Eva Sheie (00:03):
The purpose of this podcast is simple. We want you to get to know your doctor before meeting them in person because you're making a life-changing decision and time is scarce. The more you can learn about who your doctor is before you meet them, the better that first meeting will be. There is no substitute for an in-person appointment, but we hope this comes close. I'm your host, Eva Sheie, and you're listening to Meet the Doctor. We're back on Meet the Doctor. My name's Eva Sheie and my guest today is Daniel Rosen and he's a double board certified in bariatric surgery and obesity medicine. He's super famous on TikTok. I just watched his most watched TikTok at 2.4 million views and pretty excited to have him here today. Welcome to the show.

Dr. Rosen (00:52):
Thanks Eva. I'm so excited to be here.

Eva Sheie (00:55):
Where are you actually in the world?

Dr. Rosen (00:57):
I'm in New York City, center of it all. Big Apple.

Eva Sheie (01:02):
Are you the only obesity medicine specialist on your block?

Dr. Rosen (01:06):
It's just me and a bunch of med spas and chain injector sites. So in terms of a doctor who's specialized in obesity for over 15 years, who really understands the journey of patients who have lived in a body that they feel trapped in and navigating them to a 50 pound loss, a 100 pound loss, I feel like I'm the only guy on my block. Yeah.

Eva Sheie (01:33):
How did you do that 15 years ago? That was a pretty different process than it is now.

Dr. Rosen (01:38):
Absolutely. One of the things that drew me to weight loss surgery was the fact that it's not just technically interesting and challenging surgery, but you get this amazing opportunity to meet people and watch them as their body changes and as their life changes over a prolonged period of time, both before surgery and after surgery. So that's something that's very special that you don't see in a lot of other surgical specialties.

Eva Sheie (02:09):
There's a lot of transformations, but I think few as powerful as this one where our patient says, I got my life back. You gave me my life back.

Dr. Rosen (02:19):
Yeah, it's amazing. It's incredible. I really feel honored and blessed to be able to work with patients and help them achieve these life changing situations and really improve their health and prolong their life.

Eva Sheie (02:32):
You were a general surgeon before, right? You say you were doing all kinds of stuff?

Dr. Rosen (02:37):
I was a bariatric surgeon also doing a lot of hernias. I do a lot of minimally invasive hernias. Those are my two main surgical specialties.

Eva Sheie (02:45):
And were you in a hospital? Where were you doing that?

Dr. Rosen (02:48):
Yeah, for a time after my training, I had the opportunity to train in a very prestigious place, Columbia University and Cornell Medical Center for my fellowship. And after I went into practice, I was hired initially to build a bariatric program in one of the New York City hospitals and I got a lot of opportunity to do tremendous volume and help people. But for me, I really enjoyed creating my own thing and building my own brand and my own practice. When the opportunity to go into private practice presented itself, I really grabbed the bull by the horn and have been able to build a very successful practice on the upper east side, right amongst these giant institutions.

Eva Sheie (03:39):
And so were you just doing bariatric surgery then when you kind of hung out your own shingle?

Dr. Rosen (03:44):
Bariatric surgery and hernia surgery? Yeah, and what was so amazing was the emergence of these GLP one medications, which are all the rage right now, like Ozempic and Mounjaro, and realizing early on that there was a tremendous use for these medications for patients who have had weight loss surgery and are stuck or are regaining, but also for people who might want to lose weight in preparation for weight loss surgery and people who want to lose weight instead of weight loss surgery. And it's really grown in the last couple of years.

Eva Sheie (04:22):
When did you start seeing them come along? When did they hit your radar?

Dr. Rosen (04:26):
It really started I would say at the tail end of 2022 and exploded in the first half of 2023.

Eva Sheie (04:39):
You know what I've been wondering is they say, everyone says these have been around for a long, long, long time, but no one really says, I had patients on it for weight loss 10 years ago, so they were using it for diabetes. Weren't you seeing people with diabetes having side success losing weight when they were on it or were they not using it at the same doses?

