In this episode of the Chris Wolfe Podcast, Dr. Jim Stringham discusses the relationship between metabolic diseases and eye health, emphasizing the historical context of obesity, the role of environment versus genetics, and the importance of lifestyle changes in disease prevention. The conversation explores how inflammation from metabolic diseases can impact ocular health and the clinical implications for patient management. In this conversation, Chris and Jim Stringham delve into the significant impact of diet and lifestyle on health, exploring the role of GLP-1 agonists in weight management and the broader implications for holistic health. They discuss the importance of aligning physical, mental, and spiritual well-being, and the potential benefits of nutritional interventions in addressing metabolic health issues. The conversation culminates in an introduction to innovative solutions being developed to support individuals in achieving better metabolic health.
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percent of folks with either diabetes or pre-diabetes metabolic syndrome is is a huge deal is 60% of individuals you know roughly by the time you're 60 years old have some form of disease or metabolic syndrome and so recognizing this issue and and talking to docs over the past you know 10 or 15 years about this you know I thought well let's develop you know a formula based on science to help individuals deal with a gift gift doctor some ammunition for their patients again the nutrients backed by you know years of replicated science this includes carotenoids omega-3s and nutrients that you know aid in glucose metabolism and lipid metabolism and and so this product we just released it fairly recently it's called macuhealth DM hello and welcome to the crystal podcast on iCode media today again we're gonna have Dr. Jim Stringham on with us to discuss you know metabolic diseases and how they're related how the how the problem is global but how it's related to the eyes and and what can we do about those medical alcoholic diseases in our practices for our patients and i'm excited for this conversation it's one that i've been uh looking forward to having for a long time mainly because you know i see these patients all the time you know you think about patients who have diabetes in our practices patients who are overweight obese they're not insignificant i even think about our patients with ocular surface disease and inflammation how much of that is driven by things like gut health and metabolic diseases so i think it's uh it's a timely conversation to round out the year and to sort of project forward how we're going to interact with patients in 2025 so Dr. Stringham as always thanks for coming on the most common questions i get include what ophthalmological codes or evaluation and management codes should i use what iCD 10 codes do i need to build with this cpt code what cpt codes can be built together and what can't and my favorite how do i manage a patient who has diabetes who comes in for a quote unquote routine i exam these questions really highlight the confusion and uncertainty that serves as a daunting hurdle for providers makes it more challenging for them to care for their patients and provide those patients with the best opportunity for a lifetime of ocular health and clear vision that's why we built i code education for this specific purpose our mission is to provide optometrists with resources to help you understand disease states revenue cycles and billing and coding so that you can put that on autopilot and truly care for your patients check out icodeeducation.com that's EY E C O D E education.com we've developed a premier billing and coding bundle that includes all of our billing and coding resources in one place we also have a 10 discount code just for listeners of this podcast enter the coupon code EY E C O D E M E D I A 22 at checkout we'd love to work with you check out i code education.com hello dedicated optometrists are you looking 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details vision edge pro because your patients deserve the best in iHealth go to macuhealth.com and use the coupon code podcast 2024 at checkout for special discounts thanks chris i really appreciate it this is gonna be great yeah yeah i'm looking forward to so let me get right into it tell me a little bit about the kind of back you know you've done a ton of research into you know metabolic diseases and and how it stands today but give us a back story of when you think about the history of metabolic diseases and the why behind it how far back do we go and where did things start to change well i mean this is a great question and and you know you you want to look back um you know sort of as an epidemiologist to kind of scan what what's going on and what's predictive of where we are today we have data back to 1985 from the cdc on obesity in america and and we have data from the different states you can access the data actually online it's really fascinating there are powerpoint slides that show you progression through time every year that first year in 1985 we only had data on about half of the states in the united states and the reason for that is that you know obesity wasn't really a big problem uh back then if you can imagine uh so the nationwide uh prevalence of of obesity and and how we define obesity is a bmi a body mass index of 30 or higher and that for just comparison sake is a person who's five foot four and roughly 30 pounds overweight okay so that's you know as an example uh yeah can i pause on that real quick kind of certain that because there's a little bit of criticism within bmi because if you're like a big bilky bodybuilder guy like that might shift that bmi so but but the reality is is like that's a very small fraction of what we're talking about it is and i i agree with you totally i mean i've worked with athlete populations who their bmi is 32 but it's because they're you know huge muscular i mean they're certainly body fat percentage would be an easier metric or a better metric i should say the easier metric is bmi you know it's it's basically your you know height divided by weight or weight divided by height there's a formula it's pretty simple as long as you've got those two easily obtained metrics so anyhow uh that aside you know in your right it's a relatively small fraction when you're talking about you know people who are incredibly muscular driving that bmi over 30 1985 half the states uh nationwide prevalence of about eight percent uh meeting the criteria for obesity so it's you know fairly low by today's standards and some states it was more like three or four percent Colorado for example generally maybe a little healthier and more active etc and so you you fast forward through the years and you start to see you know this exponential increase and it it dovetails kind of interestingly enough you know personal computing uh the