Jeremiah Velasquez: Welcome back to another episode of Hormones Happen. I'm your host Jeremiah, also known as the optimized NP on TikTok. I've got a real special guest for you guys today. She's an NP that specializes in gastroenterology, Sarah Gallegos. Thanks for being with us.
Sarah Gallegos: Yeah, thanks for having me. It's really exciting.
Jeremiah Velasquez: Yeah, I've been trying to get you on here for a while. Me and Sarah go back. can almost say trauma bonding, back to the ICU days. But for all the listeners, Sarah, tell us a little bit about how long you've been an NP, what you've done, some of the things that you enjoy.
Sarah Gallegos: Yeah, for sure. been a nurse for over a decade now, about the same as you, so that's exciting. And nurse practitioner for three years. I've been working with gastroenterology and hepatology the whole time. So that's exciting too. I love the field. I ⁓ kind of into it, but it's definitely a growth curve and I am enjoying myself.
Jeremiah Velasquez: Fantastic. hepatology is very, relevant. And today, guys, here for a treat. We're going to be talking about Mafold. Now, just to kind ⁓ break this ice here, what is the difference ⁓ metabolic dysfunction, associated fatty liver and non-alcoholic fatty liver disease? Are they the same thing?
Sarah Gallegos: and Yeah, so funny story, they changed all the names in the hepatology world. It's actually with an S. So associated steatohepatitis is mash. So they do mash and mastled now. So that's, don't know why they've been very harping on this at all of the conferences lately. Yeah. ⁓ I guess.
Jeremiah Velasquez: ⁓ geez. Okay. ⁓ my gosh. Okay, yeah, gotta get those terms right.
Sarah Gallegos: So mastled and mash, so mastled is pretty prevalent, especially in the American population. And then mash is like mastled but with fibrosis or scarring. So just higher risk patients have more scarring of the liver that we need to kind of take a little better care of and try to get healed a little more urgently than people with just mastled.
Jeremiah Velasquez: Okay. they get away from NAFL just because of the fact they wanted to really focus on the metabolic association as opposed to saying just because you don't drink you get it?
Sarah Gallegos: Yes, absolutely. So I think the whole community, by community I mean like the hepatology community is really straying away from the stigmatism that is alcohol use, I So even the word non-alcoholic kind of just brings up the word alcohol, which is what I think they're trying to get away from, if we're being honest. But that's completely my opinion. They didn't say anything. They just have been.
Jeremiah Velasquez: Mm-hmm.
Sarah Gallegos: at all of these conferences being make sure that, it's mash now and it's massled now and they're saying associated, not alcoholic. So it's ⁓ a whole transition, I guess.
Jeremiah Velasquez: sounds like it. ⁓ with now, me if I'm saying this wrong, mass old, mass old. Well, how common is this? And like, who's who's mostly affected by it?
Sarah Gallegos: Yeah, that's right. Um, you know, the American population, did write down like a percentage too, when I saw it today. was such a huge percentage of Americans. I was like, are you serious? And so now of course I can't find it. Oh, here we go. Okay. So mass old would be a third of the American population. And they, a lot of times they present it, pronounce it mass old D.
Jeremiah Velasquez: It's a lot of people I'm It's a lot of people.
Sarah Gallegos: So two thirds of these people that mastold or mastel-D, ⁓ two thirds would be diabetics then the other two thirds of people that are obese also have it. So two thirds of two thirds of obese people have mastold.
Jeremiah Velasquez: Mm-hmm. Hmm.
Sarah Gallegos: And then only a third of diabetics and a third of obese people have MASH, which means they have scarring of their liver that needs to be reversed.
Jeremiah Velasquez: Got it. So, you know, these metabolic conditions far, outweigh the number of people who get this from alcoholism. Is that a fair assumption?
Sarah Gallegos: I think that's what they're trying to stray towards is that a lot, especially in America now, I think that these metabolic associated syndromes, I mean, there's four components of that. It's just obesity, which is BMI greater than 30, which is a huge percentage of people.
Jeremiah Velasquez: Mm-hmm. totally. That's me right there.
Sarah Gallegos: 2 diabetes or pre-diabetes, hypertension and hyperlipidemia. So those are the top four and I mean you could probably not name a single person in your life that doesn't have any one of them.
Jeremiah Velasquez: Mm-hmm. that's completely true. Now, if I was to look at a basic CMP, like what might I see that lets me know like, okay, hey, we're kind of starting down this pathway here.
Sarah Gallegos: That was a loaded question, Jeremiah.
Jeremiah Velasquez: Was it?
Sarah Gallegos: I mean, just a basic CMP. I mean, the liver function tests are in the CMP, right? So, bilirubin, alkaline phosphatase, AST, ALT, those are the top four that we look at, but don't really paint the picture. Even when you go into a CBC, so getting a platelet count, that's important for your liver disease. If you went into a differential of a CBC, the MCV of a CBC is...
Jeremiah Velasquez: basic.
Sarah Gallegos: related to your liver disease, because that has to do with the size of your red blood cells, which comes from your liver. there's so many components that come from that of your digestion of your body that come from your liver. It's a fascinating study.
Jeremiah Velasquez: you Interesting. Yeah, so you're definitely going to want some more blood work. Are you going to want like, you know, like clotting factors and stuff like that too?
Sarah Gallegos: Okay. Yeah, so if you're trying to calculate like a meld score, That's like the hepatology Bible to see how badly somebody needs a liver transplant. So that's for ⁓ severe liver disease patients that we'll have. But really if somebody just comes in to me for like elevated liver function tests, I'm a CBC diff, a CMP, an ELF test, which you can get at most labs now. That's a better measurement of fibrosis of the liver or scarring.
Jeremiah Velasquez: Mm-hmm. Mmm.
Sarah Gallegos: lipids or cholesterol, total cholesterol panel and then a TSH reflex T4. That would be the basic starting labs I guess.
Jeremiah Velasquez: why the thyroid studies?
Sarah Gallegos: Well, the thyroid beta cells come from the liver. So you know all about that. You your mechanism of action.
Jeremiah Velasquez: Okay. All right. That was a spicy way to put it. Hey, so, you know, this is a thing. ⁓ me ask you this. Can someone with a normal body weight, develop this disease?
Sarah Gallegos: No. Normal body weight. I feel like that's a loaded question too. Like normal BMI.
Jeremiah Velasquez: It is loaded. Yeah, let's say they have a normal BMI. Can they still have enough risk factors to develop this?
Sarah Gallegos: Like, last year, third. Less than 30 normal BMI? Yeah, I mean, like I said, any of the four components, right? So if you still have high blood pressure, that affects your liver. If you still have hyperlipidemia, that affects your liver. And then obviously diabetes. So sometimes people are under 30 in BMI and still have one of those three.
Jeremiah Velasquez: Sure. Now, is this reversible? Can people correct this? ⁓ thank goodness. Thank goodness. And how, Sarah, how can they do this?
Sarah Gallegos: Absolutely. Yeah. But how? So as long as you haven't gone too far is what I tell people, then we can make it better. Obviously there's the also, I don't know what the is with the number four, but hepatology loves the number four. Obesity. Yeah, has great four pillars. So one diet and exercise, two behavioral changes.
Jeremiah Velasquez: Sure, surround number.
Sarah Gallegos: Three, the medication field, which is growing immensely every day. They're doing different studies to try to find medications to reverse the fibrosis of your liver. then four is obviously bariatric surgery, which is another growing field, especially in America.
Jeremiah Velasquez: I know we've of talked briefly just in text and stuff, but what are some of the medications they're using now for this?
Sarah Gallegos: let me get my notes out. Getting so really we just talked about I mean as far as the guidelines are concerned they really have only talked about for liver fibrosis reversal. There's just the top two medications right now that have been approved by the guidelines from the hepatology, like American hepatology. Why can't I think of that term? ⁓ Yeah, the two medications are resmitteron or resdifera, which is a medication actually reverses the fibrosis of your liver.
Jeremiah Velasquez: Mm-hmm. Yeah, it's there somewhere.
Sarah Gallegos: And the second one is semi-glutite. I don't know.
Jeremiah Velasquez: semi-glute, we know all about that guys. Okay, well that's good to hear. I was just about to actually segue into what are your thoughts on the GLP-1s and their effect on this.
Sarah Gallegos: Everybody's favorite medications right now in this field is the GLP ones. I think they need a lot more monitoring than I think people are giving them credit for right now. The way that they work is amazing. The semaglutide works great, GLP-1. The ters epitide I have found works better because it's a dual acting ⁓ GLP-1 and GIP, but.