Dr. Rosen (05:03):
Well, first of all, medicine can be so regimented and siloed that someone who is treating a patient for their diabetes and seeing weight loss may be focused on the diabetes number and just happy to have that weight loss. But if a non-diabetic patient walks in, they wouldn't think, oh, I'm going to put them on this medication. They're seeing it really through a diabetes lens. And there wasn't that extension of use to a non-diabetic obese population in the medical practitioners, the endocrinologists who were using it because it wasn't indicated and it would be an off-label use until Wegovy became approved. And that was sometime in late 2022.

Eva Sheie (05:50):
I think we've all heard the commercial, the Ozempic commercial. That goes way, way back.

Dr. Rosen (05:56):
Way back. And they would say things like, you can expect modest weight loss five to 10 pounds.

Eva Sheie (06:02):
Yeah, they did say that.

Dr. Rosen (06:04):
And that's because a diabetic population doesn't lose weight as robustly on these medications than non-diabetic people. So the effect of obesity mitigation was sort of muted for the population that was getting the medication.

Eva Sheie (06:22):
Do you have a sense now that we've got a couple years of data and you've been watching people with your own eyes for who does respond the best or is there a pattern that you're seeing there?

Dr. Rosen (06:33):
It's really hard to say because everyone is so individualized in medicine. I can tell you that there are people that respond very sensitively to these medications, lose a lot of weight with very little of it and can be very successful. And then there are people who are more resistant to this medication and don't have a tremendous amount of weight loss and end up being on very high doses to achieve relatively small weight losses compared to those other people who are so sensitive to it. I don't think they've picked out everything to determine who it works for best and who it doesn't. But we do know that diabetics tend to lose less weight than non-diabetics.

Eva Sheie (07:16):
I think Sharon Osborne, after she got a bunch of media attention, I saw that she said they thought she was a hyper responder, that she responded too. Well, it's possible even that after she was off it, she kept losing and she

Dr. Rosen (07:30):
She had a gastric bypass, Sharon Osborne. So you have to understand she's having GLP one alterations that are happening in her body for years from her gastric bypass. The reason they came up with these medications or determined that these medications are so powerful for diabetes management is because of gastric bypass patients that they would check their bloods and they saw that their blood sugars were normal a day after surgery or two days after surgery even before they lost any weight. So they were like, okay, it's not strictly that their heavy and they got gastric bypass, they lose the weight, their diabetes goes away. It's like, no, their diabetes goes away right away. What is that about? And so then they used to look at their blood and they found that there were super high levels of these GI hormones called GLP one, and then they created drugs to mimic that so that you can have that impact of high GLP one and its impact on fullness and blood sugar regulation and all those things without having to do a surgery like a gastric bypass to achieve that end result. So they sort of reverse engineered it and then created a medication to mimic a gastric bypass, and that's one of the ways that GLP ones came into existence.

Eva Sheie (08:46):
What popped in my head when he said that was that with my second child, I had gestational diabetes and I remember being just stunned that as soon as the baby comes out, it's gone within 24 hours, it's not there anymore.

Dr. Rosen (09:00):
Yeah, the body goes through a lot of hormonal changes and all of these organ systems interact very intimately. So when something changes, it can have a profound impact on a disease state and the body's whole homeostasis.

Eva Sheie (09:16):
So another thing I've been wondering about is, I mean every single day I am reading and reading about these things, but that people were taking metformin for weight loss also before these kind of hit the market or before these got really popular. And what did you see happening with that? Actually, I believe that that was a story about New York City and that everyone in New York City was taking metformin.

Dr. Rosen (09:40):
Yeah, metformin would be like your entry level, intro to obesity medications. It's fairly ineffective for most people and it has a pretty high side effect profile considering how little weight reliably it will deliver. That's my experience with metformin. I don't waste a lot of time prescribing it. We have so many better tools in our tool belt.

