A great conversation with Dr. Chris Keroack, MD. Dr. Keroack shifted from a conventional weight loss doctor to functional medicine. We discuss some of the best medicines for weight loss and what type of person might be a “super responder.” We also cover new weight loss devices and surgeries, weighing the pros and the cons. We wrap up with how Dr. Keroack is currently integrating functional and conventional medicine.
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Dr. Chris Keroack Bio…..2:14
Likes and Dislikes of Conventional Medicine…..4:44
Weight Loss Surgery…..9:17
Conventional Weight Loss Medications…..15:42
Other Medically Based Weight Loss Interventions…..32:53
Functional Approach to Weight Loss…..38:13
- Changing Directions
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Dr. Michael Ruscio: Hey, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. I’m here with Dr. Chris Keroack, a good friend of mine. And gosh, so many things I want to discuss with this gentleman. But I guess, short story, of which we’ll definitely elaborate, Dr. Keroack, Chris, is a classically trained medical doctor who has, over the past several years transferred into functional medicine.
And he was actually a guy—when I was just a snot-nosed college student, didn’t know anything, he was a guy I shadowed several times and kind of took me under his wing and showed me what it would be like to be a part of the conventional medicine system. And I learned a lot from that. And we’ve stayed in touch ever since over now what is—maybe, gosh, a little over 15 years.
Dr. Chris Keroack: I think that’s right.
DrCK: Honestly, I think it was a lot of fun for me too because what you brought to the picture is really this aspect of healthy nutrition and activity, which in classically trained medicine we get very little of. I went to Tufts University. And we brag about the fact that we have four hours of nutrition and, quite frankly, no activity. So you brought something to my component that was really helpful. So it’s been a truly symbiotic relationship between the two of us.
DrMR: Yeah, it’s been a great relationship, especially as you’ve been getting more into functional medicine. We have all those common points to connect on.
Dr. Chris Keroack Bio
So I guess I’ve got to start at—tell people a little bit about your background and what you’ve been doing and what you’re doing now.
DrCK: So I’m an individual who trained in biochemistry in college. And I’m from a medical family. And I swore I wouldn’t go into medicine. So I had to try to figure out how to make a biochemistry degree work for me. And then I took a little stint and studied exercise physiology and wanted to learn a little bit more about the health and fitness background with biochemistry.
But I found I really couldn’t do everything I wanted to do with an exercise physiology background unless I pursued a PhD. And I found that—I hate to say it, but I found that the pathway to medical school was a shorter pathway than it was to get the PhD in exercise physiology.
So I went to medical school and found my way into internal medicine because I really enjoy the aspects of how the body works from the inside. And then medicine unfortunately started growing into this field of disease state and medicines to match disease—the classic “get a pill for your ill” kind of story. And I found it very, very frustrating.
So I went back into my exercise physiology and thought, “Well, what can we do to really get people healthy, not just not make them sick?” And the leading problem at the time, and still really the leading problem today, was obesity and weight management.
So I kind of stumbled into weight management, learned a lot of the classic aspects of weight management but was still stuck in this Western medicine philosophy of realistically counting calories and using medicine to potentially using surgery to help people lose weight.
And then it just so happened that we were using a fasting dietary plan that we didn’t like. And we got rid of it. And a supplement company came in and started teaching us about functional medicine. And they said, “Oh, you need to go to these seminars and learn.” And then I was hooked. It was everything I really wanted to learn.
And so now what I’m doing is weight related but much more wellness related in terms of the practical aspects of functional medicine like nutrition, metabolism, inflammation, detoxification, oxidation pathways, and ultimately very much what you do. I listen to people’s stories. I get to the foundational issues. And I help them get better.
Likes and Dislikes of Conventional Medicine
DrMR: I love it. Love it. Now, I’d love to get your perspective on what you liked from your conventional training in weight management medicine, because I think it’s very commonplace that in the functional medicine community, we badmouth medicine.
But I think a lot of the audience has heard me give credit where credit is due because there is a lot of good that’s also come out of conventional medicine. Some of these things are used more than others. But I think there’s always good in something. It’s just trying to not throw the baby out with the bathwater, so to speak.
DrCK: Very much.
DrMR: So can you give maybe a “here are the things that I thought really made a lot of sense, really worked. Here are the things that I think really don’t work or I wasn’t a big fan of.”
DrCK: The things I loved about traditional medicine and Western medicine were the ideas of the biochemistry and the cellular and molecular biology of how things worked, because that was what I studied in college.
And so we really, I think, in Western medicine, try to get to some understanding about why pathways or why disease states happen. And I think we have a genuine desire to block or alter these pathways in order for people to get better.
The thing I dislike about Western and traditional style medicine is that all of our training is really in an acute care situation. And so we go to medical school, but most of our training after medical school is in a hospital where people are near death.
And really, our goal is to just sort of stabilize them and get them out of the hospital, back into the community. And about 95% of our training is in the hospital. And so we do a lot of acute care and critical situations in the hospital.
But when we start our practice, about 95% of our work is in an office. And so now we have individuals with chronic conditions and chronic disease states, but we have all acute training. So we think that we can manage chronic diseases with the same kind of acute training. And that’s really where we fall short, that there isn’t really this just one answer or one antibiotic or one pill or one pathway when it comes to chronic illness.
So again, I really do like the science behind traditional medicine and the attempts to understand the pathways. I don’t like the fact that we don’t go far enough back into the upstream problems, but we work through chronic illnesses with acute methods. And we don’t do well.