Jeremiah Velasquez: ⁓ yeah.
Sarah Gallegos: don't think people are, I think we're prescribing them and then turning people loose too much. Like, here, take this.
Jeremiah Velasquez: Sure, sure. and see, I'm on other end of the spectrum. I feel like you should be able to go into any 7-Eleven and just pick this up off the shelf. But you and also red trutide, red trutide is gonna come out too. Now that's a triple agonist, Glucogon agonist. So talking increased metabolic rate. We're turning up that thermostat. in studies, it's outperforming terzepatide and semiglutide significantly. Can you get it from the black market, gray market? Absolutely guys, but fact of the matter is, is none of the pharmacies carry it at this point, but when they do, it's gonna be it. And you know what? Will try it? I don't know. I'm nervous because I'm on a fairly low dose of trisipatide. And ⁓ when take something like red trutide, you're way up here. You can't come back down. Like trisipatide will never be the same. So for if I can get away with trisipatide, I've been on it for over a year. I love it.
Sarah Gallegos: yes.
Jeremiah Velasquez: I don't know if I'll ever try Reddit TrueType, but I know people that are on it and they are killing it. Killing it.
Sarah Gallegos: You know people that are on this new medication that isn't out yet?
Jeremiah Velasquez: Yeah, I know people that are in the medication that's in phase three clinical trials right now. They're currently on it, in the clinical trials, and they're killing it. This stuff's more available than you think. You just type in red atruteide in Google, ⁓ gonna find some kind of online market to buy it. It's out there. And course, you know, there are clinics that are prescribing it and stuff like, I mean, I don't wanna say prescribing it because you can't prescribe it, but there are clinics offering it, but what you have to realize is this is a non-FDA approved medication. just have, that's what it is.
Sarah Gallegos: My app. you
Jeremiah Velasquez: Can you get it? Should you know you're rolling the dice, but that's everything right every time you step into your car You're rolling the dice Now far as the medications like there like a specific Order you do them like hey, this is first line. ⁓ This is second line. Do you it?
Sarah Gallegos: Yeah, so I mean, I think in your space is so much different than my space because you're very focused on like hormone therapy and you're more focused, you're able to focus more on like weight loss than I am in the GI space. A lot of times I have to focus on the side effects of these medications. Yeah, I'm having to clean up the, got dope with this and now you can't stop vomiting. ⁓ Yeah, the very severe cases of pancreatitis that we've had in the hospital and people just don't.
Jeremiah Velasquez: Totally. up the messes or... ⁓ Cool. Thank you.
Sarah Gallegos: understand that this can happen on these medications and I think that we like to put the silver lighting on it like you can lose weight and you can do well but you have to change your life while you're doing it. So I think that's important.
Jeremiah Velasquez: Super, super.
Sarah Gallegos: The other medications that I wanted you to look at though is like they're coming up with some, I wanted some mechanism of actions for you. The FGF 21 analog, have you heard of those?
Jeremiah Velasquez: Wow, FGF, why have not?
Sarah Gallegos: FGF 21 analog. So they improve your lipid and glucose metabolism, reduce your liver fat, and actually can decrease the fibrosis at the same time. So it's like doing all of the things at once, which is kind of crazy. And that's right. I know. they're testing that currently. I guess Roche picked it up. That's a big pharmaceutical company. have pan-P-par agonists that are coming out.
Jeremiah Velasquez: Yeah, sounds like a miracle medication, honestly. Yeah.
Sarah Gallegos: They reduce fibrosis as well. And more importantly, they're reducing pulmonary hypertension, which is another big problem for us in the GI hepatology space. Yep. So they're testing that one. then the oral GLP ones, obviously, they're not testing those. They're trying to come out with them. then I bet they'll be out all over in the next year if they're not out right now. I think people are prescribing them now.
Jeremiah Velasquez: Well... Mm-hmm. Really? I didn't know that. I Sure. Yeah. you bring up a really good point about, a lot of people getting on these GLP ones and using it as a crutch, And ⁓ this is reality. This, the person that does incredibly well on GLP ones is someone that's already built a foundation, They've already made ⁓ those lifestyle changes ⁓ and they're using this as a tool because It's a very powerful tool, but it's not a map. It's not going to tell you what to do. sure, can you take this, suppress your appetite, get, severely dehydrated, malnourished, plethora of problems? Absolutely. It happens all the time, unfortunately. But, I agree you. When you get on this, it's really important that you're working with someone that can at least tell you how to use this intuitively you think, ⁓ I take the shot and I lose weight. How easy could that be? There's nothing easy about this process. easy about progress, ⁓
Sarah Gallegos: Yeah, absolutely. I think far as like prescribing weight loss medications, too, I try to figure out which one's gonna work better for a lot of these patients, like the GLP ones versus the dual acting, the terzapotide, versus like we're still using Fentermine and Topiramate a lot of times for people. ⁓ And then I just listened to a brief, there's a lot of people still using like Contrave, which is one of the oldest like appetite suppressants there are.
Jeremiah Velasquez: Yeah.
Sarah Gallegos: So I mean, it depends on what the problem is for the patient. I think it's important when people come in and want help with their obesity and help with their weight loss, being like, why do you think you are overweight? And being able to talk about that a sensitive enough way that you don't offend people has also been a challenge.
Jeremiah Velasquez: it depends on where you're at, right? In place like mine, people are very forthcoming with, I've struggled with loss my whole life. It's always been purging and binging all these other issues. there's a lot of aspects to it as well, We really tie our our self-worth, to ⁓ how we present ourself, our physicalities. Whether or not that's or not, it happens, And so... I agree with you 100%. It's always important to individualize what works best for a specific person. But in my experience, tersepitide is just superior to semiglutide. Do people still thrive on semiglutide? Absolutely. You can thrive on any of them. You can thrive off of any of these, believe it or not, guys. could diet and exercise without them and do just fine too. This is really just something to make it easier. And people hate to hear that. They're like, it's cheating. I don't like easy way out. But the reality is, If you don't like the easy way out, stop driving to work, walk. we have these tools, we can use them. one of the benefits of being in, a developed country. The downside is we're being poisoned with ⁓ preservatives in the food and the in the water and BPAs. And I could put my tin foil hat on all day, but the reality is you gotta take advantage when you can. Now, if you were to see someone who had massled, And you're like, okay, these are the things you need to adjust in your lifestyle improve or reverse this. ⁓ are those key points?
Sarah Gallegos: I think... In my experience, talking to people about their lifestyle is always the first thing. So I ask people, what kind of things do you eat? And usually their answer is very generic. Like, oh, I eat really well. I'm like, okay, I need you to tell me more. Like, what does that mean? Like, what does really well mean to you? Because I'm finding that a lot of times people think really well means processed foods only once a day, once a month.
Jeremiah Velasquez: Mmm. Yeah.
Sarah Gallegos: These types of things, I think that as a society, we've kind of done that. And then like exercise, right? What kind of things are you doing for exercise? Just being more specific about it because I think an APP especially, I have the time to talk to people about these things too and I think that helps. Where doctors don't really, they have like five minutes with the patient and that's all they get. I think that's hard.
Jeremiah Velasquez: It is hard, we also didn't. This isn't something that was ever covered in the curriculum, right? I mean, our education, whether it's NPP, AMD, you we talk about this on a lot of podcasts, you don't cover this stuff. This is things that ⁓ you have to learn. And the reality is, is how many healthcare professionals do you see that are unhealthy? And they're preaching, hey, you know what, you got to do ABC. And it's like, well, it look like you take it that seriously. You know what I mean? You have to live it to really convince people to do it, right?
Sarah Gallegos: That's true. That's so true. ⁓
Jeremiah Velasquez: Yeah. I've heard some people say there are certain diets that work better for reversal of these kinds of conditions. do think Mediterranean keto is there any specific diets that you guide people towards or recommend?
Sarah Gallegos: ⁓ absolutely, I people toward the Mediterranean diet every time. It's been the number one diet in America for more than 20 years. I it's the most universally accepted. yes, keto better for some people. Yes, there are other diets that work better for other people, but Mediterranean's gonna work for the majority of people the majority of the time. I have found.
Jeremiah Velasquez: And when comes to like specific types of exercise, do you do you tell them, hey, weight training versus cardio, or does it matter or get X amount of What you know, what's the general rule on that?
Sarah Gallegos: You know, have, again, I feel like a lot of times I get to start people on this journey, but I don't get to continue the journey with them. I've been doing this for three years and I probably have only had like a handful of people that have stuck with me the whole time. Whether it's because they got busy and fell off of my charts or I sent them to you, I have done that before. So I don't always get to like see that progress. So that's a little bit.
