Eva (00:06):
You are listening to Less of You. I'm Eva.

Kami (00:09):
My name is Kami.

Eva (00:10):
Come with us as we confront our reasons for being obese while losing weight on semaglutide and roasting our past selves. And I'm back with my friend Dr. Misra. From what part of California are you in? Encino?

Dr. Misra (00:23):
Los Angeles. Encino.

Eva (00:25):
In Los Angeles. Yeah. I had such a good time talking to you on Meet the Doctor and I feel like we became friends, kind of.

Dr. Misra (00:33):
Yes we did.

Eva (00:33):
Yeah, and then we became Instagram friends too, which is unusual.

Dr. Misra (00:39):
Especially since I never go on just to post business stuff.

Eva (00:45):
Well, what I noticed is that you've finally posted a before photo of yourself.

Dr. Misra (00:50):
People are giving them to me.

Eva (00:51):
Giving pictures of you?

Dr. Misra (00:53):
Yeah.

Eva (00:53):
To yourself.

Dr. Misra (00:54):
Yeah.

(00:55):
I didn't have a lot.

Eva (00:57):
No, I don't either.

Dr. Misra (00:59):
I didn't think about this as being a journey. So I'm honored when I'm part of others because that's exactly what it is. So I didn't do a lot of befores and the before photos that I have are actually from other people.

Eva (01:17):
The ones I have are the ones my children took from below.

Dr. Misra (01:21):
Oh, that's fun.

Eva (01:21):
They're in a long string of toddlers with iPhones, they take 200 pictures and there's two in the middle of the 200 taken of me. They're so awful. They're going to make great Instagram posts. They're really bad.

Dr. Misra (01:36):
Are they objectively or subjectively bad?

Eva (01:40):
Objectively.

Dr. Misra (01:42):
Okay. Then you need to share them so I can comment.

Eva (01:45):
But when we look in the mirror ourselves, we're constantly making ourselves look better. Your kids don't do that for you. They just take pictures.

Dr. Misra (01:54):
Yeah. I think we talked about this last time that I'm redoing my website, which is its own journey because what I'm doing is also transforming. And so I had my assistant take some photos of me and when she took the photos and turn the camera over, I did not recognize myself. And I'm like, who is that? And she goes, that's you, a couple of outfit changes ago.

Eva (02:23):
I had the opposite because when you were on the show, I always pull up everybody's website on my other screen in case I have to come up with a question on the fly. And for about a minute I thought, do I have the wrong doctor's website over here?

Dr. Misra (02:36):
See, I have to redo my website. It's a must now because people are not recognizing me or it's interesting how you can be bigger yet not be seen, and then you lose so much of your weight and then suddenly you're seen. And I'm in Los Angeles where this is happening the most.

Eva (02:59):
Yesterday I was eating breakfast at a hotel with a friend in Houston and another man came in to eat breakfast and he kept turning and looking at me and after about the fourth time I was like, do I know this guy? It just couldn't believe it. But you're right, we're invisible, we're bigger and invisible and then when we get smaller, we're not invisible, which is so backwards.

Dr. Misra (03:25):
I know. It's like people don't want to see us, they don't want to acknowledge what we are, all of that, including the weight. The weight serves a purpose. My program and the way I do my own weight loss is more up here as opposed to 1, 2, 3 count calories, count macros, count micros, let's weigh things. That you can learn to do on your own. The stuff that you and I are doing right now, the stuff that a lot of my patients do without realizing it, the shedding of the weight, the shedding of what the weight represents is the real hard work.

Eva (04:06):
I think you could go for a while, losing, losing, losing, losing, and then at some point you're going to start hitting other stuff.

Dr. Misra (04:13):
Oh yeah.

Eva (04:13):
Like what you're talking about.

Dr. Misra (04:14):
Oh yeah.

Eva (04:16):
Yesterday I bought myself jewelry. That was pretty good.

Dr. Misra (04:19):
What did you buy?

Eva (04:21):
I got two new bracelets.

Dr. Misra (04:23):
Do they mean anything? Were they pretty?

Eva (04:26):
They're just pretty.

Dr. Misra (04:27):
You deserve it.