Eva Sheie (10:06):
Yeah. So how is your approach different today with the medications? Obviously obesity surgeons, bariatric surgeons had surgery in their toolbox and now here's this tool. And a lot of you, I've got to say, having talked to quite a few now are either very anti-medication or secretly giving the medication out and not telling anyone or combining the two things and approaching it in a more comprehensive way.

Dr. Rosen (10:36):
I'm all for that last philosophy, especially working with patients to find out what their goals are. A patient might want to lose a certain amount of weight but just may not be ready for surgery, and now we have something that actually might get them to their goal weight without cutting them open and rewiring their GI tract. So I have to as a responsible clinician, work with a patient from where they're at and for a certain patient surgery might be the right answer, minute one, and for another patient they would never consider surgery. And for other people they have to find things out for themselves and I can guide them on that journey knowing what I know and helping them choose between those options. I know the pros and cons of each one.

Eva Sheie (11:21):
Have you seen anything go wrong with the meds?

Dr. Rosen (11:25):
I have seen a patient who developed pancreatitis and I've seen patients misdose themselves using compound medications. That's always a fun one when your first dose by accident starts out as the highest dose you can possibly deliver. But that's the amazing thing about these medications is while you may have intractable nausea and be vomiting and need to go to the emergency room and have IVs for two or three days while you get over that very rare and unfortunate situation where you've given yourself 10 times the dose you are intending of this medication, it wears off and there isn't an overdose of true medical risk that would happen with these medications. So I would say the main thing would be the typical mild constipation and nausea from time to time. I have seen one episode of pancreatitis. The side effect profile of these medications are incredibly benign, incredibly tolerable. Dr. Terry Dubrow a plastic surgeon in Beverly Hills, he likes to say it's safer than Tylenol and I think it's not far off because they both have an extremely rare serious complication side effect profile.

Eva Sheie (12:44):
I have an elderly relative right now who's been overdosing on Tylenol for many years and is now in liver failure.

Dr. Rosen (12:54):
So there's the counterpoint, it can happen. You have to be responsible to use your medication with the guidance of a doctor to prevent taking too much every day for too long when we know that problem can build up, but taken as directed under the guidance of a provider, these medications are really safe.

Eva Sheie (13:17):
It helps if you remember what you took every day too, you can't forget that you took it and then take it again and then do it again and do it again. Yeah, it's part of the problem. I'm just saying.

Dr. Rosen (13:29):
No, I totally understand. I totally understand. That's a challenge.

Eva Sheie (13:32):
So in that one case of pancreatitis, are we talking about one out of a hundred or a thousand or how many people have you seen now?

Dr. Rosen (13:40):
Well, yeah, hundreds. Hundreds. Probably closing in on 500, so that would be 0.2%.

Eva Sheie (13:50):
Yep, pretty small.

Dr. Rosen (13:51):
And there's an incidence of pancreatitis in the general population, meaning that person may have developed pancreatitis, whether he took that shot or not, we don't know. So

Eva Sheie (14:04):
I've noticed that nausea is actually when you're too hungry. That's when it happens to me anyway. If I get up in the morning and I didn't really eat much the night before, which happens all the time, and then I might have two or three cups of coffee and then I get

Dr. Rosen (14:20):
Yeah, and that's why eating something helps nausea, which is counterintuitive.

Eva Sheie (14:25):
It is. It works. You know what my go-to is?

Dr. Rosen (14:29):
What?

Eva Sheie (14:30):
A Turkey little smoky.

Dr. Rosen (14:31):
Oh, that's like a deli cold cut.

Eva Sheie (14:35):
Yeah, I mean they're just little smokies, but they're Turkey and they are almost entirely all protein, so they're like,

Dr. Rosen (14:41):
Oh, like a little sausage, a Turkey sausage. Oh, that's great. Yeah, all protein. That's great.

Eva Sheie (14:49):
Yeah, they're awesome. I highly recommend them.

