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dr. pedram: hey! it's dr. pedram, back withdr. sara. hi! dr. sara: hi everybody. hi pedram.dr. pedram: hi, nice to see you. hello everybody. today's topic that we want to talk about isthis recent ama designation of obesity as a diagnosable disease. it sent a lot of ripplesinto the media. there's been arguments on both sides of this, and it's complicated,right? it's a complicated debate. it's something that we all are affected by one way or another,and so what we wanted to do is tease out both sides of this argument really today, and bringto light some of the challenges and issues with this so that we can talk about it andstoke a debate, because it isn't black and white. most things aren't, and so for us tobring out those topics and debate them i think

might be a healthy way to go about it.dr. sara: i love that pedram. i love that. should we dive in the pro versus con? if youlike, we're going to do a saturday night life skit tonight.dr. pedram: it might turn into one. okay, so here we go. i'll do the pros and the conshere. the pro is that ... okay, the american medical ... ama basically seen a 1/3 of adults,17% of children have basically medical conditions that are coming from obesity, right, so it'sobviously leading to the fallout of all the stuff is already there, right? that is a given.obesity is causing a lot of these problems. that isn't really being argued. they're sayingit will encourage primary care physicians to get over their discomfort about raisingweight concerns with obese patients, and studies

have found that more than half of the obesepatients have never been told by a medical professional that they need to lose weight.okay, so ... dr. sara: wait! can we hold right there?dr. pedram: absolutely. dr. sara: isn't that a stunner? i mean, really,half of people who are obese have not been told that they really should lose weight?i find that shocking and maybe a little depressing. it also makes me feel like, "okay.ã® it'sa good idea if it raises awareness because it seems like we're in the dark ages aboutobesity and the clarity about how to approach it. i think another thing that we should talkabout today very briefly is some of the determinants of why people become obese, but i'm goingto try to stay on topic right now.. didn't

you find that stunning that ...?dr. pedram: i really did. if you fly to san antonio, if you fly to certain parts of themidwest, and there's a great percentage of the people in the community probably includingthe doctors that are overweight and have a high bmi. it just becomes this kind of given,right? it's gotten to the point where there are so many obese patients that the doctorsgo, "whoa!" i've been in rooms with cardiologist who say,"well, we could prescribe diet and exercise but we know they're not going to listen, sobaaa," right, and they chuckle about it and go about their conversations about what drugswe're going to give them because it's ... there seems to be the sense of dismay in the medicalindustry where we were ... a lot of our colleagues

have given up, right? that's a problem.dr. sara: well then, this is an important intervention for them, right? if it's goingto take those among us who are jaded as physicians, who are not talking about the lifestyle changesthat are proven to move the needle when it comes to weight loss, then i think this isone of the arguments in favor of it. i think i would agree with that. i mean, i can reallysee both sides of the issue, but this is one that i think is important in terms of raisingawareness. dr. pedram: yeah.dr. sara: can i just define body mass index. i mean, maybe everyone already knows theirbmi, but body mass index just is the proportion, the ratio of your weight to height. ideally,you want that to be between about 18 and 25.

that's the normal weight, and then 25 to 30for body mass index is your overweight category. above 30 is obesity.dr. pedram: yup, and there's a lot of people in the obesity. i mean, most americans arenudging up into higher bmis, and then the obesity is starting to take the lead in alot of these markets. it's obviously an important issue, right? we all know that weight gainleads to heart disease, the diabetes, fallout from diabetes, all the stuff that comes fromdiabetes, so it is obviously relevant for all of these. the real question is, "is obesityitself a disease?" that's where ... you could say it's just a word, but it's not becauseonce you have a diagnosis ... let me be clear. the ama designating this in this capacitydoesn't make it a diagnosis. it hasn't ... it's

more of a suggestion by an industry leader,so it's nudging the argument in that direction, but that's not particularly what's happenedyet, right? dr. sara: that's right.dr. pedram: okay, so let me just tease this out real quick, so we can then just keep goingthrough this. obviously they haven't been told, which is a huge issue. then the causesof obesity are complex because of genetic stress food, medications, and all that. thereis an argument to say that self-discipline can't cure obesity alone, so it really bringsout and brings to light some of those issues. basically, it's not going to change. whatthe ama did isn't going to change it, but what they're trying to do is stoke up greatercommunication on this topic.