Jeremiah Velasquez: Yeah, yep.
Sarah Gallegos: Frustrating what was the original question though?
Jeremiah Velasquez: or weight or weight training which one's better?
Sarah Gallegos: ⁓ yeah. So I always am like, listen, you just need to move more. Either move more or change your diet. always tell people don't do both at the same time. If here, yeah, if you're here and you're morbidly obese, you gotta pick one or the other. And once you get good at one, then you can pick up the other. But I find that if you try to do all of it at once, it's too overwhelming and that doesn't work. you just need to move more. Either move more or change your diet. I always tell people don't do both at same time. And once you get good at one, then you pick up the other. But I find that if you try to do all of it at once, it's too overwhelming and that doesn't work.
Jeremiah Velasquez: I love that. That's really refreshing because you're right. If you bite off too much, you to make too many changes at once, it's not going to stick, You have to get that positive reinforcement from one thing ⁓ before you move on to the other. And the same time, you're stacking these habits. show yourself, you know what? I've been eating healthy for a months now. I have this down. I'm going to go ahead and start exercising now. ⁓ You've already put yourself in a great place to Stacking these habits is the way to go. If you try to do everything at once, like a New Year's resolution,
Sarah Gallegos: Absolutely.
Jeremiah Velasquez: There's a reason they do not work out. my general thought on it is, Build much muscle as you can. That's the number one disposal of glucose. That's where your glucose gets stored. If you wanna live longer, you wanna be harder to kill, build It's the most important thing. And I tell everyone, most of my guys on TRT, if you're not going to the gym you're not doing weight training, you're doing yourself a disservice. My women.
Sarah Gallegos: Absolutely. Of course it is.
Jeremiah Velasquez: who need to preserve bone density. if you're not doing weight training, you're doing yourself a disservice. Cardio is great too, guys, but we gotta weight train. It is so important. It doesn't have to be crazy. mean, even sometimes I'll have women just wear a weighted vest around the house. That's enough. You just gotta meet them where they're at, but weight training is so incredibly important and build as much muscle as you can to carry you through the rest of your life and you're live a longer, healthier life. Now, ⁓ yeah, that's...
Sarah Gallegos: That's great. Meet them where they're at. I like that. That was good.
Jeremiah Velasquez: meet them where they're at. Now, are there specific red flags that you might say like, okay, these are what I want you to look out for if someone's dealing with mass hold.
Sarah Gallegos: don't see a lot of mast cells. I see a lot of mash. So I see, yeah, I see patients that are already high risk. They are either serotic or they're so close to serotic that you don't want to tell them they're serotic yet because you're worried that it may freak them out. So usually for the serotic patients, it's a little more serious, right? Are you having abdominal pain? Are you having signs of GI bleeding?
Jeremiah Velasquez: Okay, sure, mash. Yeah.
Sarah Gallegos: confusion, those are the top like three that I stick to as far as like, these are really important things. for the mash patients that aren't serotic abdominal pain, I'm finding a lot of times is prevalent them. So just trying to make sure that we know what the, ⁓ that the pain isn't something more serious. like if you have gallstones, right? And you're having right upper quadrant abdominal pain and you need your gallbladder out and you're an F3 serotic. sorry, F3 liver patient, then need to get your gallbladder out. I mean, that's something that's pretty emergent because you're progressing into something more serious and when become serotic, you're a higher risk for surgery. those are kind of the warning signs that I stick to for F3, F4 serotics. And swelling, sorry, I swelling. I knew there was four. I'm telling you, the number four, it's a whole thing. ⁓ So yeah, abdominal pain, bleeding.
Jeremiah Velasquez: love for. it's square number.
Sarah Gallegos: What did I say? Confusion. What was the last one? Swelling. Inflammation.
Jeremiah Velasquez: swelling. Okay, so let me let me let me reframe it. So what should a primary care let's say to go to their primary care like what are the things the primary care may want to look for to say, Hey, think it's time that we send you to Sarah because we're not liking what we're seeing.
Sarah Gallegos: Yeah, I think that it gets missed a lot, but abdominal pain, swelling that isn't cardiac pulmonary, right? I mean, because those can cause swelling too. But lot of times like that, inflammation or any type of GI problems, people come to me with GI problems and then it turns out they have a liver problem. That happens a lot too. So those are the top three I'd say for primary care, right? Inflammation's a big one. If you don't have an explanation for your inflammation, at least look at the liver, right? So run some liver function tests they're gonna be elevated almost always in these mastoid patients. ⁓ some form of elevation probably.
Jeremiah Velasquez: Sure. Do you think like as far as consults go, it's typically delayed or do you think that from what you see, because you see these in later stages, you feel like this, people could be a lot better being proactive with getting consultation sooner.
Sarah Gallegos: Absolutely, I think nobody wants to have the conversation that you have fatty liver disease. I get those consults all the time where they're like, you have a fatty liver, go. And I'm like, well, what did they do for you? And they're like, nothing really, they just said that my liver was fatty and that was it. And the word fatty liver is just so generic that I think that we're patients a disservice by not sending them over sooner or talking to them sooner about kind of what's going on.
Jeremiah Velasquez: are some of the other testing that they do? know like they have fibro scans and they have ultrasounds, biopsies. Like what are some of the tests they do to confirm these diagnosis? ⁓
Sarah Gallegos: Yes, so diagnostically stage your liver fibrosis or scarring, we definitely do the blood work and the ELF test, which I think that primary care could utilize a lot more. An ELF test, E-L-F ELF, that's fibrosis test that you can order at Quest or LabCorp, most Quest or LabCorp. And if you can't get it, ⁓ like your insurance won't pay for it, there's actually reimbursement programs through those companies that make. the medications that they want you to use to reverse your fibrosis. Also, Novo Nordis and Madrigal, who makes res stifra. have programs where they'll reimburse you for those ELF tests if you start using them. Sorry to go off on a total tangent, which seems to be my thing. So the blood work is important that we talked about earlier. then ultrasounds and then Fibroscan is a special type of ultrasound that actually looks at the liver cells and how stiff they are.
Jeremiah Velasquez: Mmm. Okay.
Sarah Gallegos: the stiffness of your liver cells kind of determines how much scarring or fibrosis that you have.
Jeremiah Velasquez: Hmm. Are there some genetic components that play into this too? Are some people more just genetically, predisposed to having this?
Sarah Gallegos: Yes, absolutely. I also do with my elevated LFT patients an alpha-1 antitrypsin test, which isn't typically something that people are doing. Alpha-1 antitrypsin deficiency is something that puts you higher risk for cirrhosis already. So that's just one genetic component. Obviously, if you have obesity or diabetes in your family, those are things that can also put you higher risk for fibrosis of your liver. I mean, diabetics, this is the diabetic capital of Colorado, if we're being honest. So anybody that's Hispanic or African-American, you're already genetically predisposed to have liver fibrosis. That's just the name of the game.
Jeremiah Velasquez: Absolutely. Yeah. You know, I wake up every day and I'm like, not today. Thank goodness, you know. I'll try again tomorrow, but okay, we're gonna flip the script a little bit here. So we're going from hormones happen to hepatitis happens. And I'm gonna have you ask me a question. Yeah, I know. I didn't even prepare her for this. She has no idea what to ask me. Anything, hormones, weight loss.
Sarah Gallegos: Well, I I was not prepared for this at all, sir.
Jeremiah Velasquez: I know, I know, I'd put you on the spot. Told you I wasn't, and I did anyway.
Sarah Gallegos: That was terrible. Okay, when your patients come in, do you always ask them, mean, how do you start deciding what kind of weight loss program to put them on?
Jeremiah Velasquez: Sure, for me it's pretty simple. I'm a huge advocate for tris-epatide. I'm a huge advocate for the GLP-1s for other reasons than just weight loss. Weight loss is fantastic, but the in ⁓ metabolic decreasing insulin resistance, I have young healthy athletes on GLP-1s. I think the GLP-1s are an amazing medication for a multitude of different purposes ⁓ outside weight loss.
Sarah Gallegos: Thank you
Jeremiah Velasquez: Frankly, I mean, do they do well at weight loss? They do great, but you have to have the right mindset. I don't necessarily like the fast, rapid weight loss that is associated with them. We even have things like face, I heard ozempic neck, like just this stupid shit that people come up with. And it's just fear-mongering. I mean, you it can be real, right? But that's any kind of rapid weight loss. So me, really, it's, I educate them on the difference between, because we offer semiglutite torezepotide. We talk about the difference between a GLP-1 agonist,
Sarah Gallegos: real.
