and Topiramate, I actually have had success with both of those by themselves, you know, but I will also use them in combination. There's a brand named Kissimmea, which is Fentermine slash Topiramate, but if you prescribe them separate, they're both generic and just very affordable. It's cheaper, yeah. And same with Bupropion and Naltrexone. So I'm commonly prescribing any of these medications. And especially right now where it's very hard to get, either a GLP -1 agonist approved out of the gate for weight loss or just to get a supply of it. Um, I'm using a lot of these medications because patients are just eager to get on something to help with their weight loss and to kickstart their weight loss. Yep. So Paul, to end this part of the show, I just wanted to go over the counseling for GLP -1 agonists. So tell the audience like patient comes in, they're, they're having nausea, they're having constipation. And and they're just not tolerating it. Well, how can we get them to tolerate this medicine better? Well, it's Sorry for those watching the video Ali's Ali's in the mix Yeah, it's one ounce of interventions worth a pound of cure. So I I've changed my practice so that I will now do a bit more of anticipatory guidance So I the we talked about having patients have their portion sizes before starting the medications or at the same time They're starting the medications The Curbsiders (21:33.486) A lot of times patients aren't even really fully aware of what their portion sizes look like. So maybe having them kind of pay attention and then cut that in half when starting the medication and you can get around some of the nausea and the GIFs that becomes along with it. Similarly with the constipation, which can be really bothersome to patients just starting about regimen when you start the medication. By about regimen, usually something psyllium based to kind of bulk up the stools. Then if you need to, you can certainly add on Amirallax or you know, your stimulator, you know, your, your I think that you actually use the term rescue. Yeah, rescue. Rescue laxative of choice. Exactly. Okay. So cut the portion sizes down and we're giving them a psyllium fiber supplement and then some sort of rescue laxative. And I also, she, and I love the point that she made. You don't need to put everybody on the maximum dose. You know, you can, if they're having success and they're only on like half a milligram of semaglutide, then that's. That's fine. You can keep them at that dose. You don't have to push the dose. But you so usually what I've been doing is just I'll start someone on it and then a couple months, three months later, someone will say, hey, you know, can we go up on the dose a little bit? And then we'll just kind of settle out where it settles out. But I kind of follow their lead. I don't automatically push everybody up. And then the other thing is we have had some patients where the weight is just they're losing almost too much weight. They're almost like I'm worried about them becoming like almost frail. You know, they may still have weight on them, but they're just like sort of losing muscle too. Cause you don't just, your body doesn't just lose fat when you lose weight, you lose muscle and fat. So I do tell everybody you need to do some sort of exercise. You need to do some sort of resistance training to maintain some muscle mass so that you're primarily losing fat. And that is something that I think is not spoken about enough. So I really do try to talk to people about that. Cause you don't want to, um, Yeah, metabolically, it's better for you to have soft tissue mass that is muscle, lean mass. And so I want to go for that. And Paul, we should mention that since this episode came out, the GIP slash GLP -1 agonist terzepotide, which was branded as Monjaro for type 2 diabetes. Paul, what's the awesome name that is now approved for obesity? The Curbsiders (23:54.798) There is a one of my colleagues that we're trying to dissect this to figure out where it came from. Zep Bound is the name and it's the Zep from terzepotide though. For a brief point in time, we thought did it have something to do with zeppelin? And that seems like a terrible idea for it. We really couldn't make it work. But yes, now Zep Bound is the trade name for terzepotide now approved for patients who have obesity but do not have diabetes. So Godspeed and good luck getting it approved and finding it. But it's that that is on the horizon, the very close horizon for us now. All right, I think we should move on to listener questions just because we have a bunch and I want to give them some time. So Paul, William Moldowney asked about giving Prolia and Forteo, which I, so dinosumab and what is it? Teriparatide is Forteo, I believe. That's the, so these are for osteoporosis. Talk about using them. So I mean, for me, I'm not, I'm mostly, giving bisphosphonates. If a patient has a severe, you know, chronic kidney disease and they are not a candidate for bisphosphonates, that's pretty much what I'm reaching for, dinosumab. I think the main thing to remind listeners about is that dinosumab, it has to be dosed every six months. And if you stop dosing it, there was a couple articles in 2020, 2021, just talking about how patients just sort of lose a lot of the gains that they've made very rapidly. It's kind of like a bridge to nowhere in some ways. Like you just have to keep them on it. So I don't know what to do with that. I feel like it's not ideal. This is exactly, my practice pattern is exactly the same, Matt. Like if I can't do this phosphonase, it's a short step for