DrMR: Sure. Yeah, and I think that’s definitely one of the most prominent criticisms of conventional medicine, which is we’re using a predominantly acute care style intervention. And we’re trying to use that to treat an entire population, including people that don’t have acute care problems. They have chronic degenerative problems. And so that’s where we get a mismatch between the model and the population in a lot of respects.
DrCK: Sure. And you need to have that acute care. I had a friend of mine who was—he and his wife are doing functional medicine. And he calls me and says that his wife just doesn’t feel really well. And she can’t get off the couch. And I just said, “Look”—he’s a good friend of mine. I said, “I’m going to have you play doctor for a little bit.”
And so I had him go over. I said, “I need you to poke your wife in some of these corners of her belly and tell me what happens.” And pushes her in the right lower quadrant and says, “Oh, that hurts a lot.” And I said, “When you let you go, does it hurt?” And he said, “Yeah, it hurts more when I let go.”
And I said, “You need to take her to the hospital now.” And it turned out that she had appendicitis. So there’s not really a great functional medicine approach once you have appendicitis. You sort of have to go to the hospital and have surgery. So that’s where Western medicine steps in.
DrMR: Oh, absolutely. Clearly, the Western medicine model is the best for acute care without a doubt.
DrMR: It’s just trying to find that balance between the two.
DrCK: So now I get to have the best of both worlds. It’s pretty cool. I get to sort of dance in the Western medicine and the Eastern medicine worlds. And I’ve got to say, it is a lot of fun.
DrMR: It is.
DrMR: It is a lot of fun. Now, reflecting on your time when you were doing more classical weight management medicine, I know you were doing a fasting program, the low-calorie model, I think, is pushed a lot.
DrMR: But there are also surgical consults. I know you were involved heavily with surgical consults. And from what I’ve read, for people that are very overweight or obese and have not responded to other therapies, some of those gastric—gastric bands, for example, or bypass—they show a high level of efficacy. But there is also the side effect profile to guard against.
Weight Loss Surgery
So what are your thoughts with some of these more classical medicine interventions for people that—what ones do you think make the most sense?—I guess is what I’m asking.
DrCK: So I guess—let me see if I understand. So when I think of the classical methods, we have the food intervention, which for the most part in Western medicine is calories. But you and I, I think, we like talking about macronutrients and micronutrients and timing and all the other balance components, which are really fun. And then we’ll get into the functional components of elimination and detoxification. But food is first.
But we then shift into medicines to block certain pathways. And currently, there are about five different medicines that change different pathways of obesity. And we can talk a little bit about those. But you are talking about surgical interventions, which I think you’ll like because this is really where your strengths really lie in terms of the gastrointestinal tract.
DrCK: So in a surgical intervention, usually what we’re trying to do is manipulate or alter the digestive pathways of the gastrointestinal tract by either making it smaller or making it absorb things less efficiently.
DrCK: And what I used to teach—and I guess in a way I still do—is that if other chronic diseases will beat you or will catch up to you and kill you within the next two years, then that’s actually somewhat of an acute situation.
And you need to do something radical in that case, in which case we will absolutely rearrange your gastrointestinal tract. We will take out parts of your stomach. We will cut parts of your stomach and create maldigestion and malabsorption to prevent other fatal illnesses.
But the problem is—and you see this, I’m sure, in your patient population—somewhere around two years to three years, once you reorganize and restructure the digestive system, there are a lot of other feedback systems that start kicking in that create other problems.
And then when you get maldigestion and malabsorptions of macronutrients and micronutrients, that creates other problems. So I find that there’s a good acute resolution to obesity in the surgical world. But I don’t really think there’s a good long-term solution when it comes to the surgical world.
DrMR: Now, do you know what percentage of patients is able to maintain a majority of the weight loss after gastric bypass or gastric band? Is it a significant success with this procedure? Or what does that look like?
DrCK: So then it depends on how you define success.
DrMR: Right. Yeah.
DrCK: So let’s do classically defined Western medicine studies. So when we look at the classic studies, usually it’s around a 60% success rate. You say, “Oh my gosh, that’s outstanding!” But the classic understanding about success is a 10% weight loss over two years’ duration.
DrCK: And you say, “Well, that’s not what people want when they come in at 300 pounds and they want to get down to, say, 175.” So you say you have somebody who’s 300 pounds. If they lose 30 pounds over two years—10% weight loss—then that’s a success according to the studies. But you and I, we don’t really see that as a success. But statistically, it becomes a success.
DrMR: And we talked about this before where—
DrCK: And then the long-term studies really aren’t there. So that is to say, what happens 15 years and 16 years out? So that’s sort of difficult.
DrMR: Right. Right.
DrCK: And then there’s this—oh, I wish I could remember the statistical terminology. But it’s the last common research or reference point. And there’s an acronym for it. But basically what happens is, let’s say somebody comes in. They get their surgery. They come in for their two-week check up, their six-week check up, and their two-month check up.
And they’ve lost 15 pounds. And they never come back again. You can use their data point all the way out to the end if they never come back. And so if you have a drop off of, say, two-thirds of your population, you can still use them for the long-term study. So that messes with the statistics.
DrCK: So again, I look at it at the aspects of if you’re going to have a complication from your obesity that will kill you or be irreparable, you have to do something now. But you have to, as they say, count the cost because you will need to have a certain amount of supplementation both in your macronutrients and your micronutrients probably for the rest of your life. And that, I find, is a much harder thing to do for patients than the more practical functional approach that we talk about.