then one of the things that they're tryingto push forward, if it is a disease, then insurance companies will be more supportiveof obese people, and researchers will probably pursue it more aggressively, and there'llbe a lot more public health efforts to go about this as something that is a nationaldilemma, and this issue go, but obviously there's a wide range of topics and healthproblems that come which is high blood pressure, diabetes, cardiovascular disease, which wealready talked about, but there's also an increased risk of cancer.a couple of the arguments for classifying it as a disease are potentially people canreceive coverage from their insurance and are more likely to receive nutritional counseling,because right now people say, "well, i can't

afford a nutritionist." then you just lookat the dollars and sense of this whole thing, and the direct cost of obesity is over 535billion dollars a year, so what we're trying to do is ã– in this is saying that for raisingawareness, we could potentially lower our healthcare spending for problems related toobesity. dr. sara: this is another place pedram wherei find it somewhat depressing that we need to classify obesity as a diagnosis in orderto have these structural changes in terms of getting insurance to pay for some of thetreatments, in terms of doctors talking about it more in their offices and letting go ofsome of that jadedness. i wish that it didnã­t come to this. i wish it didnã­t require thestructural changes for it to be a more front

and centered topic in those seven-minute appointmentsthat are the average for appointments across the united states, but maybe we need that.dr. pedram: well, i mean push came to [inaudible 00:07:10] i guess. weã­ve been talking aboutit. every week, itã­s in the news somehow, right, and so if the country is not gettingskinnier, itã­s getting fatter, and our health problems are starting to catapult. iã­m goingto make an argument probably later. iã­m going to talk about the [inaudible 00:07:27] equip,and iã­m going to make an argument for it. i side with mark hyman on this in the youspend so many hours in the healthcare system and maybe three, four or five hours at thedoctorã­s office in any given year. then you have 8,000 something hours that youã­re justgoing about living your life.

i would put it to everyone that thatã­s wherehealth really happens. i know you stand on that same side of that fence. i donã­t thinkitã­s ã– once you get to the doctorã­s office, it is a disease process, and thatã­s a problem,but the question is how do we educate people and move the needle on the front side of thisso that it doesnã­t lead to these epidemic proportions, and you donã­t need to get allthis bypasses and stents, and all this really expensive interventions once itã­s alreadya huge problem, right? dr. sara: youã­re absolutely right. i mean,weã­re at this place right now as you were describing where two-thirds of the populationis either overweight or obese. i agree with you that the rebar hits the road where youreally are talking about the lifestyle changes,

the small decisions that we make every dayabout the food that we eat, the exercise that we get, but i also think itã­s important torecognize even with all of our research in awareness about the drivers of obesity, thatfood and exercise alone doesnã­t explain the whole story.you mentioned this briefly before. we have to look at some of these other reasons forobesity such as environmental toxins. it seems like that comes up every time you and i arein conversation as well as genetics, as well as the microbiome which i hope weã­re goingto talk about in the future session. i think some of this data that we have on microbiota,the bacteria, that many pounds of bacteria that you have in your system, and how theychange depending on which you eat, whether

you have more sugar, more fat, that changesthe bacteria and makes you more likely to be obesogenic.it sounds like weã­re going to go to the cons next. are we ready for the cons?dr. pedram: yeah, letã­s just bang it out and then start talking about it. i guess,letã­s get it all on the table, because there are strong arguments on the con side of thisas well. what people are saying, obesity should not be diagnosed as a disease. basically theyã­resaying, excuse me, telling all obese people that they have a disease has end up reducingtheir sense of control over it. there is evidence that suggests that people with addictionsor telling that they have addiction basically makes that ã– makes ã– it turns it into somesort of self-defeating spiral, right? then