me to actually have them see endocrinology and have them help me out because otherwise I just, I feel like the tools that are available are nuanced. And I'm with you, I'm not quite sure where we're going with them fully. I just rather have someone to have some comfort with them. Yeah. And if you search osteoporosis on our website, there's at least three episodes where we talk about these in depth with experts. The last thing I'll say, for Teo, teriparotide, I don't think that's being prescribed much by primary care. It's mostly in endocrinology offices. The other question William asked was about just statins, low intensity, high intensity, calcium scores. The Curbsiders (26:18.542) Paul, did you want me to take this or you want to take a crack at this one? I don't know that we're going to differ all that much. So the question is, could we talk about statins, low intensity, high intensity, and when we would use these basal lipid panels or calcium CT scores? I don't stray far from the guidelines, to be honest with you. There is almost no occasion where I would use a so -called low intensity statin. I don't know if that's not indicated per the ACCHA guidelines that I can think of. If you're going to do it, you may as well do it right. In terms of the use of like CAC scoring and that kind of stuff, I use it more as a tool to convince patients that they would benefit from statin therapy than I do it on the regular just because I think otherwise it's a relatively clear cut as to who would benefit and who wouldn't. For the most part, I don't fuss around low intensity statins. I don't do CAC scoring unless I'm really kind of on the fence with the patients they have ambivalent about statin therapy. Otherwise, that loses... between moderate and high potency statins. And those, again, I follow the guidelines for the most part. So I know that's not all that helpful, but I'm not a maverick like Watto who won't actually use his own algorithm. When the AC says jump, I say how high? I don't necessarily have my own algorithm, but I mean, low intensity just means they expect less than 30 % lowering of LDL and... moderate is 30 to 50 % lowering and greater than 50 % lowering is a high intensity statin. So you don't really know what intensity you're giving until you give them a dose and try it out and then repeat their lipid panels. So I kind of follow the lipid panels. I try to get people low, under 100, under 70, depending on their risk factors. And as far as calcium scoring goes, I do once in a while use it, especially if the patient is coming in interested about it or if they have a strong family history and their lipids don't look that bad, but they're really curious, like, what's my risk? And they don't know if they want to start a statin or not. You sometimes it will change their management. But some patients don't want to know that they have a giant lump of calcium on their coronary arteries that you can't remove. So I have, you know, I do counsel patients. I'm like, how are you going to feel about this if... The Curbsiders (28:35.246) you find out that you have it. Is that something you want to know? Because we could just treat you regardless. So it can be a double -edged sword with the calcium scoring. And I feel like we're still figuring out the best way to use them. But yeah, I don't mean to be dismissive of them. I know people who, this is their main focus and their research focus and are passionate about interventional lymphedology. I know they are big advocates for it. So I'm not. saying there's not value in it. I'm just saying I probably don't use it as nuanced a way as they probably do. Yeah. Okay, Paul, then we have one more. DG, we have time for just one more question. So DG asks, works in a free clinic and is wondering about what lab tests we order for yearly exams, just kind of thinking about good stewardship. So, and DG also asked about urine testing, which we did answer on a previous, I can't remember exactly which episode, but we did. On one of our previous shows, we did answer it. It might have been the September ones, but annual labs are not necessary for every single patient. I sort of go by indications. So if they have high blood pressure, you know, I'm checking at least a metabolic panel to make sure their kidneys are doing okay. If they have diabetes, you know, that buys you a metabolic panel, lipids, A1C, and young people that are... We're not just young people. Anybody who's having lots of sex, I offer them STI testing and everyone gets at least a one -time HIV and hep C test. So that's kind of how I go about it, but I'm not ordering like CBC, CMP, TSH, inflammatory markers, you know, A1C on every single patient. Yeah. Yeah. I don't order that on every single patient every year. I think you're just going to get yourself into some weird situations if you do that. Some patients want annual labs every year and they want to be checked for everything. I try to keep it reasonable, but I sort of go based on indication. Paul, what about you? Yeah, it's the same. I know it's not satisfying or it makes it a little bit trickier, but you have to ask yourself what exactly are you looking for? And I tend to adhere to the USPSTF guidelines for the most part. But again, if someone... The Curbsiders (30:45.742) If you check in A1C and it's stone cold normal and the risk factors don't change, you don't have to check that every six months or even every year necessarily. Unless there's some sort of risk factor change. And same thing, we were talking off air. I think different societies have different recommendations. So for