DrMR: Exactly. And last time I was home, you were nice enough to invite me to your office at the hospital to do some rotations with you. And I remember there was one of your patients that, I’m not sure if she had bypass or if she had a jejunectomy. But she was exhibiting all the signs of SIBO. And I know especially in short bowel syndrome when there has been a part of the small intestine excised, that’s been significantly correlated with small intestinal bacterial overgrowth.
DrCK: And there’s an acid—there’s usually an acid decrease in those particular components that, if my understanding is correct—you know this better than me. But as acid levels go down, I think you become at higher risk for SIBO too.
DrMR: And that’s something I very closely fact checked. And that’s been very consistently shown in the literature that long term, for example, acid-suppressing medication use has clearly been correlated with increased risk for SIBO, definitely.
DrCK: Sure. So even though I’ll sort of cut off or clamp off a certain part of the stomach, I tend to clamp off the areas of the—I want to say—you know this—it’s the gastrin cells, the lower parts of the body that I clamp off. And it will affect your ability to have acid. And then, like you say, you have these blind loops or these at least sort of one-way loops that really are a complete fertilization ground for any kind of bacteria to sort of grow unchecked.
DrMR: Right. Right. Exactly. So surgery—last ditch resort for someone who’s in dire straits, as you’re saying, weighing cost.
Conventional Weight Loss Medications
DrCK: And I tell people that it is not the easy way out. It’s actually the hard way out.
DrMR: Yeah. Yep, yep, yep. Because definitely gastrointestinal side effects have been reported there, as we’ve been talking about. So what about the medications? People have maybe heard about fen-phen or HCG or—I’m not sure. Well, of course, HCG, I don’t believe, is endorsed by conventional medicine—
DrCK: No, the FDA kind of put that down. And it’s a creative idea. But honestly, when you starve people, it’s—I tell people, “I can put you in a Turkish prison and give you bread and water. You’ll lose weight. There’s no mystery there.”
DrCK: When I give people 500 calories, that’s a pretty easy way to do things. But there are a fair amount of interesting ones that are out at this point in time. And they really work on these receptor pathways that are based, interestingly enough, off gastric bypass patients. So when we do gastric bypass or the gastric sleeve or the Lap-Band, certain chemicals and feedback systems go up or down. And we start learning the biochemistry of what signals help individuals lose weight or gain weight. And there are a couple of central ones. And there are a couple of peripheral ones.
And so centrally, you have the happy chemicals—serotonin, norepinephrine, and dopamine. And then as you start making medicines that alter serotonin, norepinephrine, and dopamine, you can affect satiety centers and help people decrease their portion sizes or choose different foods. But also, as you know, from a functional point of view, when you block certain pathways, you awaken other pathways. And so you get these other components that can be the side effect profile of blocking certain pathways.
The other ones are really, really interesting. It’s sort of working with IgF. I want to say it’s like—
DrMR: Insulin-like growth factor?
DrCK: Yes, exactly! So you’re basically playing with intestinal components. There are also some aspects of opioid blockers. So we have this philosophy that dopamine receptors and opioid receptors are kind of the center of addiction.
And if we can play around with dopamine and opioid areas, we can decrease addictions. But we also affect eating behaviors. So now, there are drugs that basically play around with dopamine and opioid receptors.
And inevitably—this is the thing I find very frustrating. They’re, again, across populations. And so the general population studies say that these drugs lead to about a 5% weight loss in the course of two years. You just say, “Oh, my gosh, that’s not a lot.” But within the drugs, there are super responders—individuals who have certain genetic predispositions. And when you change their chemistry, they lose 20% of their weight, let’s say. And then you say, “That would be a good component.”
But when I ask the drug companies and the representatives, “Can you tell me who the super responders are? Are there are any characteristics of super responders?” And they say, “No, we’re not qualified to actually tease that out in this research.”
So then, we go back to the biochemistry. We say, “Well, what does norepinephrine do? And what would a low-norepinephrine person look like if they came to your office? And what does serotonin do? And what do low-serotonin people crave in terms of their foods?” And I start trying to find, through physical exam and history, who might be super responders when I get to choose the Western medicines that I might add into a weight loss plan.
DrMR: So can you give maybe a couple drugs and a couple profiles that that drug tends to best fit with? I think people would be fascinated to hear that.
DrCK: Okay. So we’re always going to be looking at these functional approaches. So first, you want to make sure that people don’t have sensitivities to certain foods or that they’re actually toxic because of chemical exposures. And so you want to make sure that’s out of the way.
Foundationally, you want to talk about calories, macronutrients, and micronutrients. But then you have these options. One option is actually a norepinephrine reuptake inhibitor, which some they call Phentermine or the brand name Adipex. And so you say, “Well”—and norepinephrine is fight or flight. It’s like, “Oh, my gosh, tigers are on the horizon all the time. And I’ve got to be ready all the time.”
So when people don’t have enough adrenaline or enough epinephrine, they’re like, “Ugh, I’m tired. And I’m always eating at the end of the day. I’m just hungry all the time. I’m trying to get energy all the time.” You say, “Well, if I give you that fear chemical, nobody stays at the picnic once the bear shows up.”
DrCK: So always tell people that if I give you this chemical that basically makes you think there’s a bear there all the time, you’ll probably eat less. So that’s really designed for the individual who’s eating all the time. But norepinephrine raises blood pressure and heart rate, affects sleep. So you’ve got to take that into consideration. There is a medicine—
DrMR: Wait one second, Chris, before you go onto the next one. I’ve actually tried phentermine. So I just want to chime in with my own—
DrCK: I have, too. Don’t tell anybody.