internet social media smartphones that kind of thing and and so i i think you know when you're looking for causes potentially i mean that aspect of maybe not being as active plays a huge role diet certainly plays a huge role as well and so you see that exponential increase to where we are today which is a staggering and kind of harrowing statistic we're over 40 percent uh obese uh the population not even overweight just obese over and overweight what's the overweight population overweight i believe it's in the 60s 60 percent 60 i want to say 64 65 um and that's you know that's that's i believe over 27 is overweight in between 27 and 30 so so yeah there's a it's it's a massive problem and uh and and so people ask me about you know genetics and and what the role is you know of genetics you know like we're predisposed to be overweight and you know really we all we have to do is look back at these data and say well okay this is environmental genetics doesn't change that fast in 40 years uh you know this is an environmental effect uh for whatever reason something's happening here in the in the mid eighties and it's you know we're changing rapidly uh up until the modern day so well it's interesting i was talking to some i i was in fact running uh yesterday morning and i was talking to somebody about it thanks and and i was but but actually this topic came up exactly and and we were discussing you know we're it's in the morning it's a bunch of guys we're sort of just spitballing what we think might happen and why this is the case but you know there's a lot of different factors one is you know you can go down these nefarious rabbit holes um and then you can also go down the the idea of of you know have we have we allowed um you know what's part of the culture that we have that obviously you know we've changed our diets there's a lot into your point we've changed our diets we're eating more sugar you probably have some data on that um we're living more sedentary and then also what's the factors of like the the it's okay like yeah it's just your genetics like how many times do we hear that how many times is that being told to the public where it's not necessarily true and what you're saying is that it isn't true but we've believed it so now we're more likely instead of saying like no i can i can beat my genetics it's going to be hard i can or or it's not genetics at all but but it's environmental it's going to be hard i'm gonna have to change behavior but because we've accepted as a culture that it is that there is a genetic component or so many of us have then it's like well no matter what behavior i have it's not going to matter so there's this or underlying actually social um detriment to to what's going on that that robs people of their authority over this so that's a lot what do you think about that you're absolutely right i mean and these are i mean this is a great line of reasoning to challenge you know the genetic predisposition for things and you know up until really the last 40 or 50 years you know genetics was considered uh you know destiny so for instance macular degeneration if it's in your family it's just a matter of time before you go blind i mean that was the conventional wisdom really but now we know that you can do so much for that disease and really all diseases over the lifespan you know and these are you know behavioral modifications you know in terms of eating behavior activity physical activity huge effects you can reduce your risk by 70 percent with regard to macular degeneration by making lifestyle changes and again consistently over your lifespan so i want you yeah can you elaborate on that because i obviously we're talking about metabolic disease but but that's a number that nobody really talks about and so first can you can you cite that uh that that data and then um 70 percent i mean that's good lifestyle changes over you know lifestyle choices over time not necessarily changes but choices over time can impact your outcome that's not a number that that would align with like a reds too for example arids too the best you could do would be to supplement right and that would be an old supplement and it would only give you about 25 percent risk reduction yeah and so and and you look at the arids data and i know we're getting mildly off topic here we'll come back but i think this is really important to talk about in in this sort of uh global scheme of things um you look back at epidemiology uh and and this is johana sedans work from 1994 july mars in 2011 both find that a lifetime you know of you you take a snapshot of folks who are of advanced age and you look at their life uh you know you know you know that they lived in terms of diet exercise etcetera behaviors and then where are they uh when they're 75 80 years old do they have macular degeneration you know heart disease etc what's their bmi and you find you know consistently that this was replicated you know this july mars replicated what johana sedan found uh basically a 45 reduction in risk for development of of AMD and then if you don't smoke and you have you know pretty good physical activity you know three to four times a week vigorous physical activity that number becomes 71 percent reduced risk for AMD and that's you know that's a huge right that i mean if there were a drug that could do that yes i mean it would just you know you give everybody that drug unfortunately it requires discipline it requires you know good be healthy behaviors throughout your lifespan and arid's looked at only people with macular degeneration they did not look for a preventative effect and so a lot of good came out of arid's i you know i i do have you know my you know battles with it occasional oh yeah yeah certainly it i'm on the side of prevention and so we didn't look at really prevention other than prevention of progression to the right state right but the idea of getting way out in front of it was kind of lost in that study and so but there is a lot you can do and and this is true of anything related to say metabolic syndrome uh you know it's a long game and and so what we want to do for patients is to say okay you know you might not be in a great place right now but there's a lot you can do that's positive it does require required discipline and uh and that's that's the key you know as human beings we always gravitate towards what's easy uh and and is it easy uh to go out and physically exercise like you do chris you know every morning going out for run um you know in the cold temperatures that are in Nebraska this time of year don't remind me that's it's hard it's hard right and so yeah i'm here in phoenix that's 75 percent anyway but uh but no it's it's hard regardless of temperature right you have to get up you know wake yourself up get out of bed and go and run you know and and uh that's that's not easy so the easy thing is to kind of like well you know wake up sit on the couch you know and and same