Dr. Rosen (14:52):
The amazing things about these medications is how they help people who might otherwise be driven by cravings as we all are from time to time. But we find that people who suffer from obesity tend to have a louder food chatter in their head that's more distracting than someone who is not carrying that disease and the ability of these medications to quiet that food noise and help people say, I guess I should eat something. Let me have something that will be good for my body, focusing on protein and veggies to fuel myself rather than, Ooh, I want that hamburger, I want that pizza looks good. Ooh, that taco smells delicious. And being driven by their cravings helps them come into a calorie deficit and drive that weight loss.

Eva Sheie (15:42):
I'm glad you brought up food noise because this is one of those really unexpected things that comes with it, and I think on the day to day when you realize it's gone, you kind of go, wait a second, I can think about other things. And it's so freeing, and so that's one of the first things that comes up and it's so joyful because you realize that you're not all this previously occupied mind time or mind space is now free to think about other things.

Dr. Rosen (16:14):
You had no idea you were a prisoner.

Eva Sheie (16:16):
I didn't know until I wasn't.

Dr. Rosen (16:20):
Right, and you thought that that's how everyone must think, but those other people are just better at me than me at restricting, and that's a fallacy. Patients with obesity don't eat any worse typically than someone without obesity. They may have biochemical differences that makes them lack fullness after a certain amount of meal that makes them go for seconds because they don't experience the same satiety from a given amount of food, but that's not a failure of will or a lazy disposition that's biochemistry and differing levels of hunger and fullness based on the same amount of food input.

Eva Sheie (17:05):
The other really big shocking psychological thing I think that came up was after a little while I realized my number one problem to solve in my life wasn't losing weight. And it was for probably, I started when I was 10 maybe, and now I'm 47. That's a long time to make losing weight your number one problem in your life and it would kind of come and go. You have good times and not so good times, but it's never gone. And then once I realized that I could actually work on the second problem in my life, or the third one or the fourth one or the fifth one, I was so grateful.

Dr. Rosen (17:41):
And that making such huge strides in that first issue wasn't the answer to all your other problems.

Eva Sheie (17:49):
No, it turns out they're still there, but we're confronting them now. It was removing the biggest blocker in your life and now you have to adjust to what your life is like without the big blocker. It's different.

Dr. Rosen (18:03):
And for those people around you as well, because relationship dynamics change. Someone who's married to someone struggling with obesity at 280 pounds, feeling like they can't be active, feeling like they can't socialize, not wanting to leave the house feeling bad about themselves might be a very different dynamic than having your husband or wife lose 70 pounds, feel great about themselves, get attention from people outside their marriage, positive attention and being able to deal with that as the spouse of someone undergoing this transformation can be a challenge and can really put relationship dynamics and flux.

Eva Sheie (18:45):
You're raising a lot of imagery in my head of the characters on my 600 pound life.

Dr. Rosen (18:50):
Really? I don't watch it.

Eva Sheie (18:51):
Oh, you've never seen that?

Dr. Rosen (18:53):
I have seen it. I don't watch it. I find it to be exploitive. It is. I find it to be in the category of hoarders. I find my 600 pound life to be in that same category of television, of reality television that really paints obesity. By focusing just on such an extreme representation of it, it does a disservice to it as a disease that affects so many people in so many different ways, and I have problems with that, so I tend not to watch it.

Eva Sheie (19:25):
It is a really sad show. As a marketer, I recognized when it started that they were trying to do something different in order to get cases for themselves, for their practice, and they honed in on a niche that was really kind of like rubbernecking, like the rest of us can gaw and stare because right.

Dr. Rosen (19:43):
And those patients deserve treatment and it's incredibly important work that Dr. Now does out of his clinic in Texas, but it's not a part of my surgical practice. I personally, in private practice, I'm not looking to take on cases that are such high risk because you really need to have a comprehensive center really built around you to take care of patients like that from the nuts to the bolts from the first floor to the top.

Eva Sheie (20:11):
So is there an upper limit to the kind of patient that you'll take?

Dr. Rosen (20:14):
I try and keep my surgeries to ideally under 450. Sometimes I'll go into the four eighties and under 500, but I will always try and get them to lose weight before surgery and now we have GLP ones to help achieve that.