DrMR: So, yeah. To share my own experience, I haven’t tried it for weight loss. I’ve actually tried it as an ergogenic aid to enhance performance.
DrCK: Oh yeah.
DrMR: Truth be told, I think most people listening get that I probably have way too much on my plate in terms of a lot of work, a lot of responsibilities, a lot of research, everything else.
DrCK: It’s lucky that you’re superhuman.
DrMR: Yep. Yeah. I don’t feel like that, yeah. And to stay true to my own advice, I’m working to have enough help so I don’t have to do this in the long term because I harp on the importance of lifestyle and balance. So I want people to know that I’m working toward that endpoint. It’s just, for me, this is sort of a short-term sacrifice for a long-term objective.
DrCK: Absolutely. Sometimes, you need a cup of coffee to make it through the day. I totally understand.
DrMR: Exactly. Exactly. And so what I found is sometimes that even caffeine doesn’t have enough kick. And so I’ll do a double espresso with a phentermine.
DrMR: And it is fantastic for really just kind of jacking you up. I haven’t found it great for writing. I haven’t found that I have that deep thinking.
DrMR: But it’s more I’ve got 120 emails I want to smash through in the next six hours, and none of them are super deep emails. It’s good for that type of work. And definitely, I’m less hungry. I’m more warm. And you feel jacked up. It’s not a way I’d want to walk around all the time.
DrMR: Because you do feel internally stressed. And when I first found it, I thought it was great. And then I ended up using it just to run the experiment for three days in a row. And at that third day, I said, “This is definitely a once-in-a-while type of thing for me anyway.” And I just want to share that because it does. This NNRI—
DrMR: Norepinephrine reuptake inhibitor.
DrCK: Non-selective reuptake inhibitor, norepinephrine, yeah.
DrMR: Yeah, it makes you feel stressed is what I’m saying.
DrCK: And for me—so I was doing it because it was getting to be summertime. You want to sort of look good on the beach. And I wanted to lose that last 5 or 10 kind of thing. And so I started taking half of it.
And I found, oh my gosh, I finished all my work half an hour early. And I just wasn’t even eating. I would work out. I would go home. I would go to bed at a reasonable time, like 10 o’clock. And I would toss and turn until 2 in the morning.
DrCK: I’d sleep from 2 to 4. And I’d wake up and feel great. And after about day three, the better part of the doctor in me was sort of like, “This is bad. I’m going to burn out if I keep this up.” And so this component about finals or deadlines—sometimes you really have to burn the midnight oil, and you have to use what you have to use to burn the midnight oil. But I could see it would have been a problem for me as well.
DrMR: Yeah, it’s that long term. And I’ll actually never forget something that you said to me, Chris, way back when I was a student and still trying to sort through all the information I was learning. I was on the “stress is bad” kick.
DrMR: And probably I had swung way too extreme with trying to de-stress. And you turned to me, and you said, “You know, Michael, stress is to life as to tension on the strings of a violin.”
DrCK: That sounds pretty smart. I’m glad I said that.
DrMR: I’ve never forgotten that. And I’ve carried that forward with me. And I’ve shared it with many of my friends and patients in interactions because I thought that was just beautiful. Without enough tension on the strings of a violin, it won’t play.
DrMR: If they’re too loose or they’re too tight, it won’t work. You have to have that right amount of stress.
DrCK: And what’s interesting is that’s missing in Western medicine too. We focus so much on this concept of homeostasis; everything’s in balance. And finally, I get into your world. And I start learning about something—if I get it correct—something called allostasis, which is the idea that you have these external stressors like exercise that actually stimulate growth. But you don’t want to have too much so that you break the components of the strings on the violin. But you’ve got to have enough to keep it taut so it actually makes music.
DrMR: Absolutely. Yep. Yep, that’s it. Allostatic load. You want to have that right balance. And we had a great exercise physiologist, Mike Nelson, on awhile back who—he’s been using heart rate variability as a great tool to preempt if someone has been training too much. And I’ve had a number of patients that have been struggling with that training/over-training line. And I’ll just refer them to Mike to start doing coaching with him on that.
DrCK: Yeah, because we never over-trained in our days, did we?
DrMR: Yeah. No, never. All right, so we have one drug there and our own personal musings about that drug.
DrMR: What was the next one you were going to talk about?
DrCK: The one that came out after that—because Adipex was too stimulatory. They actually realized that here we have an upper. And some people actually need downers.
And so there were these downers for people who would eat at nighttime. And somehow, you would try to shut their brain off so they would just go to bed. And so it was actually a combination of phentermine and topiramate, known as Qsymia or taking topiramate separately called Topamax. Now, Topamax isn’t FDA approved, but we would use it anyway. So what you would do is you would have this combination upper and downer type drug. So that way, you’d get enough stimulation to suppress your appetite but not so much stimulation that you couldn’t sleep at night.
DrCK: And so the topiramate/phentermine combination, Qsymia, was this combination of uppers and downers for people who just didn’t have a very good pattern of eating but they needed to sleep.
DrCK: So there are three more that came out. One was Belviq, which was a serotonin agonist or a serotonin simulator. And serotonin is really rich in carbohydrates. And also aspects of just eating alone will basically affect serotonin, happiness. And so if we can mimic serotonin, we have smaller portion sizes, and we avoid carbohydrates. So again, that becomes part of it. But there’s more serotonin in your gastrointestinal tract than there is in your brain. So it’s wrought with gastrointestinal side effects.