Jeremiah Velasquez: GLP one with a GIP agonist and then I let them make the decision and usually the deciding factor will be their budget will typically be the cost, you know, so that's okay I mean the reality is is these medications aren't necessarily cheap I do hope in the future it comes to a point to where it can be accessible for everyone insurance will start ⁓ this for just about anyone and it'll be very affordable for cash pay I really hope that that's the future because ⁓ really kind of cleaning up a mess that we've already developed and you develop these addictions in a young age. mean, how many of us grew up eating Lucky Charms, Fruit Loops, and they called it cereal for breakfast. it's, know, how can you not have a sugar addiction later in life? Like it's just, we're set up for failure and now we have something that can help to fix it. And we're being price gouged and stigmatized and, ⁓ you know, I know where we're going to go with it. I just kind of go day by day, but there's nothing more rewarding getting someone, having someone reach out to me saying,
Sarah Gallegos: Thank
Jeremiah Velasquez: It's absolutely changed my life. I feel better. Anxiety is much better. I hear that all the time. A of women with their perimenopausal symptoms feel so much better. Fertility, fertility improves too. It has a lot of ovarian support. And then of course, decreased insulin resistance and metabolic disease. These are as close to miracle drugs as we can get, but it's important to know it's a tool. At the end of the day, it's a tool. ⁓ And it's gonna work if you work it. So that's really about it. That's the conversation we'd have. If you called me, text me, that's what that conversation would sound like because I put you in control. I let you choose. I don't say you can't be on this. You have to be on this. ultimately, I think We deserve to have a say our And I take that very seriously.
Sarah Gallegos: was a really good answer. Did you practice?
Jeremiah Velasquez: Yeah, I did. Yeah, I did. I you text me before the podcast. Sarah, in closing all this, what one thing ⁓ you to let people know as far as, hey, if I'm concerned about this, this is something that's weighing heavily on my mind. What should do tomorrow?
Sarah Gallegos: If you're concerned about liver disease, you mean?
Jeremiah Velasquez: Yes.
Sarah Gallegos: Dr. Azar says only you can control what you put in your mouth.
Jeremiah Velasquez: That's true, 1000%, I agree with that.
Sarah Gallegos: He says it every single day. you can control what you eat and drink every single day.
Jeremiah Velasquez: Enough. It's like Smokey the Bear, only you can prevent forest fires, right? Only you can prevent liver disease, okay? Yeah.
Sarah Gallegos: It's true. I did have one more hormone question though. Can I ask you another question?
Jeremiah Velasquez: Of course you can. Yeah, yeah, of course. We're still in Hepatitis Happens.
Sarah Gallegos: hepatitis happens. ⁓ I have two things. it really make my job a lot easier if primary care providers would 100 % of the time after getting elevated LFTs check for viral and autoimmune, well, at least viral hepatitis.
Jeremiah Velasquez: Yeah, that's your that's your podcast. And how do we do that,
Sarah Gallegos: lot of times there's like an acute viral hepatitis panel you can order or even a chronic viral hepatitis panel. Hepatitis happens, speaking of viral hepatitis, hepatitis B vaccine, has anyone been talking about this? Because my head is getting ready to explode. It's bad, hepatitis B is not curable. You can't cure it and you can think whatever you would like to think about vaccines. I have no opinion on everybody else's opinion.
Jeremiah Velasquez: Yeah. Right? ⁓ no.
Sarah Gallegos: Medically, do not want to treat hepatitis B patients 10 years from now, 20 years from now. It's terrifying. So hepatitis B vaccines, look into it, look into what hepatitis B is, how you can get it, and just, we should be testing for it more, especially as these vaccines get more scarce. So yeah, the viral hepatitis question.
Jeremiah Velasquez: Huge, yeah. Okay, I love it.
Sarah Gallegos: That's something that PCPs can test for. And then the question I had for you was about the thyroid,
Jeremiah Velasquez: Mm. Mm. Confusion.
Sarah Gallegos: Are you not testing people's thyroid when you're seeing them for weight loss? Function.
Jeremiah Velasquez: Nah, it depends, we can. is the thing, we can test for anything that they want specifically, but we defer a lot to their primary care providers. ⁓ So, assume that they have a primary care provider. We can always get labs. I'm more than happy to get and explain several things for them. But as you know, weight loss is encompassing. There are so many different factors to it. Thyroid can be huge, ⁓ hormones can be huge. ⁓ And again, you gotta meet patient where they're at. At what point do you draw the line between, we're a hormone weight loss clinic and a primary care clinic, ⁓ so that's really kind of where you have to differentiate and delineate because there's a lot that goes into it, Like let's say you want full workup of that thyroid, We're going to need to start palpating it, ultrasound if there's a nodule, ⁓ potential, know, fine aspiration biopsy. There's a lot of things that go into it. So, you know, checking thyroid, cool, ⁓ but then what do do when it's not good, right? They go to their PCP.
Sarah Gallegos: ⁓ sorry.
Jeremiah Velasquez: So, you know, the reality is, depending on their symptoms, depending on their intake forms and stuff like that, we can usually kind of differentiate some things. And ⁓ I had some people, and this is more so with hormones, have I had some people come in ⁓ have these really vague symptoms and it's not, hormones causing your issues, low ferritin levels in women who have very heavy menstrual cycles, I see it all time. get that iron up, guess what? You feel like a million bucks again. It wasn't hormones the reality is, it's very complex, but once again, I offer it. Because worst case scenario, let's say you take it, doesn't help, doesn't do anything. Okay, well that was, you know, diagnostic too, right? Didn't work, something else is wrong. that's my thought process on it.
Sarah Gallegos: And then like the psychological of weight management. you, honestly, just because I'm also practicing in the same area as you, are you referring people to, I mean, who are you referring people to? Because I feel like in this area, it's just so hard to good support. Yeah.
Jeremiah Velasquez: For psych? No, haven't referred anyone to anything. And I agree it is kind of scarce. But just because someone's overweight, I don't typically tell them they need to go seek ⁓ psychiatric treatment. ⁓
Sarah Gallegos: Well, no, that's not what mean. No, I just mean, like, if people are having a hard time, I mean, we need to take that into consideration. They're emotional health, and I think that's something that's easy to dismiss, but also, like, should we be sending them somewhere? Should somebody be talking to them? Obviously, I'm not qualified to do that, and you're not gonna take that on either. So, I mean, what do we do?
Jeremiah Velasquez: Hey, what I is just, leveling. I like to be very supportive. I reach out frequently and we have a small win, they're like, hey, I lost three pounds, like, that's fantastic. That is really good. And I'd be sure to emphasize this. It's not the medication that lost those three pounds. was you. You did that. You're doing a fantastic job. And if you just build up, you give them a better opinion of themselves, they're going to do better because We have a habit of forming an opinion of ourself based on what other people think. We let other people determine our value, determine our worth. And if you are around people who are very positive and very supportive, that's a great circle. If you're in people who are just very dismissive and they're very negative against your goals, you're never gonna thrive. I tell you to get rid of that circle, go to a new one. And so do feel like, and I can't this, but I assume ⁓ that with my positive behavior supportive nature towards... towards just anyone who's trying, think it helps. I it does. I'd like to think so at least. Helps me sleep at night. Hey, that's it. I help myself. I help everyone I can, you know, because the reality is, it shouldn't this hard. It shouldn't be this hard for us to just try to live our best life, I really do wish in a perfect world one day, I'd to think that we have full access of our healthcare and it's affordable and we can be on hormones we want. We can be on the...
Sarah Gallegos: Yeah, I agree. You've helped me.
Jeremiah Velasquez: medications we want and we're able to make these decisions on our own with guidance, not dictation from medical providers. But knows? Who knows what will happen? But I appreciate everything you do. There's no doubt about it. You do a fantastic job. And I'm really happy you came on the podcast. Do you have anything you'd like to say? Any closing words?
Sarah Gallegos: Yeah. Hepatitis happens, I can't believe that's what you titled it. I love that for me, I'd love to come back. I just love hepatology, I think it's amazing. I think that the liver's amazing, it can do so good and bad things to the human body and I think people need to know more about it. We take it for granted, it heals itself until it doesn't anymore, so it's important.
Jeremiah Velasquez: Yeah.
Sarah Gallegos: for us to take care of it and for us to take care of each other. And I think the more information we have as a general public, the better because that's we do, right? Knowledge is power.