Eva Sheie (20:29):
Yeah. So is it feeling easier now that you have the GLP ones to get those people in shape?

Dr. Rosen (20:34):
Oh yeah. The hardest thing to do is to get them to then still want surgery when they've lost 60, 70 pounds, they're like, why don't I stay on this? And sometimes I have to say like, okay, and a lot of them will not get close to where they want to get and then we'll have to do surgery. But for some people, they're happy with the gains they've achieved or the losses they've achieved and decide that they want to wait with surgery and see how things go from a maintenance perspective.

Eva Sheie (21:02):
I told you before I started that my number right now is 70 pounds and my daughter is 62 pounds and I cannot carry her. I try to carry her in the morning when I need her to get up. Sometimes I have to pick her up to wake her up or if I have to take her to bed, she's really heavy, but that's how much I used to carry on my person, which that's insane to me. I remember running up the stairs at church halfway, six months ago maybe when I got to the top, I went, did I just run up the stairs? What just happened? It was so weird.

Dr. Rosen (21:39):
Those non-scale victories.

Eva Sheie (21:41):
Yeah, I have a lot of them.

Dr. Rosen (21:43):
There. It's amazing.

Eva Sheie (21:45):
Where do you see it going? There's tons of controversy. Everyone wants to argue about what's happening and where we're going, and I think maybe the biggest argument is what happens when you go off of it, you're just going to gain it all back.

Dr. Rosen (22:01):
Well, we just had a study come out Epic put out a study from

Eva Sheie (22:05):
Epic, the EMR?

Dr. Rosen (22:06):
Epic, the MR, yeah, put out a study.

Eva Sheie (22:08):
I didn't realize they were studying stuff.

Dr. Rosen (22:09):
But I think they can pull data and pool data and they said that for patients who were on Ozempic for a three to six month course, so a short course and just with Ozempic, which would be semaglutide, they found that after a year 20% of the patients gained their weight back, 20% of patients lost weight from the date they stopped the medication and 60% of the patients had maintained some degree of their weight loss. And some people will jump on that and say, see a fifth of people who take it gain all their weight back. I would on those people go even further and say the three fifths of people who hadn't gained all their weight back, a lot of them over time will gain it all back because that's what happens when you stop a medication to treat a chronic disease. If you have high blood pressure and you're on high blood pressure medication, it makes your blood pressure go down and then when you get off the disease, the physiologic mechanisms that gave you high blood pressure are still part of your body and a chronic disease that you carry and your blood pressure as those medications leave, your system comes back up.

(23:23):
So even if you make lifestyle changes, typically they'd have to be extremely drastic, like working out an hour a day, six times a week and having a very restrictive diet in order to maintain weight loss off these medications and combat the return of hunger that you're going to see as the levels drop in your system.

Eva Sheie (23:47):
So what's the answer?

Dr. Rosen (23:50):
The answer from me is understanding what a patient's motivations are. Some patients may want to lose 50 pounds and then see how they view off of it and follow up is key. So if that patient finds themselves doing their best, putting in a top effort from an exercise and clean eating perspective and they've still gained five pounds, then you need to have a conversation with them. Maybe it's time to go back on it. Perhaps you have to be on a three week course of GLP one medications to take those five pounds off and then you'll be able to be off it for three weeks on it. For one, maybe you need to be on a mid-level dose all the time. Maybe that dose that you are on to get to your goal, you can take every other week or half of it. Maintenance looks different for everyone.

(24:39):
Some people will be able to be off these medications and to some degree keep a significant portion of their weight loss off, but I suspect that will be the minority and especially if you've lost a lot of weight with the medication, you could expect to be on it for a long time. What will be interesting will be to see as each new medication gets released by the drug companies, does it push you further? Are you able to use less of it? Will there be a medication you'll have to take once a month and then all of a sudden the hangups of being on a medication become less over time and we have more data in terms of how to manage this for years and years and decades.