DrCK: And serotonin is linked to migraines. And so when you take the medicine, you get headaches. So you can see there are other—when you play with pathways, you can get into problems.
DrMR: There’s no free lunch in biology.
DrCK: No, no.
DrCK: But you sort of say, “Well, look.” You have patients say, “I just can’t get my head around the food. I just can’t do this.” And you say, “Well, what if I give you”—to use your terminology—“an ergonomic aid? What if I give you something for a couple of months to get the habits in place?” And then it actually becomes a practical tool to use.
The one that came out next was something called Contrave, which was dopamine and opioid blockers, naltrexone. So it’s Wellbutrin and naltrexone put together. And I saw this, and I said, “Oh.” I said, “This is a crazy drug,” because it’s all addiction centers.
So these are the people who sort of say, “I’ve got to have chocolate. I can’t have my life without chocolate.” Or just, “I don’t know. I’m an angry dog in the cellar when it gets to—and I let it out. And I just can’t stop eating.”
So this tends to help, I think, individuals—the super responders are the ones who are just addictive type eaters who don’t even know what they’re doing, mindless-type eaters.
DrCK: Also ex-smokers and ex-drinkers who choose food as their new addiction—it tends to help them.
And then the new kid on the block is something called Saxenda, which is this IgF modulator. And you think about IgF. And it actually came out of a diabetes medicine. And so it actually helps a lot for individuals with insulin resistance.
And so that classic apple shape and the cardio metabolic disease states. The problem with that one is it’s injectable. And so people are not too keen on needles even though the needles are small. And as much as it was only found in rats, it brought about—when you play with these sort of hormone type modulators, you really mess up the orchestra of hormones.
DrCK: And so there were some thyroid things that went on. But again, all these drugs, from an acute response viewpoint, they’re helpful when somebody can’t get out of their own way, when somebody really needs an edge. I had a lady today who’s just—she’s really trying to follow the plan.
But she just can’t do it. And she’s trying to get rid of gluten. And she just can’t do it. And we put her on Adipex, the phentermine, and I added 5-HTP, the serotonin. So we’re kind of mimicking the concepts of fen-phen to try and just say, “Hey, we’ll try this for a couple of months. But you’ve got to watch out for blood pressure, sleep, and nausea and these kinds of components from the serotonin.”
And then we say, “Oh, well, I lost this. I know what I’m doing. I’m a lot more focused.” I say, “Okay, good. Now, let’s take the medicines away and see if the habits remain.”
DrMR: Now, I really, really like that model. And I’m thinking that people listening are probably going to really appreciate that approach, because I think we qualify someone for using a drug at that point where someone has gone through diet, lifestyle. We’ve talked about different diet and lifestyle interventions or managing stress. Perhaps they’ve looked into a thyroid problem. They’ve looked into a gut problem. But they still need some help.
DrMR: I think when used in this context, it really makes the most sense. And especially if you’re using it as a short-term aid to help get over the hump.
DrMR: And then you try to withdraw.
DrCK: And you can profile people.
DrMR: That’s makes sense.
DrCK: Which is what you and I do all the time, which is—
DrMR: Yes, exactly.
DrCK: You listen to their history, and you’d put together their personality. You say, “Ah, this is the kind of prototype that would respond to this chemical. Or this is the kind of person that would respond to this medication.” As compared to just, “Well, this is the one we use. We don’t know how it works. But the studies say that you’ll lose 5% of your weight.” It’s just like, “Well, you’re the kind of person that really you love carbohydrates. And you have a tough time with portion. So serotonin is probably where we should aim for because that’s a little bit more related.”
DrMR: Yeah, I really like that model of trying to use some of the aspects of the patient to find who might a super responder be because I think, if we’re all honest with ourselves, there is definitely a subset of patients that struggle with weight loss.
DrMR: For some, it can be a tough thing. So I like to not be overly idealistic and think that the reason why the person is not losing weight is because they didn’t try ketogenic hard enough.
DrCK: Yeah, yeah.
DrMR: They didn’t try paleo hard enough. They didn’t try Mediterranean hard enough. I think if someone goes through some of these basic and very important dietary interventions and doesn’t get a ton of traction, let’s be open to a more integrative approach on this.
DrCK: Yeah. The example I tend to—some people get frustrated. They say, “Well, I don’t want to use medicines.” I said, “Well, if you had a broken leg, would you be willing to put on a cast?” They go, “Of course!” And I said, “Well, technically, that’s Western medicine. So when you have a vulnerability that impedes your performance or your own goals, we put aids in place to help you. But once the bone heals, do you keep the cast on?”
And the patients always say, “No, I don’t keep—” No, we don’t. So we use the cast to protect the vulnerability until it heals. Then we take the cast away to see if you can do this on your own. I always tell people, if you go walking around and you see a young tree that has sticks on it, you say, “Well, the tree is growing.” You see an old tree with sticks all around it and support systems all around, you say, “That tree is sick.”
DrCK: And it’s always like, “Well, you really want to use it appropriately, for the appropriate amount of time, at the appropriate dose and then get rid of it once the system has recovered or restored.”
DrMR: Agree completely. And I try to do the same thing even with natural medicines. I think adrenal support is a good example. Once we’ve seen someone have an improvement that has been stable with their adrenals for anywhere from two to four months, we have them slowly curtail off their adrenal support.
And most patients are able to come off it without needing to be on it any longer. And sometimes, I feel like I’m one of the few people who is recommending this. But it’s trying to get people on less stuff—
DrCK: Oh yeah.
DrMR: Rather than more stuff.