Jeremiah Velasquez: Knowledge is power. Awesome, Sarah. Thanks for joining us today.
Sarah Gallegos: Yeah, thanks for having me. It's really exciting.
Jeremiah Velasquez: Yeah, I've been trying to get you on here for a while. Me and Sarah go back. can almost say trauma bonding, back to the ICU days. But for all the listeners, Sarah, tell us a little bit about how long you've been an NP, what you've done, some of the things that you enjoy.
Sarah Gallegos: Yeah, for sure. been a nurse for over a decade now, about the same as you, so that's exciting. And nurse practitioner for three years. I've been working with gastroenterology and hepatology the whole time. So that's exciting too. I love the field. I ⁓ kind of into it, but it's definitely a growth curve and I am enjoying myself.
Jeremiah Velasquez: Fantastic. hepatology is very, relevant. And today, guys, here for a treat. We're going to be talking about Mafold. Now, just to kind ⁓ break this ice here, what is the difference ⁓ metabolic dysfunction, associated fatty liver and non-alcoholic fatty liver disease? Are they the same thing?
Sarah Gallegos: and Yeah, so funny story, they changed all the names in the hepatology world. It's actually with an S. So associated steatohepatitis is mash. So they do mash and mastled now. So that's, don't know why they've been very harping on this at all of the conferences lately. Yeah. ⁓ I guess.
Jeremiah Velasquez: ⁓ geez. Okay. ⁓ my gosh. Okay, yeah, gotta get those terms right.
Sarah Gallegos: So mastled and mash, so mastled is pretty prevalent, especially in the American population. And then mash is like mastled but with fibrosis or scarring. So just higher risk patients have more scarring of the liver that we need to kind of take a little better care of and try to get healed a little more urgently than people with just mastled.
Jeremiah Velasquez: Okay. they get away from NAFL just because of the fact they wanted to really focus on the metabolic association as opposed to saying just because you don't drink you get it?
Sarah Gallegos: Yes, absolutely. So I think the whole community, by community I mean like the hepatology community is really straying away from the stigmatism that is alcohol use, I So even the word non-alcoholic kind of just brings up the word alcohol, which is what I think they're trying to get away from, if we're being honest. But that's completely my opinion. They didn't say anything. They just have been.
Jeremiah Velasquez: Mm-hmm.
Sarah Gallegos: at all of these conferences being make sure that, it's mash now and it's massled now and they're saying associated, not alcoholic. So it's ⁓ a whole transition, I guess.
Jeremiah Velasquez: sounds like it. ⁓ with now, me if I'm saying this wrong, mass old, mass old. Well, how common is this? And like, who's who's mostly affected by it?
Sarah Gallegos: Yeah, that's right. Um, you know, the American population, did write down like a percentage too, when I saw it today. was such a huge percentage of Americans. I was like, are you serious? And so now of course I can't find it. Oh, here we go. Okay. So mass old would be a third of the American population. And they, a lot of times they present it, pronounce it mass old D.
Jeremiah Velasquez: It's a lot of people I'm It's a lot of people.
Sarah Gallegos: So two thirds of these people that mastold or mastel-D, ⁓ two thirds would be diabetics then the other two thirds of people that are obese also have it. So two thirds of two thirds of obese people have mastold.
Jeremiah Velasquez: Mm-hmm. Hmm.
Sarah Gallegos: And then only a third of diabetics and a third of obese people have MASH, which means they have scarring of their liver that needs to be reversed.
Jeremiah Velasquez: Got it. So, you know, these metabolic conditions far, outweigh the number of people who get this from alcoholism. Is that a fair assumption?
Sarah Gallegos: I think that's what they're trying to stray towards is that a lot, especially in America now, I think that these metabolic associated syndromes, I mean, there's four components of that. It's just obesity, which is BMI greater than 30, which is a huge percentage of people.
Jeremiah Velasquez: Mm-hmm. totally. That's me right there.
Sarah Gallegos: 2 diabetes or pre-diabetes, hypertension and hyperlipidemia. So those are the top four and I mean you could probably not name a single person in your life that doesn't have any one of them.
Jeremiah Velasquez: Mm-hmm. that's completely true. Now, if I was to look at a basic CMP, like what might I see that lets me know like, okay, hey, we're kind of starting down this pathway here.
Sarah Gallegos: That was a loaded question, Jeremiah.
Jeremiah Velasquez: Was it?
Sarah Gallegos: I mean, just a basic CMP. I mean, the liver function tests are in the CMP, right? So, bilirubin, alkaline phosphatase, AST, ALT, those are the top four that we look at, but don't really paint the picture. Even when you go into a CBC, so getting a platelet count, that's important for your liver disease. If you went into a differential of a CBC, the MCV of a CBC is...
Jeremiah Velasquez: basic.
Sarah Gallegos: related to your liver disease, because that has to do with the size of your red blood cells, which comes from your liver. there's so many components that come from that of your digestion of your body that come from your liver. It's a fascinating study.
Jeremiah Velasquez: you Interesting. Yeah, so you're definitely going to want some more blood work. Are you going to want like, you know, like clotting factors and stuff like that too?
Sarah Gallegos: Okay. Yeah, so if you're trying to calculate like a meld score, That's like the hepatology Bible to see how badly somebody needs a liver transplant. So that's for ⁓ severe liver disease patients that we'll have. But really if somebody just comes in to me for like elevated liver function tests, I'm a CBC diff, a CMP, an ELF test, which you can get at most labs now. That's a better measurement of fibrosis of the liver or scarring.
Jeremiah Velasquez: Mm-hmm. Mmm.
Sarah Gallegos: lipids or cholesterol, total cholesterol panel and then a TSH reflex T4. That would be the basic starting labs I guess.
Jeremiah Velasquez: why the thyroid studies?
Sarah Gallegos: Well, the thyroid beta cells come from the liver. So you know all about that. You your mechanism of action.
Jeremiah Velasquez: Okay. All right. That was a spicy way to put it. Hey, so, you know, this is a thing. ⁓ me ask you this. Can someone with a normal body weight, develop this disease?
Sarah Gallegos: No. Normal body weight. I feel like that's a loaded question too. Like normal BMI.
Jeremiah Velasquez: It is loaded. Yeah, let's say they have a normal BMI. Can they still have enough risk factors to develop this?
Sarah Gallegos: Like, last year, third. Less than 30 normal BMI? Yeah, I mean, like I said, any of the four components, right? So if you still have high blood pressure, that affects your liver. If you still have hyperlipidemia, that affects your liver. And then obviously diabetes. So sometimes people are under 30 in BMI and still have one of those three.
Jeremiah Velasquez: Sure. Now, is this reversible? Can people correct this? ⁓ thank goodness. Thank goodness. And how, Sarah, how can they do this?
Sarah Gallegos: Absolutely. Yeah. But how? So as long as you haven't gone too far is what I tell people, then we can make it better. Obviously there's the also, I don't know what the is with the number four, but hepatology loves the number four. Obesity. Yeah, has great four pillars. So one diet and exercise, two behavioral changes.
Jeremiah Velasquez: Sure, surround number.
Sarah Gallegos: Three, the medication field, which is growing immensely every day. They're doing different studies to try to find medications to reverse the fibrosis of your liver. then four is obviously bariatric surgery, which is another growing field, especially in America.
Jeremiah Velasquez: I know we've of talked briefly just in text and stuff, but what are some of the medications they're using now for this?
Sarah Gallegos: let me get my notes out. Getting so really we just talked about I mean as far as the guidelines are concerned they really have only talked about for liver fibrosis reversal. There's just the top two medications right now that have been approved by the guidelines from the hepatology, like American hepatology. Why can't I think of that term? ⁓ Yeah, the two medications are resmitteron or resdifera, which is a medication actually reverses the fibrosis of your liver.
Jeremiah Velasquez: Mm-hmm. Yeah, it's there somewhere.
Sarah Gallegos: And the second one is semi-glutite. I don't know.
Jeremiah Velasquez: semi-glute, we know all about that guys. Okay, well that's good to hear. I was just about to actually segue into what are your thoughts on the GLP-1s and their effect on this.
Sarah Gallegos: Everybody's favorite medications right now in this field is the GLP ones. I think they need a lot more monitoring than I think people are giving them credit for right now. The way that they work is amazing. The semaglutide works great, GLP-1. The ters epitide I have found works better because it's a dual acting ⁓ GLP-1 and GIP, but.
Jeremiah Velasquez: ⁓ yeah.