Eva Sheie (25:19):
So the question is really why can't we just stay on it? Why does everybody say we have to go off of it?

Dr. Rosen (25:25):
I don't say that. Who says you have to go off of it? The drug companies certainly aren't interested in you going off of it.

Eva Sheie (25:30):
No, they're not. They're not.

Dr. Rosen (25:33):
And I think that they doctors, we default to a hope that our patients will be on as few medications as they need to be while still optimizing their health. So it's an evolution and because we don't have data that it's safe for 10 years because this medication has been out 10 years now. There have been GLP ones that have been out for 10 years that people have been on though not let's say tirzepatide semaglutide. It's getting towards that 10 years and they have been safe, but there's just a natural reticence and desire to protect patients from the unknown and a patient's innate desire to not put things from outside their body into their body and to live as much as they can without medication or interventions that drives that trend to get off the medication or feel like you should be able to get off the medication. I have a much more realistic view of it for most of my patients.

Eva Sheie (26:37):
What's your thoughts on people who only have five or 10 or 20 pounds to lose? Is it okay for people like that to use it too?

Dr. Rosen (26:46):
Absolutely. Why can't someone use this medication to lose five pounds? A patient's allowed to have a breast implant. Are breast implants, cheating? Is getting a tutor for your SATs cheating? Is taking an airplane to LA when you can walk cheating?

Eva Sheie (27:02):
You could ride a horse.

Dr. Rosen (27:02):
You could ride a horse. That's right. And the person who rides a horse should be lauded and congratulated, but I don't think, I would think they are the most efficient traveler cross country. I think there is technology available to that person that they might want to take advantage of if their goal is to get to the other side of the country as easily as possible or as comfortably as possible or with the greatest chance of success.

Eva Sheie (27:33):
How did we end up here?

Dr. Rosen (27:35):
As a people, like you and me biologically, as a country?

Eva Sheie (27:41):
As a country.

Dr. Rosen (27:43):
How did we end up here? It's a great question. That's a really great question. It's so complex. It's so multifactorial. You have the farming policies from the sixties and seventies, fence post defense post. You had to plant your fields. The government subsidized you. Anything you couldn't sell, the government would buy at a good price. So farmers were incentivized to plant as much as they could and there were surpluses. So you had surpluses in corn and soybeans, which are the two main cash crops in the US and then you have an entire industrialization and food industry built around processing all of this excess farm products into soybean oil and corn syrup. Then you have the development of food scientists and creation of products that utilize all of these different manufactured calories basically. So you have the American diet being so changed by that policy. Then you have the expansion of the road system and the development of all of these fast food restaurants, which are fast because they can churn it out for someone who's on their way somewhere else.

(28:53):
You don't have to sit for two hours to have this long meal. And so it really took advantage of the car culture in America from the fifties and the sixties. So you have a proliferation of fast food. You have this notion of America and everything's bigger here, so portion sizes are out of control compared to Europe. You have sedentary lifestyle that's come into effect with computers and our workplace shift from outdoor manual labor jobs into service jobs that burn no calories over the course of the day. And our biology, our biology isn't made for the world we've built for ourselves.

Eva Sheie (29:30):
I once looked back on, when I started working from home in 2007 was when I started sitting all day and I calculated that if I gained, it was less than one pound a month for that entire time that that was how it got where it got. It wasn't like I just all of a sudden ate more. I just sat more.

Dr. Rosen (29:54):
Right, right. And your body had access to food. Food is everywhere, in every cupboard, in every cabinet being inundating us by advertising constantly. Those advertisements are calculated to elicit the strongest possible visceral reaction from a craving perspective in us, and we're being engineered into consumption that we wouldn't normally pursue. But these medications offer a glimmer of hope and a window into a new future. It is going to revolutionize everything. You see food companies changing their projections, looking at decreases in consumption for the people who are on these medications. Walmart has looked at people who come and pick up their Ozempic, Wegovey, Mounjaro or Zepbound prescriptions and how much do they buy in the grocery section of the supermarket versus people picking up other medications and how much do they buy and seeing a decrease in the number of calories purchased for the GLP one using consumers.