DrCK: What I’ve heard it called is green medicine. So basically, people come in to the holistic functional medicine doctor on eight medicines. And then they leave with eight supplements.
DrCK: And it’s like, well, I don’t know whether you’ve really helped them.
DrMR: Right. Yeah.
DrCK: So you’ve changed the colors of the pills in their box. But you haven’t really done anything in terms of the foundation.
DrMR: Well said.
Other Medically Based Weight Loss Interventions
So any other more medically based interventions regarding weight loss that you wanted to go into?
DrCK: So we have the medications and we have the components of the surgery. There are some really curious things that are coming out now that are devices. They’re noninvasive devices that really blow your mind in terms of the science. And they sound like they’ll work. But again, they’re really only short term. So there are these pacemakers that you can place inside the stomach, because my understanding is that, very much like the heart has a pacemaker, the stomach also has a pacemaker. And it will fire out electricity to tell you that you’re hungry.
DrMR: Yeah, they’re actually used to treat something called—or a similar type—to treat gastroparesis.
DrMR: There’s actually a pacemaker that can be installed to treat really severe gastroparesis.
DrCK: And so what this pacemaker does is it tries to confuse the electrical stimulation of hunger to tell the person that they’re not hungry.
DrMR: Hmm. Interesting.
DrCK: My understanding is it works about 50% of the time. And it really depends—
DrMR: 50? Or 1-5?
DrCK: No, 5-0. So 50% of the time.
DrCK: But it really depends on whether you can get the wires, the electrodes nailed into the mucous barrier, because you have to tack it into the mucous barrier of the stomach. And I don’t know it as much as a surgeon would. But I gather it’s a tough thing to attach to. They fall off. And then it doesn’t work.
DrMR: Gotcha. So this is an invasive—I’m assuming this is not a laparoscopic procedure.
DrCK: Oh, it is! It’s a laparoscopic. They do all this stuff with little hands and down the tube. Yeah, you do this—
DrMR: Oh, wow!
DrCK: I imagine you do this under partial anesthesia, but it actually is done endoscopically. That’s crazy, huh?
DrMR: Wow. Yeah, that is.
DrCK: And the other one that they are trying to develop is this latex sleeve that they place from the pylorus through the duodenum. And so what happens is you have a condom, basically, from the pylorus to the duodenum that doesn’t absorb nutrients. And so you eat. And then the nutrients don’t get absorbed. And you excrete the nutrients. And you wind up losing weight. One problem with that, obviously, is that you need some nutrients to go in.
DrCK: And so you may actually run the risk of malabsorption. And the other thing is that it can dislodge and basically get stuck further down. And that actually becomes a relatively surgical problem.
DrMR: Yeah, that could be a huge—especially if it caused a complete occlusion.
DrMR: I could see that being a huge problem.
DrCK: And then the last thing that they, I think, are reintroducing—it was kind of hot about a decade or two ago. And now it’s being reintroduced is the balloon. So they basically place a balloon inside the body of the stomach and inflate it and leave it there. So what happens is it acts as a mechanical device or a mechanical obstruction. And so you fill up faster because the balloon gets in the way. So you can’t fill up your stomach 100% because the balloon takes up—oh, I don’t know—20% of the volume. But again, the balloon can pop and basically slide down into the intestines. And that can be a problem.
DrMR: Interesting, interesting. Well, I think some of these have more appeal than others. And just something I’d like to echo because there are always two voices that go through my head when I hear these things. One is—is this stuff really needed? But then the other is—why not remain open to these things?
DrMR: And then I always try to answer that question in my own head so people can maybe see how weird I am because I have all these voices. Maybe I need to see a psychologist. I don’t know.
But the way I satisfy those two questions that shoot through my head are—of course, we want to qualify someone who might need these things.
DrMR: So first, go through all the foundational steps that we always harp on. And then after that, I think it’s important that we remain open because there are some things that are not modifiable.
DrMR: For example, the environment in utero, early antibiotic use, cesarean section birth, lack of breastfeeding—all of those have been shown to alter to microbiota and cause one to have an increased chance of having metabolic problems later in life. So there’s a part of this hand that people can be dealt that is non-modifiable.
DrMR: And so it’s just important that we don’t get up on our high horse and be overly idealistic and be open to the fact that some people are going to need more help than others. Let’s just try to have a logical hierarchy of steps to work through to make sure that we qualify the right people for the right treatments.
DrCK: And I think also in the functional medicine model, we deal, not only with the physical but mental and the spiritual side of the things. And people are sort of in that desperate state oftentimes. And we in Western medicine have a horrible reputation of judging people in regards to that, especially in the obese population. But I tell people, I say, “Look, all of us have habits that, if taken to an extreme, would kill us.” And looking inward and just saying what sort of things do I—what tiger cubs do I take into my apartment thinking that they won’t grow up?
DrCK: And everybody has something that they really have to keep under wraps and keep in check and, if taken to an extreme, would kill them. And so I always stay empathetic toward the individual who’s struggling because, quite frankly, we all struggle with something.
DrMR: Exactly. Well said.
Functional Approach to Weight Loss
So, Chris, what are you doing? We talked a lot about the stuff that you’ve done maybe more so before. But tell us a little bit more about as you’ve changed directions more so into this functional model.
DrCK: Ah, that’s funny because that’s the name of the book, right?
DrMR: Yeah, yeah.
DrCK: That’s nice. I like that. Little plug there.
DrMR: So little plug for—so Chris just wrote a book—I want to talk about that a little bit more in a moment—called Changing Directions. And I thought that was a really great title for encompassing what you’ve done, which is change directions from more conventional into a more integrative functional. So what are some of the key things that you’re doing now in practice?