instance, I am not above checking a lipid panel in someone who's a little bit younger, say in their 20s. But what I'm looking for is familiar hyperlipidemia with that. I'm looking for an LDL cholesterol greater than 190. If that comes back and it's like 103. I don't need to check it every single year because that patient would not qualify for statin therapy based on most of the major guidelines. So, you know, it's something you just have to sort of know what you're looking for, how risk factors change and how it would actually change your management. But so there's not one boilerplate set of annual labs that get on patients because I just don't, it's not cost effective. And oftentimes you end up getting things that you don't know what to do with. So I just, I have to have something I'm looking for specifically in order for me to pull the trigger on the lab tests, like an annual CBC one. a 25 -year -old non -menstruating man is just not helpful. There's no reason to go for that, just to go for it, unless they're giving you symptoms of anemia or you have some other specific concerns. So yeah, I tend to follow USPSTF and really look at risk factors and think about how it's going to change by management. So there's not much that is just indicated annually just because. And for your analysis, I mean, you don't have to order an annual year analysis unless the person has... a condition that requires it. So I guess if someone has CKD and you're checking for proteinuria, you can do the microalbumin creatinine ratio or protein creatinine ratio. But unless you're working somebody up for some urinary complaint, you don't necessarily need a urinalysis. That's what I would say. Yeah, I agree. Paul, we have some quick picks of the week before we leave the audience. Let me go first. Paul, I just rewatched... Edge of Tomorrow, aka Live Die Repeat, Tom Cruise and Emily Blunt. I don't know why, Paul. I just love that movie. I mean, it's, I think... You love it because it's good. It's good. The suits are so cool. I have a huge crush on Emily Blunt from that movie. I mean, it's just, yeah, it's a fun movie. Tom Cruise, genuinely funny of it. Like a truly great comedic performance, at least in the early third of the movie, like laugh out loud funny, like just terrific performances all the way around. The Curbsiders (33:08.238) Yeah, as the love story part of it is like, he's falling in love with Emily, you're like, damn, I love her too. How did this happen? Yeah. Yeah, great hard sci -fi. Like it actually, it holds up to analysis. Like it's a good movie. I agree with that recommendation. Paul, what about you? What are you recommending? I have, have you heard of Blue Eye Samurai, Matt? No, sounds cool. It's a series on Netflix. It's an animated series and it is... Gorgeous it is created and written by this husband a wife team. So Michael Green and Amber Noizumi and it looks tremendous it said in the 17th century and basically it's about This half -white half Japanese sword master named Mizu who was looking for vengeance against four white men who? Illegally are in Japan when it closed its borders at that time. And so it's this it's the samurai Cereal basically that looks incredible and it's just it is violence but well written and nuanced the characters rule like there's this this the main lead Mizzou has a sidekick named Ringo who is just like one of my favorite animated characters I think of all time like just genuinely funny and sweet and sort of You just grow to the love kind of everyone and become really invested in it and it's so I'm about a third of the way through it But it is lots of violence tons of nudity So it's it's not for it's not animated show for kids, but I have just I have been loving it and it's I can't think of the last time I enjoyed a cartoon this much, so I would highly recommend Blue Eye Samurai available streaming on Netflix right now. All right. I'm putting it in the show notes for everybody as we speak. Also, so Jen doesn't have to look these up later. OK, so we got we got him in there, Paul. All right. So that's two picks of the week. And I should mention, Paul, that this is the end of the episode. So you want to do an outro? Oh, yeah, I forgot. Every so often, Matt, with these especially, I've. It just evolves into me having a conversation with my friend Matt and I forget we're actually recording these things. The Curbsiders (35:10.83) This has been another episode of the Curbsiders, bringing you a little knowledge food for your brain hole. Yummy? Get your show notes at thecurbsiders .com and sign up for our mailing list to get our weekly show notes in your inbox. Plus, each month you'll get our Curbsiders Digest, which recaps the latest practice changing guidelines, articles, and news in internal medicine. And we're committed to high value practice changing knowledge and we want your feedback. So you can message us on Discord or you can send an email to askcurbsiders .gmail .com. Please subscribe, rate, and review the show on Apple Podcasts, YouTube, Spotify. It really does help people find the show. I wanted to give a special thanks to all of you, our wonderful patrons. We couldn't do the show without you, literally keeping us afloat. So thank you so much. Our technical production is done by the team at PodPace. Elizabeth Proto runs our social media. Chris the Chew Man Chew runs our Discord. Jennifer Watto runs our Patreon. And Stuart Brigham composed our theme music. And with all that, Until next time, I've been Dr. Matthew Franquado. And as always, our main doctor, Paul Nelson Williams, thank you and goodbye.