Eva Sheie (31:09):
When we started this recording, I had a snack. It was two apricots, two dried apricots.

Dr. Rosen (31:14):
You're stuffed.

Eva Sheie (31:15):
And that was a treat.

Dr. Rosen (31:18):
To wake up, start your day and it be two o'clock and you're not thinking about food is an entirely new existence for a lot of people. And it's bringing a lot of attention to the disease of obesity and a reframing for people about the disease of obesity. That's been a long time coming. We still deal with a lot of obesity bias. We see obesity bias in the prior authorization process for patients who could be or should be on this medications and insurances aren't approving it, the fact that they have to jump through so many hoops in order to get this medication, but if they have high cholesterol, I can get them a statin just by nature of the numbers.

Eva Sheie (32:03):
Yeah. And it's pretty inexpensive too.

Dr. Rosen (32:06):
What's inexpensive?

Eva Sheie (32:07):
Statins.

Dr. Rosen (32:08):
Statins are, well, there's a price difference for sure, but I don't think insurance companies should be rationing care based on the cost. If they don't like the cost, they can talk to the drug companies, but they shouldn't be saying, well, no, you have to be on this ineffective medication for six months before we'll give you the effective one because the ineffective one is much cheaper.

Eva Sheie (32:28):
In terms of shortages. Okay, so let's say in New York City you can get a prescription or it's one of your patients and you're happy to give them the right prescription. Are there shortages? How are you dealing with those?

Dr. Rosen (32:41):
Absolutely. Patients will work so hard to get a prescription. Then the patient and the doctor will work so hard to get that prescription approved through a prior authorization. The insurance company finally approves it and then the pharmacy is unable to obtain the medication because of a shortage. It's quite frustrating. For a lot of my patients, we utilize compound medications to bridge the gap because compound medications are accessible. That's what a compound pharmacy is supposed to do in this situation. They're supposed to bridge the shortfall of medications that cannot be produced fast enough to meet demand by the diseased population. So when a medication is on the FDA shortage list, compound pharmacies are legally allowed to make that medication without violating any patents, and therefore provide needed medication for those patients. If there wasn't a market compound, pharmacies wouldn't make it. So there's clearly a demonstrated need and until the drug companies are able to deal with their supply issues, it's critical for treating patients who are affected by access to the medication because of production shortages. To have this avenue to obtain what they need.

Eva Sheie (34:01):
Even when you're covered by insurance, is the cost of compounding sometimes less than what the insurance will cover?

Dr. Rosen (34:08):
Sometimes it's a little less, sometimes it's a wash, sometimes it's a little more. I've had patients who prefer to have the compound medication, even if it's a little more for the peace of mind, knowing that they can get it when they need it and reliably and predictably for a lot of people, it's also significantly cheaper.

Eva Sheie (34:33):
I've learned so much just from talking to you today, and I already knew kind of a lot, but I don't get the chance to talk to an expert very often, at least not on this topic. So I'm very glad that you agreed to come on the show.

Dr. Rosen (34:47):
I'm happy to come on and it's something I'm passionate about because I've seen how difficult it can be for patients with obesity, especially in our society, which treats them as second class citizens and the ability for someone to just blossom into the best version of themselves as they are given the tools to control and combat this disease. It's something I feel really blessed to be a part of as a healthcare provider and an advocate for my patients in that way.

Eva Sheie (35:19):
My next question is really important. You're Lisa Marie Presley TikTok as 2.4 million views. How are you going to top that?