DrCK: So really, what I’m trying is, I’m trying to develop a little bit more of a timeline and a little bit more history taking to understand the individual as a complex organism rather than just a biochemistry experiment.
DrCK: So you really want to understand where a person’s coming from, what they’re struggling with, what they desire in terms of their goals and really have a much more all-encompassing-type model to understand the aspects of what patients would want in terms of being healthy and optimal. And so what I found is as I’ve been incorporating a lot more of the basic aspects of balance in an individual’s life, that turns out to be very ancient in its viewpoint and very Eastern in terms of ayurvedic and Chinese-style medicine. And so there are all these forces in the Chinese medicine ayurvedic world. And different people call them different things.
But usually, there are these forces of nutrition. So what you eat and what you take in, in terms of nutrition or in terms of macronutrients and micronutrients. And then metabolism, which is sort of like how much muscle mass versus body fat do you have and how well do your mitochondria or your batteries work. So I sort of take a little bit more understanding about that. Inflammation, which is honestly everything that you do on a day-to-day basis, which is how is your gastrointestinal tract responding to the outside world? How is your immune system working? Detoxification, which is how do you get rid of your garbage? Does your liver work? Does your kidney work? Does your colon work? And then oxidation—at a microscopic or a cellular level, are you managing your fuels in an efficient way? Or is it inefficient and you’re creating free radicals and oxidation pathways?
DrMR: Gotcha. So someone comes in. Maybe help the listener who doesn’t understand a lot about the science and the names of things like oxidation and detox. Mary Sue comes in. She’s 30 pounds overweight. She’s got some bloating. She’s eating a Mediterranean-type diet, but it’s not great. She’s getting six hours of sleep a night. She’s got moderate stress at work. Where would you maybe start? I know it’s hard to answer. But are there some—if we were to apply the 80-20.
DrMR: What’s the 20% of stuff that you get the 80% return out of?
DrCK: So I’m going to cheat a little bit here and tell you what my dad, who—I think he’s about to turn 90. And he was an emergency room physician. And when I was going into medicine, he told me, he said, “Listen to the patient. They’re telling you the diagnosis.” And I actually think that was actually some—it wasn’t Hippocrates. But it was Osler that may have actually said that, one of the fathers of medicine. “Listen to the patient. She’s telling you the diagnosis.” So I tend to go in to see Mary Sue. And I say, “It’s nice to meet you today. My name is Dr. Keroack. We run a place to bring people back to the best health of their lives. So tell me a little bit about what brought you in and what I can do to help you.” And then honestly, people tell you everything. And people are shocked. People will say, “No doctor has ever asked me that before.” And then what happens is you just—you have to perk up your ears and just really listen to the telltale signs of the five foundational factors.
And that’s what I look for—the five foundational factors. Food—what is it you eat? Activity—how do you move? Stress—what affects you and how do you cope with it? Sleep—are you getting that rest and recovery? And then community, because you become who you hang around with. And so those are the foundational factors, I think, in functional medicine that make the biggest difference. So we have somebody, “Well, I’m on a Mediterranean diet.” Well, what made you choose that? And so they’re like, “Well, I’m sort of on it.” Well, what things get in the way? Well, what makes you only partially on it? What are you sleeping like? And are you active? And then you find out, what’s work like? And you just put all these components together in terms of food, movement, stress, sleep, and community.
And quite frankly, if you really want an interesting book, get the book Outliers and learn about that town, Bangor, Pennsylvania, about the Rosetta Italians who basically had a great community, ate like the Europeans, and they had health factors that were so much better than the surrounding towns because they moved, they ate, they slept, and they had a great community with no stress.
DrMR: Right. I agree. And as you were saying that, there was something that popped into my head that I just want to throw out there for people to think about, which is as I’ve gone further and further into my functional medicine career, I’m really doing exactly what you’re saying, Chris, which is listening to the patient. But I want to maybe crystallize what I think that means in some respects. I’ve even gotten away from trying to fit people into even the functional medicine diagnoses because people now come in. And I ask, “What are your top three to five health concerns?” And I get a list of diagnoses.
DrMR: Adrenal fatigue, thyroid autoimmunity. And I’m saying, “I don’t want to know what you think you have. I want to know what’s bothering you.”
DrCK: Very good.
DrMR: People say they have adrenal fatigue, and they’re not even tired. Then why do you have adrenal fatigue? “I don’t know. I read about it.”
DrMR: So I think it’s really important to cut through even the functional medicine diagnoses, as much as I love them, and really listen to the patient. You get so much from that.
DrMR: Trying to not fit them into the adrenal box, the Hashimoto’s box, but listening to what they have going on.
DrCK: I was just thinking that what pops in my head is this—if you’re going to hone that down even more. Sometimes, what I’ll talk about is deficiencies and irritants. And the baseline questions are—so tell me what’s bugging you? What are the things throughout the day that really bug you? And those are irritants.
DrCK: And then, what are the things that you feel are missing in your life? What are the things that you really want to do that you just don’t do? And those are deficiencies. And yeah, there are chemicals that are irritants. And there are micronutrients that are deficiencies. But you find out so much when you say, “Hey, what’s bugging you? And what’s missing in your life?”
DrMR: Yeah, I totally agree. And I would piggyback on top of that, loosely we look for these misses in diet and lifestyle, which sometimes just catching one of those misses can be huge. And then there’s usually just one or two other things more medically, if you will, that need to be addressed. And I haven’t found that it’s this super elaborate. There are nine diagnoses. There are 15 pathways that are altered.