Eva (04:28):
And I bonded with the designer when I was in the store and I really liked her.

Dr. Misra (04:33):
That's amazing.

Eva (04:34):
I mean, the other thing I did yesterday was because I was in Houston and they have a much bigger Nordstrom, I ran through there and I picked up some stuff and really nice lady helped me. She kept bringing me what I thought was the wrong size. I kept telling her, that's not going to fit.

Dr. Misra (04:54):
What size?

Eva (04:55):
It's a 12.

Dr. Misra (04:57):
Okay.

Eva (04:57):
And she was like, no, I really think it is. And I was like, okay, fine. And now I have a bag full of twelves.

Dr. Misra (05:06):
I just bought scrubs. I was almost tempted to wear my old scrubs cuz they all have my logo. My new scrubs, I haven't settled on a color and I had to figure out my size. So I bought four different scrubs or five different colors, different sizes. I am an extra small.

Eva (05:24):
What?

Dr. Misra (05:25):
I am an extra fricking small. I haven't been an extra small in a very long time, but I'm also petite. I should mention that I'm only five two.

Eva (05:36):
I'm very tall.

Dr. Misra (05:37):
Yeah. I'm like, I'm shorty.

Eva (05:42):
That's fantastic.

Dr. Misra (05:44):
It is. It's a lot to digest. I like to talk about my journey because I think it's so important when you're going through this yourself as a patient to know that a doctor maybe has gone through it too.

Eva (05:59):
It's everything, I think.

Dr. Misra (06:01):
See I was not a lifetime obesity person. I was a situational, and then every time I tried to diet it would get worse because the cause of what caused, the trauma, the situation that caused my weight gain didn't go away. I had to address it over time. But there's different types of people. That was a 10 year journey for me. That wasn't a small journey. That wasn't a three year covid journey that some people have also, where they were fine and then covid kind of changed them, messed them up, and now they're just in a different situation and older and now perimenopausal with women or hitting 40, 50 with men.

Eva (06:47):
Would you be willing to share with us what the cause was for you?

Dr. Misra (06:51):
Maybe eventually?

Eva (06:53):
Okay.

Dr. Misra (06:54):
Yeah. It is a little more provocative than I would like to talk about right now.

Eva (06:58):
Let's talk about something else that's provocative like side effects.

Dr. Misra (07:02):
Side effects. Alright.

Eva (07:05):
If you're on Reddit, all you see is like I am barfing, I can't stop throwing up or I can't go to the bathroom. Help me, help me, help me. It's like probably 80% of the Reddit posts are one of those two things.

Dr. Misra (07:19):
The side effects can be anything. Nausea. We're talking about gut hormones that we are directly targeting. We are causing gastric emptying delays, we're slowing. We are causing all these different things going on in the gut. So obviously we're going to have a lot of gut related side effects. So nausea, vomiting, constipation, diarrhea, abdominal upset, bloating, abdominal pain, GER or reflux is a huge one that I have patients have.

Eva (07:54):
I remember in my first month I kept saying I'm having reflux, I'm having, they're like, that's not a side effect.

Dr. Misra (08:01):
It is a side effect.

Eva (08:04):
Yes it is. What was yours?

Dr. Misra (08:06):
Hiccups.

Eva (08:07):
Hiccups.

Dr. Misra (08:08):
Oh my god, that was terrible. I had hiccups for months.

Eva (08:12):
Then did you do anything funny to get them to go away?

Dr. Misra (08:15):
No. I think I screamed a lot at insurance and got terrified and terrified some people, so.

Eva (08:20):
You know can plug your nose and swallow three times and they just go away, right?

Dr. Misra (08:24):
Right. Halloween came and went. The hiccups went a little later.

Eva (08:33):
I think I have kind of two questions. What other side effects do you hear patients complain about and don't they go away for most people?

Dr. Misra (08:40):
Fatigue.

Eva (08:41):
Fatigue. Yeah, definitely.

Dr. Misra (08:43):
Hair loss. A little bit of joie de vivre when eating reduction, the joy of eating the good meal effect. I don't know how to describe it.