Sarah Gallegos: don't think people are, I think we're prescribing them and then turning people loose too much. Like, here, take this.
Jeremiah Velasquez: Sure, sure. and see, I'm on other end of the spectrum. I feel like you should be able to go into any 7-Eleven and just pick this up off the shelf. But you and also red trutide, red trutide is gonna come out too. Now that's a triple agonist, Glucogon agonist. So talking increased metabolic rate. We're turning up that thermostat. in studies, it's outperforming terzepatide and semiglutide significantly. Can you get it from the black market, gray market? Absolutely guys, but fact of the matter is, is none of the pharmacies carry it at this point, but when they do, it's gonna be it. And you know what? Will try it? I don't know. I'm nervous because I'm on a fairly low dose of trisipatide. And ⁓ when take something like red trutide, you're way up here. You can't come back down. Like trisipatide will never be the same. So for if I can get away with trisipatide, I've been on it for over a year. I love it.
Sarah Gallegos: yes.
Jeremiah Velasquez: I don't know if I'll ever try Reddit TrueType, but I know people that are on it and they are killing it. Killing it.
Sarah Gallegos: You know people that are on this new medication that isn't out yet?
Jeremiah Velasquez: Yeah, I know people that are in the medication that's in phase three clinical trials right now. They're currently on it, in the clinical trials, and they're killing it. This stuff's more available than you think. You just type in red atruteide in Google, ⁓ gonna find some kind of online market to buy it. It's out there. And course, you know, there are clinics that are prescribing it and stuff like, I mean, I don't wanna say prescribing it because you can't prescribe it, but there are clinics offering it, but what you have to realize is this is a non-FDA approved medication. just have, that's what it is.
Sarah Gallegos: My app. you
Jeremiah Velasquez: Can you get it? Should you know you're rolling the dice, but that's everything right every time you step into your car You're rolling the dice Now far as the medications like there like a specific Order you do them like hey, this is first line. ⁓ This is second line. Do you it?
Sarah Gallegos: Yeah, so I mean, I think in your space is so much different than my space because you're very focused on like hormone therapy and you're more focused, you're able to focus more on like weight loss than I am in the GI space. A lot of times I have to focus on the side effects of these medications. Yeah, I'm having to clean up the, got dope with this and now you can't stop vomiting. ⁓ Yeah, the very severe cases of pancreatitis that we've had in the hospital and people just don't.
Jeremiah Velasquez: Totally. up the messes or... ⁓ Cool. Thank you.
Sarah Gallegos: understand that this can happen on these medications and I think that we like to put the silver lighting on it like you can lose weight and you can do well but you have to change your life while you're doing it. So I think that's important.
Jeremiah Velasquez: Super, super.
Sarah Gallegos: The other medications that I wanted you to look at though is like they're coming up with some, I wanted some mechanism of actions for you. The FGF 21 analog, have you heard of those?
Jeremiah Velasquez: Wow, FGF, why have not?
Sarah Gallegos: FGF 21 analog. So they improve your lipid and glucose metabolism, reduce your liver fat, and actually can decrease the fibrosis at the same time. So it's like doing all of the things at once, which is kind of crazy. And that's right. I know. they're testing that currently. I guess Roche picked it up. That's a big pharmaceutical company. have pan-P-par agonists that are coming out.
Jeremiah Velasquez: Yeah, sounds like a miracle medication, honestly. Yeah.
Sarah Gallegos: They reduce fibrosis as well. And more importantly, they're reducing pulmonary hypertension, which is another big problem for us in the GI hepatology space. Yep. So they're testing that one. then the oral GLP ones, obviously, they're not testing those. They're trying to come out with them. then I bet they'll be out all over in the next year if they're not out right now. I think people are prescribing them now.
Jeremiah Velasquez: Well... Mm-hmm. Really? I didn't know that. I Sure. Yeah. you bring up a really good point about, a lot of people getting on these GLP ones and using it as a crutch, And ⁓ this is reality. This, the person that does incredibly well on GLP ones is someone that's already built a foundation, They've already made ⁓ those lifestyle changes ⁓ and they're using this as a tool because It's a very powerful tool, but it's not a map. It's not going to tell you what to do. sure, can you take this, suppress your appetite, get, severely dehydrated, malnourished, plethora of problems? Absolutely. It happens all the time, unfortunately. But, I agree you. When you get on this, it's really important that you're working with someone that can at least tell you how to use this intuitively you think, ⁓ I take the shot and I lose weight. How easy could that be? There's nothing easy about this process. easy about progress, ⁓
Sarah Gallegos: Yeah, absolutely. I think far as like prescribing weight loss medications, too, I try to figure out which one's gonna work better for a lot of these patients, like the GLP ones versus the dual acting, the terzapotide, versus like we're still using Fentermine and Topiramate a lot of times for people. ⁓ And then I just listened to a brief, there's a lot of people still using like Contrave, which is one of the oldest like appetite suppressants there are.
Jeremiah Velasquez: Yeah.
Sarah Gallegos: So I mean, it depends on what the problem is for the patient. I think it's important when people come in and want help with their obesity and help with their weight loss, being like, why do you think you are overweight? And being able to talk about that a sensitive enough way that you don't offend people has also been a challenge.
Jeremiah Velasquez: it depends on where you're at, right? In place like mine, people are very forthcoming with, I've struggled with loss my whole life. It's always been purging and binging all these other issues. there's a lot of aspects to it as well, We really tie our our self-worth, to ⁓ how we present ourself, our physicalities. Whether or not that's or not, it happens, And so... I agree with you 100%. It's always important to individualize what works best for a specific person. But in my experience, tersepitide is just superior to semiglutide. Do people still thrive on semiglutide? Absolutely. You can thrive on any of them. You can thrive off of any of these, believe it or not, guys. could diet and exercise without them and do just fine too. This is really just something to make it easier. And people hate to hear that. They're like, it's cheating. I don't like easy way out. But the reality is, If you don't like the easy way out, stop driving to work, walk. we have these tools, we can use them. one of the benefits of being in, a developed country. The downside is we're being poisoned with ⁓ preservatives in the food and the in the water and BPAs. And I could put my tin foil hat on all day, but the reality is you gotta take advantage when you can. Now, if you were to see someone who had massled, And you're like, okay, these are the things you need to adjust in your lifestyle improve or reverse this. ⁓ are those key points?
Sarah Gallegos: I think... In my experience, talking to people about their lifestyle is always the first thing. So I ask people, what kind of things do you eat? And usually their answer is very generic. Like, oh, I eat really well. I'm like, okay, I need you to tell me more. Like, what does that mean? Like, what does really well mean to you? Because I'm finding that a lot of times people think really well means processed foods only once a day, once a month.
Jeremiah Velasquez: Mmm. Yeah.
Sarah Gallegos: These types of things, I think that as a society, we've kind of done that. And then like exercise, right? What kind of things are you doing for exercise? Just being more specific about it because I think an APP especially, I have the time to talk to people about these things too and I think that helps. Where doctors don't really, they have like five minutes with the patient and that's all they get. I think that's hard.
Jeremiah Velasquez: It is hard, we also didn't. This isn't something that was ever covered in the curriculum, right? I mean, our education, whether it's NPP, AMD, you we talk about this on a lot of podcasts, you don't cover this stuff. This is things that ⁓ you have to learn. And the reality is, is how many healthcare professionals do you see that are unhealthy? And they're preaching, hey, you know what, you got to do ABC. And it's like, well, it look like you take it that seriously. You know what I mean? You have to live it to really convince people to do it, right?
Sarah Gallegos: That's true. That's so true. ⁓
Jeremiah Velasquez: Yeah. I've heard some people say there are certain diets that work better for reversal of these kinds of conditions. do think Mediterranean keto is there any specific diets that you guide people towards or recommend?
Sarah Gallegos: ⁓ absolutely, I people toward the Mediterranean diet every time. It's been the number one diet in America for more than 20 years. I it's the most universally accepted. yes, keto better for some people. Yes, there are other diets that work better for other people, but Mediterranean's gonna work for the majority of people the majority of the time. I have found.
Jeremiah Velasquez: And when comes to like specific types of exercise, do you do you tell them, hey, weight training versus cardio, or does it matter or get X amount of What you know, what's the general rule on that?
Sarah Gallegos: You know, have, again, I feel like a lot of times I get to start people on this journey, but I don't get to continue the journey with them. I've been doing this for three years and I probably have only had like a handful of people that have stuck with me the whole time. Whether it's because they got busy and fell off of my charts or I sent them to you, I have done that before. So I don't always get to like see that progress. So that's a little bit.