A lot of times, the approach just becomes very simple when you learn how to listen and cut into the right thing. And I just offer that because one of the things—I always reflect and try to learn from the things that I see in the clinic. I’m seeing more and more people come in with almost like a textbook of, “Here’s my diagnosis, and here’s the pathways that are wrong.”
DrMR: And as a clinician, a lot of times, that information is not really the most important thing. It’s just trying to figure out, as you said, maybe the diet and lifestyle deficiencies and irritants and then what is the maybe one or two things that are truly wrong underneath the surface that need to be more medically remedied. And then the person can be cut loose and go live their life.
DrCK: Right. And then there’s a—in Western medicine, we call it premature closure, which is basically when you get too many diagnoses from a patient, you start closing your mind off to all the options. And you really want to be humble in regard to the fact that nobody can know everything. And you really want to listen. Sometimes, things won’t fit together. And I tell some of those harder cases where you’ve sort of walked down a pathway for months and then you realize, oh no, the patient is not any better. I usually joke with them and say, “Well, we should fire me as the doctor and hire me again.” Which is something—it’s just like, “Clearly, I have walked down the wrong pathway in terms of trying to help you. What we need to do is start from the beginning. Tell me your story as if I’ve never heard it.”
DrCK: Oh, my gosh, and then all of a sudden, you find out things that they didn’t tell you the first time that were so incredibly critical.
DrMR: I agree. I agree.
What else? Anything else you want to add to that as we kind of wrap toward a close?
DrCK: It’s a great job, isn’t it?
DrMR: I love it.
DrCK: It’s just such a great job because you really get to bring this elite aspect of hardcore science down to—I don’t know—a level that everybody is on common ground. And you get to really just be a healer. You get to just step into the personal aspect of people’s lives and enhance it.
And it’s just very humbling. And it’s just so gratifying. And it makes the long hours and the paperwork and the reimbursements I’d say somewhat worth it. Nah! It’s really worth it. It’s really worth it.
DrMR: And you’ve written a book called Changing Directions. And I was honored that you asked me to write one of the recommendations in the book. And I’m in there on page 3, I think. So it was cool.
DrCK: Did you highlight it, too?
DrMR: Yeah, highlighted it. Sent a picture of it. Put it up on my wall.
DrCK: That’s so cool.
DrMR: Sent a copy to Mom—all those cool things. But do you want to tell us a little bit about the book? I think you’ve already hinted at some of that with your model. But do you want to expand on that a little?
DrCK: Really, there’s always this push to try to reach other individuals with what you do, because you tend to be in charge of a community that’s really local. But you love what you do and you want to reach other people. And I got asked to talk a little bit about what I did at a national conference. And I said, “What do you want me to talk on?” And they said, “Talk on anything you want.” And I’m like, “Anything I want?”
And I was thinking about this model, about the Western model and the Eastern model and how to marry the two of them. And what came to mind for me was actually this great scene—I’m going to date myself, so I apologize—this great scene from The King and I with Yul Brynner and Deborah Kerr where they’re actually—Deborah Kerr represents the Western world, and Yul Brynner represents the Eastern world. And she’s teaching him how to dance. And it’s this beautiful scene where they’re actually dancing together. They’re learning how to dance.
And I was thinking, “Why can’t medicine be like that?” Why can’t you have the Western world and the Eastern world actually dance together and actually work together? And then we sort of struggled back and forth about what to call this.
And I said, “Well, honestly, this is like turning Western medicine on its ear and completely turning it around.” And that’s where we came up with the idea of, yeah, you’re actually changing directions. And you’re finding the true path and working in harmony with all the aspects of Western medicine and Eastern medicine.
DrMR: I like it.
DrCK: And so what I did was I kind of put into plain English this idea about the complexity of Western medicine and Eastern medicine so that way you can—using this idea about changing directions, you can actually navigate. You can find your way.
So when you go to the supermarket, you know what to get. You can go to the supplement store and know what to find. When you go to the chiropractor, you know what to ask. And you know what to express. When you come to the Western medicine physician, you’ll know what to check and what to look out for. And—I don’t know—it’s a little bit of a field guide to healthy living.
DrMR: I like it. And I know it’s been a lot of work. We were talking before we started the recording that it’s—man, it probably takes some—
DrCK: Well, you know firsthand because you’re working through it, too.
DrCK: You do have to put a certain portion of your life on the shelf for a time period. So very much like we talked about this in acute care model, I’m going to use this method for a short period of time to get a certain goal. And you do need to count the cost. And sometimes, you don’t count the cost until you’re in it. And I always—I’ll caution people out there. When you have a project, make sure you count the cost before you start buying materials.
DrMR: Yeah. Yeah, well said. All right, my man. Well, this has been a great chance to catch up. And I’ll look forward to seeing you next time I’m home. Chris’s office is about 20 minutes from where I grew up. And usually, I go home for Christmas to see my family. And so I’m trying to make it a routine practice now to pop in and to see him at the office.
DrCK: I’m hoping that you’ll do it. And I also am heading out to California for the Functional Medicine annual meeting in May. So I get to see what it’s like out there.
DrMR: Yeah, I’ll show you around as best I can.
DrCK: Good deal.
DrMR: All right, Chris. Well, thanks again. Hopefully, we’ll have you back on at some point in the near future. And keep fighting the good fight.
DrCK: Thank you. You as well, Mike.
DrMR: All right. Thanks, Chris.
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