Eva (08:56):
Didn't, somebody famous just say that they quit taking it, cuz they wanted to enjoy eating again. Terry Dubrow maybe?

Dr. Misra (09:02):
Oh, I don't know. I don't really follow celebrities and stuff like that.

Eva (09:06):
Oh, he's a plastic surgery celebrity.

Dr. Misra (09:09):
Double celebrity. Yeah, I mean a lot of my patients, sometimes what I do is targeted treatments and we prepare for vacation time and we decide what we want that to look like, especially where we are along the journey because some people choose to lower their dose during the vacation or skip the dose or I do compounding because we can't always get it. And so we will do, I like the compounding simply because we can do targeted treatments so we can do less. We don't have to do whatever the pen says.

Eva (09:43):
Yes because that's actually a big benefit. You can't customize a pen.

Dr. Misra (09:48):
You cannot customize a pen, but you can customize your care.

Eva (09:53):
They kind of use the pen, I don't want to say it's a weapon, but part of the way they control how it's being used and who it's being sold to is through the actual packaging itself.

Dr. Misra (10:07):
Yes. So before ZepBound came out, I was so excited because I had heard and thought that there would be a vial, but then I was also kind of shocked that if there was a vial, what would they do? Because it's so easy to replicate Ozempic, which is a whole conversation in and of itself, just ozempic, many episodes. But Ozempic is now only approved for diabetes type two and so it only goes up to one milligram no longer two milligrams. So it's Wegovy that is only for obesity now, but it's kind of not obvious. And so people don't know about this change of formulary on insurance. It's the same medication, but you need to now process it as a new medication. But Ozempic has the pen and the manufacturer actually has on their website an alert because there are people, individuals we don't know who, that are replicating the Ozempic pen and putting serial numbers and lot numbers and if you're a pharmacist and you've never maybe seen Ozempic and we just came out of Covid, so maybe you did some virtual schooling, I don't know, and you're finally putting your hands on these meds, they look so familiar and similar, but there's nothing in them or there's something harmful in them or there's just saline in them so you're injecting nothing.

(11:32):
So when Zepbound came out and they came out with a pen of a different color, I thought, okay, well I guess they had no choice because they probably saw what was happening with Ozempic with the pens and then they get the FDA approval so they can ramp up manufacturing and obviously they want to keep the cost high. As an entrepreneur, I can understand that having a proprietary groundbreaking, novel, innovative thing, but something that medically changes the game for life, for health, for everything and not to make that so readily available that I can't get behind.

Eva (12:15):
Yeah, let's come back to the whole packaging thing. I find it fascinating, but I'm not sure it's really that exciting for everybody. I'm obsessed with how stuff works. Why do they make these decisions and why do they do it the way they do it? Reverse engineering, but okay, so the other scary that comes up all the time is the paralysis thing. And someone said to me recently, there is no such thing as stomach paralysis that does not exist.

Dr. Misra (12:44):
So there is bowel obstruction, which means that, there's different things that can cause an obstruction. We can have movement not moving. There's also obstruction in, you've eaten something like a hairball, like a plumbing, and so there is something literally obstructing your gut and so nothing can pass. There's partial and complete. There are a number of things that cause bowel to slow down. One of the most popular opioids. Opioids cause the bowel to slow so much so it can cause bowel obstruction. And if we are relying on obstruction as being a reason to not take these meds well, we're going to find all sorts of adverse effects. And this is where you talk to your doctor and you see what the benefit is and what is not.

Eva (13:42):
Lucky for me, I would never wish this on my worst enemy, but I have a 6-year-old who's had chronic constipation and so I've learned a lot about what you can and can't do to get that system back on track and she can't do it for herself. It's been going on actually for about three years. So we're like experts now. But it took a long time to get that dialed in. Have you seen things work well to keep people from even just ending up constipated? How do you suggest they prevent it?

Dr. Misra (14:17):
So initially when I do my consultation with patients, I don't tell them to change anything. I ask them how things are because I don't want to affect how they feel. I want to know from them and then I have them meet with me the day or the day after injection, generally I want to hear from them, which is a little bit different because I think most doctors are like, here's your pen and go, no, I want to know you don't go. I want to know. So I don't really do any bowel stuff unless they contact me and say, Hey, I'm suffering in this way. And then we will of course meet and discuss and then I do a physical exam if they want to meet in person or virtually, we try to figure out what's going on. Magnesium is one of my favorite supplements and it is so important because in the western diet we are very magnesium deficient already.