theyã­re saying, ã¬look, if insurance willmake adjustments to cover these procedures that will treat obesity, more people willopt for bariatric surgery and maybe not ã–ã® which is obviously a lot more drastic of aroute than going for say nutritional intervention or lifestyle coaching, or things that wouldpotentially change it, but it take a little of buying from people.it might be an easy up doubt is one of the arguments. patients could use the diseaseclassification as a crotch. weã­ve seen this with other things, and say, ã¬oh well, i havethis.ã® then basically one of the arguments is, ã¬what about gmos? what about chemicaladditives? what about all these endocrine disruptors? all stuff that youã­re talkingabout right now that might ã– there are lifestyle

and society problems that we need to lookat beyond what people are doing that are obese.ã® there are obesogenic types of things out there.then that really begets the question of why, right? why is america obese? why is this adisease? then thereã­s the socioeconomic stuff. impoverishedcommunities donã­t have access to or canã­t afford properly balanced diets in a lot ofways. if all you can afford is a dollar a meal at mcdonaldã­s for your kids every day,and at least itã­s food, i understand that. you got to feed your kids, so not having accessto proper nutrition and information about the nutrition, and all the kind of disproportionatecarbo loading in cheaper food is also a big problem with this obesity thing. that is somethingthat needs to be talked about again i think

on a macroeconomic society scale.thatã­s really the argument, because theyã­re saying these changes needed are politicaleconomic, and so if we had safe neighborhoods where people could go out and play, and playin the park and exercise like they used to. maybe that isnã­t the thing. having availabilityto foods and access, and make it more affordable, and making the workplaces maybe a little moreencouraging towards health and fitness, and allowing midday breaks to go out and do stuffand not being so production-oriented is a big argument.then there is one of the smaller argument that talks about the bmi calculator maybebeing a little too general and not accommodating for some individual characteristics, and sosome doctors are arguing for a better standard

to diagnose these patients. thereã­s obviouslya lot of argument that we can make on both sides of that, but thatã­s the long and theshort of what i can have in front of us here to go for. i know you have a lot of opinionson it, so iã­ll let you start, and then weã­ll keep circling around in finding if we couldfind some common ground with the other people. dr. sara: well, this argument against it ã–the arguments that you just listed i think are ã– many of them are compelling and reallygreat fruitful thought. i heard the learned helplessness argument that people are justgoing to have this sense of, ã¬oh! well, iã­m doomed. iã­m obese. itã­s a disease, and soiã­m going to give up my power around this and take the latest pharmaceutical,ã® insteadof stepping into the lifestyle tweaks, the

redesign that you and i know and love. i thinkthat argument for me is less persuasive. i can see it on more a population level howthat is true. some of the things you mentioned about structuralchanges and how itã­s not just the physiology; itã­s also the governmental and societal issuesthat lead to a more obesogenic culture. those remind me of an atlantic article that i justread about michael pollen. i happen to live here in berkeley with michael pollan, journalist-author.he is a proponent of really stepping away from the big food industry and focusing oneating the foods that our great grandparents would recognize.this atlantic article was saying, ã¬to really affect change in terms of food in this country,we have to work with big food.ã® how do we

do that? itã­s not going to be as successfulto work outside of the system. i think that thatã­s an argument that is also in favorof opposing obesity as a diagnosis. give me your opinion on that.dr. pedram: i got a few. let me tease them out. one is ã– i spent some time with brucelipton who talks a lot about placebo effect and positive impact on your belief systemsand how your outcomes are in health, but the obvious opposite of that is that is the noceboeffect which is if you tell someone they some negative disease or diagnosis, then all ofa sudden, it starts this negative spiral, right? we know this from people who are givencancer diagnoses. itã­s almost like a curse because then in a lot of ways, itã­s like,ã¬oh my god! iã­m going to die.ã® then they