Dr. Rosen (35:29):
Yeah, I feel really sad about that video because its success in some ways is built on such a tragic story, and what was important for me in that video was to get out to as many people as possible who have had intestinal bypass operations like Lisa Marie Presley had so that they could be aware of the subtle symptoms early on that can be going on for many years before something becomes drastic and leads to a potentially life-threatening situation. I also wanted to address some of the quick pile on and demonization that she was receiving after her death as a drug user or using GLP ones when there wasn't any proof of either and the way that was quickly picked up by the media to demonize GLP one use when that was all the trend. And in some ways it still is. To top it, I'm just going to try and educate people, be entertaining if possible while doing it and letting the TikTok algorithm take things and do it as it may.

Eva Sheie (36:40):
Yeah, you hit the jackpot. It was very funny. I particularly enjoyed the crepe paper demonstration of how long her intestine was.

Dr. Rosen (36:51):
I recently took, operated on a patient who had intestines of that length. It is a dramatic level of intestinal length. Most people do not have 900 centimeters of intestine. I just had a patient who had about 980 centimeters of intestines, so that's quite long.

Eva Sheie (37:08):
Is that just like a genetic freak anomaly thing?

Dr. Rosen (37:12):
Everyone's different. We all come in all different shapes and sizes and intestinal lengths, and there is a correlation between longer intestines and obesity because you have that much more length to absorb every single calorie.

Eva Sheie (37:29):
Yeah, that makes sense. So if you make it shorter, you would absorb less calories?

Dr. Rosen (37:35):
Not exactly.

Eva Sheie (37:36):
Sort of.

Dr. Rosen (37:37):
If you bypass a portion of it, you can get the food further downstream to stimulate the GLP one release that happens at the very end of the intestines. We try not to have malabsorption where you eat a ton and then you only can absorb so much and the rest is pooped out, for lack of a better word, because that can lead to a lot of diarrhea and it's not really healthy. So we try not to think of the intestinal bypass operations as malabsorption operations, but rather hind gut activation operations, and the activation is GLP one release.

Eva Sheie (38:18):
Yeah, it's all related. What do you like to do when you're not at work? You said do you have an 8-year-old?

Dr. Rosen (38:25):
I have four girls. I'm a real girl, dad. I like to spend time with my kids. I like to snowboard. I like to go bike riding. I like to sleep when I have that luxury. It's a great luxury and I'm just really a family guy when I'm not working.

Eva Sheie (38:46):
Girls are the best.

Dr. Rosen (38:48):
The best. So blessed. I have girls from two to 17 every five years I have a girl.

Eva Sheie (38:55):
That's quite a spread.

Dr. Rosen (38:57):
I want to have a kid in diapers forever. Some kid, one kid in diapers. I get to have every stage manifested at one time. They love me, they hate me. One's going off to college, the other's being potty trained. I get to have every joy all the time.

Eva Sheie (39:17):
That's one way to put it all in perspective, I think.

Dr. Rosen (39:20):
Keeps you young.

Eva Sheie (39:21):
Yeah, it sure does. If someone's listening and they want to find you online or on Instagram or TikTok, where should they go?

Dr. Rosen (39:30):
Dr. Daniel Rosen DR, which are also my initials, but also stand for Doctor. And then Daniel Rosen is my handle for Instagram and TikTok. We're also expanding our YouTube page coming up, which will probably be Dr. Daniel Rosen as well. So keep on the lookout for that.

Eva Sheie (39:48):
Thank you for joining us today. I'll make sure we put all those links in the show notes. I'm so glad to have met you.

Dr. Rosen (39:53):
Thank you, Eva. If you ever have any questions, feel free to reach out. I'm excited to see what kind of content this was able to generate and continuing the conversation.

Eva Sheie (40:04):
Me too.

Dr. Rosen (40:05):
Alright, take care everybody.

Eva Sheie (40:10):
If you are considering making an appointment or are on your way to meet this doctor, be sure to let them know you heard them on the Meet the Doctor podcast. Check the show notes for links including the doctor's website and Instagram to learn more. Are you a doctor or do you know a doctor who'd like to be on the Meet the Doctor podcast? Book your free recording session at Meet the Doctor podcast.com. Meet the Doctor is Made with Love in Austin, Texas and is a production of The Axis, T-H-E-A-X-I-S.io.