(15:11):
This is the integrative medicine side of things and we don't even check magnesium properly as doctors. It should be checked as RBC magnesium, not serum magnesium. When serum magnesium is low, your cellular level of magnesium is already way too low. So magnesium is important, fiber is important. Figuring out when you inject what you feel and what cravings kind of are removed and what cravings are new, these are cues that your body tells you that kind of get covered over time through genetics, through muscle memory, through bad habits, through bad coping, through not coping, whatever we want to call it.

Eva (15:52):
One of the things they ask me often at my follow-up is, so how's your appetite? Are you getting hungry? They're worried that I'm hungry? Yeah, I get hungry, but it's because I'm hungry.

Dr. Misra (16:03):
What they want to know is, are you ready to go to the next dose, the next higher dose? That's an indirect way of kind of asking that question. And how much is this medication still working for you? It's not an appropriately phrased question I think, but I think what they're trying to get at.

Eva (16:22):
I wish they would just say what they mean.

Dr. Misra (16:25):
And mean what you say.

Eva (16:26):
Yeah. I think what's sort of nicely tied to this issue is, back to the psychological stuff, is that people who haven't been on it or don't have a lot of weight to lose. I've heard a lot of this language from providers around, now you get to learn how to eat, now you get to learn how to eat healthy and you get to learn how to change your habits. Oh, isn't going to be so great to be healthy? And this always sets me off.

Dr. Misra (16:53):
I know because it's like, shame on you for doing everything wrong all your life. Right? Shame on you.

Eva (16:59):
Still shaming me.

Dr. Misra (16:59):
Yes. The language needs to change. It needs to be, this is just a new way to live without torturing yourself. That's what I tell my patients. Let's enjoy this.

Eva (17:12):
I always think this is sort of like, one time my husband ended up in the hospital for high blood pressure and was caught, it was caught by the optometrist who took his blood pressure and said, oh my gosh, you got to go to the ER right now. And I used to always be like, why are you checking my blood pressure at the eye doctor? And then they saved his life. So I was like, okay, nevermind. So the doctor in the ER, in the hospital kept telling him, no more cokes. Don't drink any more cokes. He's like, I haven't had a coke in 20 years. I know he was making a lot of assumptions about my husband's diet based on what he looked like, instead of asking him, do you drink soda? That would've been an easier way to go about that.

Dr. Misra (18:00):
Did he have a soda sitting next to him?

Eva (18:03):
Never.

Dr. Misra (18:05):
Because we do have patients that are supposed to be without food surgeries in the hospital that they're here for maybe hyperglycemia, severe, they were in a coma and then someone brings them a burger and a soda while they're on an insulin drip.

Eva (18:22):
That's like a lowest common denominator thing.

Dr. Misra (18:25):
I know, but it's unfortunate that that was the first thought.

Eva (18:31):
The assumptions are where we get into trouble though. Or going back to my blood pressure example, they won't think twice about putting you on, he's got four pills he takes every day and he has to take him for the rest of his life. Why?

Dr. Misra (18:46):
There's a number of reasons people don't like blood pressure medication. One of the most common is it makes you feel like garbage. You feel fatigued when your blood pressure is very high for a prolonged period of times, your organs are used to that pressure and then when we reduce the pressure, sexual dysfunction happens, fatigue happens, we get exhausted, it doesn't feel good. We want to feel good. But doctors don't prepare you always for that because they don't have the time to tell you that or they're burnt or they're restricted in what they can and cannot say. And so if you don't prepare the patient for what may happen, then they're going to drop it all four at once.

Eva (19:30):
When you have a good doctor who has time to listen to you, it makes all the difference in the world.

Dr. Misra (19:36):
Yes.

Eva (19:37):
Okay. So for today, I want to go through one more big misconception, which is compounding is bad and people are taking these things that aren't FDA approved. It just came up two days ago with somebody who said her dad was just in a rage about these drugs because they're not FDA approved for weight loss. We were like, yeah they are.