got to change their whole headspace and theirframe because we tend to be that way. we tend to be hypochondriacs by nature, and when youã­regiven some disease classification, a lot of people take it the wrong way.being told you have this disease called obesity is a challenge, because i do believe in medicalcursing. i do believe that we have to be very careful in how we diagnose and communicatediagnosis because it can dramatically impact the way theyã­re going to orient with thatnews, and so ã– iã­ve been around healthcare long enough to say that not many of our colleaguesare the best communicators. dr. sara: oh no, pedram, really?dr. pedram: i mean, god bless them. theyã­re out there doing good work, but itã­s justthat they just ã– i got someone coming in

seven minutes, and i got to go in there andtell this lady sheã­s got breast cancer. okay, right? itã­s horrible. thatã­s the way thesystem is set up. for me, that drags us back into that macroeconomic systemic thing. wetalked about this in the vitality movie. i know you and i talk about this all the timeis that there is a broken medical system. itã­s all about the reimbursement and drivingunits through machines and generating revenue for things.itã­s dehumanizing in a lot of ways, and so i think that that element of that dehumanizingcapacity of the system which ã– there is a lot of good news on there. we can talk aboutthat later in the later show, but thereã­s a lot of positive light coming through indifferent models for healthcare now, but the

traditional system has been very bad at that,right? itã­s alienated a lot of people. it made people with heart disease go to reikihealers exclusively, and go off their medications sometimes for better or for worse, and sothereã­s been a lashed back that has i think come from some of the miscommunication andthe poor bedside manner that comes from the nocebo effect.but systemically, i couldnã­t agree more. weã­re doing a story. we were with just lyfekitchen. weã­re doing a story with a number of these big food suppliers, and thereã­sa lot of these guys. lyfe kitchen just got a couple operations guys, former mcdonaldã­sguys that i think are trying to burn off some karma now, right? theyã­re doing a clean supplychain, healthy food model in a fast food capacity.

youã­re right. the systems are already there.all you really need to do is replace bad food with good food, and youã­ve got yourself avery finely-tuned trillion-dollar food delivery system thatã­s already in place.if the consumer says, ã¬hey! i donã­t want to eat this garbage. i want organic. i wantnon-gmo. i want this. i want that,ã® then ã– and theyã­ve [inaudible 00:17:39] withtheir dollars and they put their money where their mouth is, then the corporations arehappy to oblige because, ã¬hey look!ã® theyã­re in the business of selling whatever it isso long as they have their spread in their margin. iã­m a big advocate of voting withyour dollars and changing the healthcare system on the frontend.look, if you are already coming in with hypertension,

youã­re on six drugs, and you need a stent,itã­s hard to say, ã¬well, you should start eating broccoli, and youã­re going to be okay.ã®itã­s a great thing to say, ã¬for the long term ã–ã®dr. sara: [inaudible 00:18:08] might say that. dr. pedram: [inaudible 00:18:09] would saythat. yeah. thereã­s so much liability there that if someone has a heart attack the nextday, are you at fault? a lot of doctors really shy away from that because of the liability,and thereã­s a lot of lawyers out there sharpening their ã– thereã­s amount of medical malpractice.thatã­s a big thing, right? thereã­s medical malpractice, and then thereã­s lawyers thatare going after doctors doing whatever they do.my take on it is if you systemically start

changing the food delivery system, and dealingwith macroeconomics. weã­ve talked about this the other day with the farm bill. now thereare some provisions in there to really allocate some of the subsidies for healthier food optionsand organic produce. to me, that is a very welcomed news because i think that that canmove this whole debate around much more than doctors changing a word and turning it intoa diagnosis. dr. sara: i agree with that. i love this idea.i want to translate the vote with your dollars into a message which is go to mcdonaldã­sand demand your kill. how is that? dr. pedram: i want that.dr. sara: when i think about some of the fast food places that i go to, and i can thinkof a couple that are here in the bay area