Jeremiah Velasquez: Yeah, yep.
Sarah Gallegos: Frustrating what was the original question though?
Jeremiah Velasquez: or weight or weight training which one's better?
Sarah Gallegos: ⁓ yeah. So I always am like, listen, you just need to move more. Either move more or change your diet. always tell people don't do both at the same time. If here, yeah, if you're here and you're morbidly obese, you gotta pick one or the other. And once you get good at one, then you can pick up the other. But I find that if you try to do all of it at once, it's too overwhelming and that doesn't work. you just need to move more. Either move more or change your diet. I always tell people don't do both at same time. And once you get good at one, then you pick up the other. But I find that if you try to do all of it at once, it's too overwhelming and that doesn't work.
Jeremiah Velasquez: I love that. That's really refreshing because you're right. If you bite off too much, you to make too many changes at once, it's not going to stick, You have to get that positive reinforcement from one thing ⁓ before you move on to the other. And the same time, you're stacking these habits. show yourself, you know what? I've been eating healthy for a months now. I have this down. I'm going to go ahead and start exercising now. ⁓ You've already put yourself in a great place to Stacking these habits is the way to go. If you try to do everything at once, like a New Year's resolution,
Sarah Gallegos: Absolutely.
Jeremiah Velasquez: There's a reason they do not work out. my general thought on it is, Build much muscle as you can. That's the number one disposal of glucose. That's where your glucose gets stored. If you wanna live longer, you wanna be harder to kill, build It's the most important thing. And I tell everyone, most of my guys on TRT, if you're not going to the gym you're not doing weight training, you're doing yourself a disservice. My women.
Sarah Gallegos: Absolutely. Of course it is.
Jeremiah Velasquez: who need to preserve bone density. if you're not doing weight training, you're doing yourself a disservice. Cardio is great too, guys, but we gotta weight train. It is so important. It doesn't have to be crazy. mean, even sometimes I'll have women just wear a weighted vest around the house. That's enough. You just gotta meet them where they're at, but weight training is so incredibly important and build as much muscle as you can to carry you through the rest of your life and you're live a longer, healthier life. Now, ⁓ yeah, that's...
Sarah Gallegos: That's great. Meet them where they're at. I like that. That was good.
Jeremiah Velasquez: meet them where they're at. Now, are there specific red flags that you might say like, okay, these are what I want you to look out for if someone's dealing with mass hold.
Sarah Gallegos: don't see a lot of mast cells. I see a lot of mash. So I see, yeah, I see patients that are already high risk. They are either serotic or they're so close to serotic that you don't want to tell them they're serotic yet because you're worried that it may freak them out. So usually for the serotic patients, it's a little more serious, right? Are you having abdominal pain? Are you having signs of GI bleeding?
Jeremiah Velasquez: Okay, sure, mash. Yeah.
Sarah Gallegos: confusion, those are the top like three that I stick to as far as like, these are really important things. for the mash patients that aren't serotic abdominal pain, I'm finding a lot of times is prevalent them. So just trying to make sure that we know what the, ⁓ that the pain isn't something more serious. like if you have gallstones, right? And you're having right upper quadrant abdominal pain and you need your gallbladder out and you're an F3 serotic. sorry, F3 liver patient, then need to get your gallbladder out. I mean, that's something that's pretty emergent because you're progressing into something more serious and when become serotic, you're a higher risk for surgery. those are kind of the warning signs that I stick to for F3, F4 serotics. And swelling, sorry, I swelling. I knew there was four. I'm telling you, the number four, it's a whole thing. ⁓ So yeah, abdominal pain, bleeding.
Jeremiah Velasquez: love for. it's square number.
Sarah Gallegos: What did I say? Confusion. What was the last one? Swelling. Inflammation.
Jeremiah Velasquez: swelling. Okay, so let me let me let me reframe it. So what should a primary care let's say to go to their primary care like what are the things the primary care may want to look for to say, Hey, think it's time that we send you to Sarah because we're not liking what we're seeing.
Sarah Gallegos: Yeah, I think that it gets missed a lot, but abdominal pain, swelling that isn't cardiac pulmonary, right? I mean, because those can cause swelling too. But lot of times like that, inflammation or any type of GI problems, people come to me with GI problems and then it turns out they have a liver problem. That happens a lot too. So those are the top three I'd say for primary care, right? Inflammation's a big one. If you don't have an explanation for your inflammation, at least look at the liver, right? So run some liver function tests they're gonna be elevated almost always in these mastoid patients. ⁓ some form of elevation probably.
Jeremiah Velasquez: Sure. Do you think like as far as consults go, it's typically delayed or do you think that from what you see, because you see these in later stages, you feel like this, people could be a lot better being proactive with getting consultation sooner.
Sarah Gallegos: Absolutely, I think nobody wants to have the conversation that you have fatty liver disease. I get those consults all the time where they're like, you have a fatty liver, go. And I'm like, well, what did they do for you? And they're like, nothing really, they just said that my liver was fatty and that was it. And the word fatty liver is just so generic that I think that we're patients a disservice by not sending them over sooner or talking to them sooner about kind of what's going on.
Jeremiah Velasquez: are some of the other testing that they do? know like they have fibro scans and they have ultrasounds, biopsies. Like what are some of the tests they do to confirm these diagnosis? ⁓
Sarah Gallegos: Yes, so diagnostically stage your liver fibrosis or scarring, we definitely do the blood work and the ELF test, which I think that primary care could utilize a lot more. An ELF test, E-L-F ELF, that's fibrosis test that you can order at Quest or LabCorp, most Quest or LabCorp. And if you can't get it, ⁓ like your insurance won't pay for it, there's actually reimbursement programs through those companies that make. the medications that they want you to use to reverse your fibrosis. Also, Novo Nordis and Madrigal, who makes res stifra. have programs where they'll reimburse you for those ELF tests if you start using them. Sorry to go off on a total tangent, which seems to be my thing. So the blood work is important that we talked about earlier. then ultrasounds and then Fibroscan is a special type of ultrasound that actually looks at the liver cells and how stiff they are.
Jeremiah Velasquez: Mmm. Okay.
Sarah Gallegos: the stiffness of your liver cells kind of determines how much scarring or fibrosis that you have.
Jeremiah Velasquez: Hmm. Are there some genetic components that play into this too? Are some people more just genetically, predisposed to having this?
Sarah Gallegos: Yes, absolutely. I also do with my elevated LFT patients an alpha-1 antitrypsin test, which isn't typically something that people are doing. Alpha-1 antitrypsin deficiency is something that puts you higher risk for cirrhosis already. So that's just one genetic component. Obviously, if you have obesity or diabetes in your family, those are things that can also put you higher risk for fibrosis of your liver. I mean, diabetics, this is the diabetic capital of Colorado, if we're being honest. So anybody that's Hispanic or African-American, you're already genetically predisposed to have liver fibrosis. That's just the name of the game.
Jeremiah Velasquez: Absolutely. Yeah. You know, I wake up every day and I'm like, not today. Thank goodness, you know. I'll try again tomorrow, but okay, we're gonna flip the script a little bit here. So we're going from hormones happen to hepatitis happens. And I'm gonna have you ask me a question. Yeah, I know. I didn't even prepare her for this. She has no idea what to ask me. Anything, hormones, weight loss.
Sarah Gallegos: Well, I I was not prepared for this at all, sir.
Jeremiah Velasquez: I know, I know, I'd put you on the spot. Told you I wasn't, and I did anyway.
Sarah Gallegos: That was terrible. Okay, when your patients come in, do you always ask them, mean, how do you start deciding what kind of weight loss program to put them on?
Jeremiah Velasquez: Sure, for me it's pretty simple. I'm a huge advocate for tris-epatide. I'm a huge advocate for the GLP-1s for other reasons than just weight loss. Weight loss is fantastic, but the in ⁓ metabolic decreasing insulin resistance, I have young healthy athletes on GLP-1s. I think the GLP-1s are an amazing medication for a multitude of different purposes ⁓ outside weight loss.
Sarah Gallegos: Thank you
Jeremiah Velasquez: Frankly, I mean, do they do well at weight loss? They do great, but you have to have the right mindset. I don't necessarily like the fast, rapid weight loss that is associated with them. We even have things like face, I heard ozempic neck, like just this stupid shit that people come up with. And it's just fear-mongering. I mean, you it can be real, right? But that's any kind of rapid weight loss. So me, really, it's, I educate them on the difference between, because we offer semiglutite torezepotide. We talk about the difference between a GLP-1 agonist,
Sarah Gallegos: real.