Dr. Misra (19:58):
These drugs are FDA approved for weight loss. There's a reason that,

Eva (20:02):
Did you miss that news?

Dr. Misra (20:03):
I guess there were other things on the news at the same time. I dunno what else to say.

Eva (20:07):
He just wanted to be mad I guess.

Dr. Misra (20:09):
Maybe, you know this space does create anger for a lot of people and it's so interesting because there's so many reasons why. The anger is coming from the manufacturer for copying and not getting paid, I guess. The anger is coming from patients not getting access. The anger is coming from Canada to the US saying, why are you taking our drugs? The anger is coming from the compounding pharmacies that are doing it right, getting blamed for doing it wrong because certain compounding pharmacies are doing it wrong. The anger is from you're cheating. Why do you lose the weight so quickly? I didn't get to lose the weight that quickly. I had to do this, this, this, torture myself, restrict, go on keto for like 50 years and I just shrank five pounds and then you get to do this and lose 50? Personal trainers are angry because maybe their jobs are at risk.

Eva (21:02):
Even Walmart's angry.

Dr. Misra (21:04):
Why is Walmart angry?

Eva (21:05):
People are buying less food.

Dr. Misra (21:06):
That's right. That's right. I heard about that. And that is

Eva (21:09):
The bariatric surgeons are angry.

Dr. Misra (21:12):
They should be happy that their patients may have less incidents of dying on the table.

Eva (21:17):
Right.

Dr. Misra (21:17):
I get it. I get the anger. I'm angry too. I'll tell you, there's some anger within the physician space going, you're creeping in my lane. What are you doing treating the obesity? I'm not a ABOM, I'm certified. I actually refuse to sit for the exam because I'm already internal medicine, integrative medicine, I practice aesthetics, I've done like I'm clea certified, I'm a U-S-C-I-S civil surgeon. I mean I have an FDA and a B-C-M-A-S background. How many certifications do I need? Why do I need to prove that I can treat obesity when I've already been doing it for almost 15 years? I don't understand it. And then there's people who just run for the obesity medicine exam, sit for the exam, but have never treated it. So there's anger everywhere.

Eva (22:03):
Or lived it.

Dr. Misra (22:04):
Or lived it or lived it. A lot of anger, a lot of feelings. But that talks about the emotionality of this space, about how complex it is because the anger is everywhere. The emotions are, you know, I am angry that I'm being seen as an extra small, but I wasn't seen as an extra large, large in my scrubs. It's hurtful. I'm the same person.

Eva (22:34):
I am the same person too, but lately I've been feeling like I'm more me than I was.

Dr. Misra (22:39):
There's space for you now.

Eva (22:41):
There's space. Yeah.

Dr. Misra (22:44):
You're creating you, these boxes that you were, gone.

Eva (22:49):
So are you.

Dr. Misra (22:51):
Yeah. One of the things I started expanding upon with my practice is because patients talk to me more about what their fears and concerns are. Disaster preparedness medication. Last week we had a state of disaster here in California and then Friday I was literally sitting down to talk with the patient and the earth, we had an earthquake and I was like, did I just sit down, because of the weight related old me sat down in the chair and the earth started shaking and I thought, I'm still a little big. Wow. I just shook the whole house. No, that was an earthquake in Malibu, just as I was meeting the patient and I'm thinking that I sat in my chair. I ran up, I grabbed a dog, I had my phone. I realized, oh, I have to go back in, I have another dog. I just got another puppy. But yeah, so disaster preparedness, I call it a apocadoc, medications for disaster. And patient advocacy because there is so much impropriety in this space that I offer myself, even though I might not write the prescriptions as an advocate and a consultant while they're in this journey. So they can ask me questions if they can't access their Med Spa or their doctor because they have an HMO type of plan or something like that.

Eva (24:09):
Yep. That's great. I have my own earthquake story from last week. I went to game night with some ladies from church and the hostess had this beautiful mid-century table in mid-century chairs. They were clearly antiques. And so she had the setup where the two on the ends had arms and the other four didn't have arms. So I'm sitting in the arm chair and you know that horrible sound where the creek precedes the crash.