and around nationally. one is [chipotle 00:19:24],i can get a really good meal in [chipotle 00:19:25]. i can also go to ã– there is anotherplace. iã­m blanking on the name of it right now, but they actually have a kill salad ontheir menu, and itã­s a fast food restaurant. i do feel like we ã– iã­m a big fan of usingthese large systems that are in place already in getting better food, getting the organicproduce, getting the more nutrient dense foods to people as a way of countering the obesogenicdiet that we tend to eat. when we started talking about some of theseother drivers of obesity beyond how much you eat, and it turns out that weã­re actuallyeating less now than we were recently. we are turning that ship around. weã­re not exercisingmore. we need to work on that. these other

drivers like the genetics, the microbiome,the environmental toxins, i want to maybe give a hopeful message around now, becausei have found in my practice, and i think you found this too pedram, that there are manyways to amplify the innate intelligence of the body, and to improve your detoxificationwhether itã­s as simple as taking probiotics which has been shown now in humans to reduceinsulin resistance, the early root cause that leads to obesity.you can do that with things like your fork, with probiotics that you take. i just wasreviewing the study looking at five different supplements that increase insulin sensitivity.thereã­s many strategies that people can use. i donã­t want this to just be a dim and gloomconversation about should it be a disease

or not, and to have a sense of hopelessnessabout trying to reduce or reverse the obesity of epidemic.dr. pedram: i love it. i think we should just jump into this because this is where peopleare really struggling too is. i think we can agree that the old model of calorie countingand input versus output is itã­s obviously failing for a lot of people for a plenty ofreasons. letã­s tease some of the stuff out. you have people who have insulin sensitivity,insulin resistance issues. basically, theyã­re uncontrolled in their blood sugar, and thentheir adrenals jumped in. every time the adrenals jump in to try to balance out the blood sugar,you get a cortisol bump, and cortisol tells your body, ã¬hey! go ahead and store somefat for a rainy day,ã® weã­re in trouble.

you have that whole adrenal access. then youhave the stuff that we talked about in a previous show when we talked about endocrine disruptorsand toxins coming in the body, and being stored in the fat. one of the articles i think atthat point we had reviewed was this whole notion that fat cells will hold the toxinsthat our body doesnã­t know what to do with. then once we go through some detox and thebody starts letting go of these toxins by utilizing the fat, these toxins are in thebloodstream. the body doesnã­t know what to do with them again, and so it signals thethyroid to slow down, and get us to get fat. dr. sara: thatã­s right. yeah, the toxic loadgoes up as you lose weight, which is one of those terrible ironies. thatã­s also one otherimportant point. i donã­t want to interrupt

you, but very briefly. for folks who wereoverweight and obese who have more fat, they also have a higher toxic load at these environmentaldisruptors. compared to lean individuals, they have more of these environmental toxins.itã­s just another factor that throw in in terms of that vicious cycle that you weretalking about of getting fatter and fatter and fatter no matter what you do.dr. pedram: yeah, and then thereã­s also the skinny fat, right, because you get peoplewho donã­t necessarily present as obese but then you start measuring their visceral fat,and theyã­re still carrying a lot around the organs, which then itã­s the insulin resistance,and then the whole metabolic syndrome stuff starts coming up again. whatã­s the numberone reason people go to the doctorã­s office?

a lot of times itã­s fatigue. i donã­t feelwell, [inaudible 00:23:34], and so what is that; where is it coming from?also, i think that the ifm and some of these different groups that are doing some wonderfulwork and advancing medicine at this point are bringing to light some of the more complicatedarray of medical conditions that are coming from environmental and lifestyle issues rightnow that 90% of the doctors out there have no idea about. theyã­re still in that oldmodel. guys, the science is there. the science is there, and it takes the industry 10 to20 years to catch up with the science sometimes. remember, medicine is a business, but scienceis science, and so if youã­re following good science and you see the stuff there, are yougoing to wait 10 to 20 years for the medical

industry or the business to catch up and finallyhave your old guard doctor say, ã¬hey! it turns out broccoli is good for you,ã® or areyou going to spend the next 20 years getting better and thriving and living with vitalityin this world? i really encourage people who are listeningto this to really look at whatã­s out there and whatã­s some of the new data is pointingto and showing. if you got one of those bah humbug doctors, you might want to go ask arounda little bit because ... and youã­re reviewing literature all the time as am i. i got studieslighting on my desk every day. it just makes you scratch your head and say, ã¬oh my goodness!this is huge. how do people not know about this?ã®dr. sara: i know. itã­s still stunning to