Jeremiah Velasquez: GLP one with a GIP agonist and then I let them make the decision and usually the deciding factor will be their budget will typically be the cost, you know, so that's okay I mean the reality is is these medications aren't necessarily cheap I do hope in the future it comes to a point to where it can be accessible for everyone insurance will start ⁓ this for just about anyone and it'll be very affordable for cash pay I really hope that that's the future because ⁓ really kind of cleaning up a mess that we've already developed and you develop these addictions in a young age. mean, how many of us grew up eating Lucky Charms, Fruit Loops, and they called it cereal for breakfast. it's, know, how can you not have a sugar addiction later in life? Like it's just, we're set up for failure and now we have something that can help to fix it. And we're being price gouged and stigmatized and, ⁓ you know, I know where we're going to go with it. I just kind of go day by day, but there's nothing more rewarding getting someone, having someone reach out to me saying,
Sarah Gallegos: Thank
Jeremiah Velasquez: It's absolutely changed my life. I feel better. Anxiety is much better. I hear that all the time. A of women with their perimenopausal symptoms feel so much better. Fertility, fertility improves too. It has a lot of ovarian support. And then of course, decreased insulin resistance and metabolic disease. These are as close to miracle drugs as we can get, but it's important to know it's a tool. At the end of the day, it's a tool. ⁓ And it's gonna work if you work it. So that's really about it. That's the conversation we'd have. If you called me, text me, that's what that conversation would sound like because I put you in control. I let you choose. I don't say you can't be on this. You have to be on this. ultimately, I think We deserve to have a say our And I take that very seriously.
Sarah Gallegos: was a really good answer. Did you practice?
Jeremiah Velasquez: Yeah, I did. Yeah, I did. I you text me before the podcast. Sarah, in closing all this, what one thing ⁓ you to let people know as far as, hey, if I'm concerned about this, this is something that's weighing heavily on my mind. What should do tomorrow?
Sarah Gallegos: If you're concerned about liver disease, you mean?
Jeremiah Velasquez: Yes.
Sarah Gallegos: Dr. Azar says only you can control what you put in your mouth.
Jeremiah Velasquez: That's true, 1000%, I agree with that.
Sarah Gallegos: He says it every single day. you can control what you eat and drink every single day.
Jeremiah Velasquez: Enough. It's like Smokey the Bear, only you can prevent forest fires, right? Only you can prevent liver disease, okay? Yeah.
Sarah Gallegos: It's true. I did have one more hormone question though. Can I ask you another question?
Jeremiah Velasquez: Of course you can. Yeah, yeah, of course. We're still in Hepatitis Happens.
Sarah Gallegos: hepatitis happens. ⁓ I have two things. it really make my job a lot easier if primary care providers would 100 % of the time after getting elevated LFTs check for viral and autoimmune, well, at least viral hepatitis.
Jeremiah Velasquez: Yeah, that's your that's your podcast. And how do we do that,
Sarah Gallegos: lot of times there's like an acute viral hepatitis panel you can order or even a chronic viral hepatitis panel. Hepatitis happens, speaking of viral hepatitis, hepatitis B vaccine, has anyone been talking about this? Because my head is getting ready to explode. It's bad, hepatitis B is not curable. You can't cure it and you can think whatever you would like to think about vaccines. I have no opinion on everybody else's opinion.
Jeremiah Velasquez: Yeah. Right? ⁓ no.
Sarah Gallegos: Medically, do not want to treat hepatitis B patients 10 years from now, 20 years from now. It's terrifying. So hepatitis B vaccines, look into it, look into what hepatitis B is, how you can get it, and just, we should be testing for it more, especially as these vaccines get more scarce. So yeah, the viral hepatitis question.
Jeremiah Velasquez: Huge, yeah. Okay, I love it.
Sarah Gallegos: That's something that PCPs can test for. And then the question I had for you was about the thyroid,
Jeremiah Velasquez: Mm. Mm. Confusion.
Sarah Gallegos: Are you not testing people's thyroid when you're seeing them for weight loss? Function.
Jeremiah Velasquez: Nah, it depends, we can. is the thing, we can test for anything that they want specifically, but we defer a lot to their primary care providers. ⁓ So, assume that they have a primary care provider. We can always get labs. I'm more than happy to get and explain several things for them. But as you know, weight loss is encompassing. There are so many different factors to it. Thyroid can be huge, ⁓ hormones can be huge. ⁓ And again, you gotta meet patient where they're at. At what point do you draw the line between, we're a hormone weight loss clinic and a primary care clinic, ⁓ so that's really kind of where you have to differentiate and delineate because there's a lot that goes into it, Like let's say you want full workup of that thyroid, We're going to need to start palpating it, ultrasound if there's a nodule, ⁓ potential, know, fine aspiration biopsy. There's a lot of things that go into it. So, you know, checking thyroid, cool, ⁓ but then what do do when it's not good, right? They go to their PCP.
Sarah Gallegos: ⁓ sorry.
Jeremiah Velasquez: So, you know, the reality is, depending on their symptoms, depending on their intake forms and stuff like that, we can usually kind of differentiate some things. And ⁓ I had some people, and this is more so with hormones, have I had some people come in ⁓ have these really vague symptoms and it's not, hormones causing your issues, low ferritin levels in women who have very heavy menstrual cycles, I see it all time. get that iron up, guess what? You feel like a million bucks again. It wasn't hormones the reality is, it's very complex, but once again, I offer it. Because worst case scenario, let's say you take it, doesn't help, doesn't do anything. Okay, well that was, you know, diagnostic too, right? Didn't work, something else is wrong. that's my thought process on it.
Sarah Gallegos: And then like the psychological of weight management. you, honestly, just because I'm also practicing in the same area as you, are you referring people to, I mean, who are you referring people to? Because I feel like in this area, it's just so hard to good support. Yeah.
Jeremiah Velasquez: For psych? No, haven't referred anyone to anything. And I agree it is kind of scarce. But just because someone's overweight, I don't typically tell them they need to go seek ⁓ psychiatric treatment. ⁓
Sarah Gallegos: Well, no, that's not what mean. No, I just mean, like, if people are having a hard time, I mean, we need to take that into consideration. They're emotional health, and I think that's something that's easy to dismiss, but also, like, should we be sending them somewhere? Should somebody be talking to them? Obviously, I'm not qualified to do that, and you're not gonna take that on either. So, I mean, what do we do?
Jeremiah Velasquez: Hey, what I is just, leveling. I like to be very supportive. I reach out frequently and we have a small win, they're like, hey, I lost three pounds, like, that's fantastic. That is really good. And I'd be sure to emphasize this. It's not the medication that lost those three pounds. was you. You did that. You're doing a fantastic job. And if you just build up, you give them a better opinion of themselves, they're going to do better because We have a habit of forming an opinion of ourself based on what other people think. We let other people determine our value, determine our worth. And if you are around people who are very positive and very supportive, that's a great circle. If you're in people who are just very dismissive and they're very negative against your goals, you're never gonna thrive. I tell you to get rid of that circle, go to a new one. And so do feel like, and I can't this, but I assume ⁓ that with my positive behavior supportive nature towards... towards just anyone who's trying, think it helps. I it does. I'd like to think so at least. Helps me sleep at night. Hey, that's it. I help myself. I help everyone I can, you know, because the reality is, it shouldn't this hard. It shouldn't be this hard for us to just try to live our best life, I really do wish in a perfect world one day, I'd to think that we have full access of our healthcare and it's affordable and we can be on hormones we want. We can be on the...
Sarah Gallegos: Yeah, I agree. You've helped me.
Jeremiah Velasquez: medications we want and we're able to make these decisions on our own with guidance, not dictation from medical providers. But knows? Who knows what will happen? But I appreciate everything you do. There's no doubt about it. You do a fantastic job. And I'm really happy you came on the podcast. Do you have anything you'd like to say? Any closing words?
Sarah Gallegos: Yeah. Hepatitis happens, I can't believe that's what you titled it. I love that for me, I'd love to come back. I just love hepatology, I think it's amazing. I think that the liver's amazing, it can do so good and bad things to the human body and I think people need to know more about it. We take it for granted, it heals itself until it doesn't anymore, so it's important.
Jeremiah Velasquez: Yeah.
Sarah Gallegos: for us to take care of it and for us to take care of each other. And I think the more information we have as a general public, the better because that's we do, right? Knowledge is power.
Jeremiah Velasquez: Knowledge is power. Awesome, Sarah. Thanks for joining us today.