Dr. Misra (24:38):
Yes.

Eva (24:39):
I broke the chair.

Dr. Misra (24:40):
Oh my god.

Eva (24:41):
And I just stood up and laughed. I knew it wasn't because of my weight that I broke the chair, the chair just broke.

Dr. Misra (24:46):
Finally.

Eva (24:47):
Yeah.

Dr. Misra (24:49):
It's not me, it's your chair.

Eva (24:54):
I felt so bad, but I just laughed like, oh no.

Dr. Misra (24:57):
But you just said it was an antique.

Eva (24:59):
They didn't think it was any big deal either. I'm sure it wasn't special, but.

Dr. Misra (25:03):
You probably weren't the first to break a chair. Yeah. Oh my gosh.

Eva (25:10):
Texas earthquake.

Dr. Misra (25:12):
Texas earthquake. There's been quite a few quakes recently, the earth is moving. But I love how extra small scrubs just about to sit down with the patient, and then I was late to that patient encounter and completely rattled and I was like, I'm so sorry we just had an earthquake. I thought I sat down. But no,

Eva (25:33):
That's awesome. I love it.

Dr. Misra (25:36):
So I sent you a video, talk about provocative. It's a 10 minute long video of me fighting with insurance about ozempic and the change of formulary. You should watch it.

Eva (25:50):
I will.

Dr. Misra (25:50):
With some popcorn.

Eva (25:52):
I can't eat popcorn.

Dr. Misra (25:54):
Oh, teeth.

Eva (25:55):
No, it just doesn't sit well.

Dr. Misra (25:58):
I'm a popcorn eater.

Eva (26:00):
There's something else that I can't eat anymore.

Dr. Misra (26:03):
Ooh, this is a good topic. What did you stop eating with some of the weight loss?

Eva (26:08):
There's one of my go-to recipes is Turkey chili and it has black beans and pinto beans. Just takes too long to go through. It sits for too long.

Dr. Misra (26:18):
I can't drink coffee.

Eva (26:20):
What?

Dr. Misra (26:21):
I know I had to switch to Indian tea.

Eva (26:24):
Oh, you told me this. You told me this. My life would be ruined without coffee. What should we talk about next time? You going to come back?

Dr. Misra (26:33):
Hell yeah.

Eva (26:34):
Okay, good.

Dr. Misra (26:34):
You going to have me back?

Eva (26:36):
Yeah. You're going to be a regular.

Dr. Misra (26:39):
I love it. I'm excited to be a regular because I am regular.

Eva (26:45):
Magnesium.

Dr. Misra (26:46):
Magnesium, pre and probiotics, Metamucil, that's a big one, Cilium husk. Let's see, senna sometimes, occasional laxatives when needed. You got to do what you got to do to poop it out sometimes. But generally I do find that the bowel stuff does correct itself because people simply reach for different alternatives. What do you want to talk about?

Eva (27:14):
Next time?

Dr. Misra (27:14):
Next time, yeah.

Eva (27:16):
Nutrition.

Dr. Misra (27:18):
Okay. Good nutrition. Bad nutrition.

Eva (27:21):
Well, I think there's a balance between food and supplements and I've always leaned towards, I'd rather get my nutrition from food than from supplements. And when you don't eat that much, you have to actually think about it differently. So that's a mind shift that I have to eat for nutrition instead of eat as little as possible. That's my before and after. I was like, I never had to eat for nutrition before. Just like I never had to go to the gym to be strong. The purpose was to not gain any more weight or to lose weight, always.

Dr. Misra (27:55):
You are stronger than you probably know given everything that you've done put together. Me too. Me too. My patients too. But we measure strength in different ways.

Eva (28:10):
Follow us on Instagram @LessofYoupodcast. Are you confronting the same challenges and have a story to tell? I'd love to hear your story on our Skinny Shot Stories podcast. Contact me for more details at skinnyshotstories.com. If you're a doctor and would like to learn more about sponsoring this or any of our cosmetic surgery and weight loss podcasts, go to lessofyou.com. Less of You is a production of The Axis, theaxis.io.