me that almost every day i get pushed backfrom conventional doctors who say, ã¬adrenal dysregulation, thatã­s not an entity. youradrenals are either perfectly fine or theyã­re in failure. thereã­s no middle ground.ã® youand i both know that thatã­s not true. actually, thereã­s thousands of studies to show thatyour adrenals and their function in that in between state is really important to pay attentionto, and can be assisted with lots of problems including the obesity, and high blood sugar,and insulin resistance. dr. pedram: mark hyman calls it diabesity.really, i mean the crisis that we have in this country is really a blood sugar crisisin a lot of ways, because people we had this common nonfat thing going on for a long time.a lot of things that weã­re looking at now

is how the body processes sugar, and how thatsugar gets transformed to the fat, right? if youã­re up in the morning having your wholegrain cereal with your low fat milk and your cup of orange juice thinking youã­re doingyourself a favor, you might want to look again because thatã­s pretty much getting convertedinto triglycerides, and leading to this problem. at some point, i know you were told that thatã­sa good breakfast. dr. sara: yeah, not anymore, right? what didyou have for breakfast today pedram? dr. pedram: i had turkey vegan and a free-rangeorganic eggs, and some broccoli and some carrot sticks in the car on the way in.dr. sara: nice, nice. dr. pedram: yeah. i got some veg in there.i got some good protein source. i like eating

a good solid breakfast because i need my energyall day. iã­m not going to borrow from tomorrowã­s energy today by drinking coffee all day justto get through, right? everyday should be its own kind of profit center if you willevery day. dr. sara: okay, weã­re getting some reallygood quotes out of you today. itã­s pretty stunning. i want to add in one little piecehere. i have recently started testing my blood sugar almost every morning, and yes, i ama total mit biohacker, but even so, itã­s not expensive to do this. you can get a littlekit from the pharmacist. i was learning just last year from mark hyman when his book bloodsugar solution came out about how the range that we use as usual, the normal range thatwe use for fasting blood sugar in the morning

which has been 70 to 99 for decades is probablyoutdated. if you want to use an optimal range, itã­sreally more 70 to 86. when you have a fasting blood sugar 87 or higher, that signals someof the early faces of insulin resistance, so i love to give our listeners practicaltools that you can use, and testing your fasting blood sugar might be one of those, or eventake a look at the fasting blood sugar that your conventional doctor has tested for you.usually, theyã­re willing to do that one. see what your score is. if your score is 99,thatã­s not good; thatã­s not normal. we need to do something about it.dr. pedram: yeah, i couldnã­t agree more. i mean, just because i mean what is it, 120s?if you have a fasting blood glucose of 127

three times in a row or something, then allof a sudden you are diabetic, right? what if youã­re a 125, does that suddenly makeyou not diabetic, or does that make you on the road to diabetes and something that reallyneeds to be looked at? that leads us back to this obesity as a diagnosable illness typeof thing. at what point is that a problem? well, itã­sa problem when itã­s a problem on a functional level, when your body systems start to breakdown.theyã­re not working correctly, and youã­re not processing sugar and youã­re storing itas fat that you donã­t need. do you wait until you have 30 more pounds of that fat you donã­tneed to call it a problem, or do we ã– do you sort out the problem when the body systemsare yelling and screaming saying, ã¬hey, i

have an issue here,ã® so that you can course-correctalong the way. if youã­re fasting blood sugarã­s alreadycoming up, if you are already hovering high in the hundreds but not quite at 127, thatis a functional blood sugar issue, as far as iã­m concerned, period. that needs to belooked at because itã­s going to mess with your hormones. itã­s going to mess with youradrenals. itã­s going to mess with your mood. iã­ll tell you, itã­s going to mess with yourmarriage. i canã­t tell you how many hypoglycemics marriages iã­ve saved just by fixing bloodsugar issues with people, because people get cranky man. it is not pretty.dr. sara: it is not pretty. iã­m telling you a coupleã­s therapy is not the answer in thatsituation. it can be as simple as getting

some protein and getting the right vegetables.i totally agree with that. dr. pedram: yeah, and you could talk it outall you want. if i go too long without eating a, iã­ll eat this desk. i donã­t care whatit is. i was just on a consult with a patient this morning actually about this. she missismeals all the time. then someone brings in donuts or cookies or what have you into theoffice, and once youã­re already hungry that youã­re already in survival mode, the brainis saying, ã¬look on me. go get me some sugar, and i donã­t care,ã® so youã­re not in yourfrontal lobe. youã­re not in your cognitive rational thinking parts of your brain to say,ã¬oh! that might not be good for me.ã® you just grab and say, ã¬yum, sugar,ã® right?itã­s pretty predictable guys. i can predict

every single day right around noon, iã­m goingto be hungry, right? it always shocks me when people are like, ã¬oh my god! iã­m so hungry.ã®well, itã­s lunch time; what do you expect? we can really look at predicting that stuff.yeah, youã­re a popular gal over there doc. dr. sara: yeah, sorry about that.dr. pedram: no, itã­sã­s all right. the problem is when the phones arenã­t ringing, right?we know youã­re relevant. dr. sara: i think itã­s the plumber.dr. pedram: long story short guys, have snacks around. i mean, we canã­t get into the veryspecifics on this show right now in this format, but we can drill into it later. i was thinkingof maybe having mark hyman, maybe johnny bonn, maybe getting some of our colleagues and friendson a show with us in this near future to talk

about this stuff, and taking questions frompeople too to be able to hash out some of these things. long story short, have healthysnacks around, so youã­re not surprised when youã­re hungry. if you are already hungryand itã­s too late kind of thing, just nosh here and there a little bit. then you donã­tgo to these big valleys where there all of a sudden you got to eat a double cheese burgerbecause youã­re starving. dr. sara: really good point, and i was justlooking this morning at mark hymanã­s list of ã– on his quiz where he is asking peoplewhether they might be insulin resistant or not. you just raised a few of them, but ithink it might be worthwhile just to mention some of them. one is getting irritable orcranky if you go more than two to three hours

without a meal. thatã­s a sign that your bloodsugar is swinging wildly too high and then too low.also, if you feel really calm after eating, like if you eat, and then you feel reallycalm, that can be a sign of these blood sugar swings that are happening, having increasedthirsts. there is a long list on his website. heã­s got many different factors that he askspeople about, but also that patient you were describing who skips a meal and then hearsjungle drums unless she starts eating donuts, thatã­s a really common one, not being ableto stop when she started eating carbohydrates. thereã­s a long list of symptoms that we cantalk about. i also wanted to say for our listeners. ifyou have questions for us, put them in the

comments section. we want to hear your questions.suggest future topics. we really want to hear from you.dr. pedram: yeah absolutely. weã­re doing this for you guys. we hope this was usefuland relevant. if so, share it with your friends, and get it out there. let us know what youwant to hear. let us know who youã­d like on the show, and weã­ll get them for you.we got a lot of friends in high places, and weã­ll bring these wonderful people to theparty. the whole point is to stoke a dialogue. itã­snot about saying black or white; obesity is disease or not disease. itã­s the why, andgray is where all the magic happens. for us to delve into the why is really where i thinkwe can fix a lot of these things by educating

people to learn how to help themselves.doc, i want to thank you very much for your time.dr. sara: we got so many good quotes out of you today pedram.dr. pedram: excellent! dr. sara: yeah, my pleasure. iã­m going tobe careful not to borrow it from tomorrow today. iã­m going to stay within my profitcenter today. thank you for that one. dr. pedram: itã­s all yours.dr. sara: thank you. dr. pedram: all right, weã­ll see you againnext week. dr. sara: okay, bye everybody.dr. pedram: bye everybody.