thing with diet the easy thing is to eat easy foods and you know have something pre-made uh maybe fast food whatever it's much easier i agree and the stuff tastes great i mean it's very savory and you know sweet whatever and um and so it's a little harder to eat healthy and you know whole foods and prepare your own food cook that kind of thing so we're you know i don't want to say people are lazy i say people are just you know it's easier and so you know really it's hard to argue with that approach but you have to be disciplined i think to be healthy so my comment there would be the so some of the guys that um that i that i hang around with they'll say you just got to pick your heart you know like if you if you get up and and sit on the couch all day long and you know eat eat greasy food and like that might seem easy now but at some point it's going to be hard for most of us it'll be hard uh and i and i and i think once you get into a habit what they would tell you is like once you're in a habit that becomes easy it would actually be really hard for me to change my lifestyle or for some some of them for sure some of these guys that i'm around to change their lifestyle now i feel like i'm sounding a little bit preachy and that's not the that's not the point the point is is that you know any there there are hard things all the time and this is one of them it's probably worth by taking the harder path at least initially because then the longer-term path becomes easier perhaps and so so i want to kind of come back to metabolic disease because i think it was really apropos when you were talking about macular degeneration and some of those earlier studies when when you add in all of those things none of that was supplementation that you mentioned right if you talk about prevention none of those things i mean there might have been you know good healthy lifestyle choices there might have been you know we're gonna pick whole foods that are that are colorful um but of that 70 percent i didn't hear you mention anyway and maybe there was a component of it but but ultimately it was it was largely related to or connected to things that would drive lower risk of metabolic disease so having said that you know um that's pretty controllable and yeah it really is and i you know we think about we talked about macular degeneration and you know you think about other you know age related diseases and when you think about disease just in a general sense you think well okay you you catch a disease or you get a disease and with age related disease you know anything you know neurodegenerative disease like macular degeneration alzheimer's disease you know cardiovascular disease as well which you know the incidence rises precipitously with age you think well okay you get to a certain age and then you get it that's not how it works it it's a gradual cumulative damage that's manifest as disease at some point in your life now that's why we see age related disease happening to people in their 50s we see you know legitimate cases of macular degeneration for instance you know happening occurring in the late 40s early 50s like not juvenile not you know early onset it's legitimate macular degeneration and it's you know it's these predisposing factors you know excessive oxidative stress and inflammation um you know as a as it turns out exercise plays a role perhaps through epigenetics diet impacts epigenetics as well it suppresses these you know genes these factors that you know lead to aging of tissues and damage and so you know one of the major themes here that i want to impart to the audience is that it's a long game and so you make small changes and you know you mentioned supplementation you know that's you know where my studies are you know interventional studies with carotenoids omega-3s these specific nutrients have really strong effects and they're the ones that were determined to be the driving causes in the epidemiology that i mentioned earlier that led to these massive you know reductions in risk for developing at for instance AMD but this this goes for other diseases of aging as well and and they also help in the interim you don't have to wait until you're 70 or 80 years old to realize benefit uh but but yeah it's it's a long game and that's a that's a major point well and so okay i want to talk a few about a few things um first because i well actually let's let's keep on the long game all right so in in your research when we think about if it's the long game and you're talking about people in their 50s who might want to have an impact on their longer term period of life sure you know how much how much are they going to have to start changing in their 50s what about in their 40s what about in their 30s like let's say you've you know you were active in high school and you go 10 years and you just and you and you active your diet changes you're not not very good for 10 years like how do we talk to patients about you know listen i've got you're 35 years old and we can impact change or we're 40 years old and now we're i mean i think about how hard it would be for me to change my behaviors now at 43 as ingrained as they are as part of my identity as they are all my behaviors good and bad right it'd be really hard so how do we handle that clinically how do we handle that with our patients you know because i mean because the thing is it's like so i'm i'm sitting here thinking about you know my patient that's that's got type two diabetes mild retinopathy 49 years old obese right doesn't look that heavy but really by definition obese and i'm sitting here thinking like the conversation i'm having with you about hey and i'll ask them hey do you want to go work out in the morning and they'll say well it's too cold it's too dark i need to get in shape it's like that's the point but but but like to really have that conversation it's like i don't want to be defeatist i have the conversation but like that change for that guy is infinitely harder than than or actually i would say if i'm that guy in my state should say and you say chris i want you to get up in the morning and hang out on the couch and eat a burger all day long and munch all day long like that behavior change for me would be infinitely hard just like his behavior change would be infinitely hard so what do we do with that that's a that's a good perspective and i'm i'm with you you know i've been physically active it's a habit now and i agree it would be hard to go back it would be hard to go back to you know after my high school days eating a lot of fast food and and you know my body was used to processing it now if i i mean my daughter uh has a part-time job she's in high school she works at taco bell and she'll occasionally bring home you know some food for me and i'll try it you know and whatever and and it's like whoa you know i just don't feel right you know and and so it's that whole thing but in reverse right and and so right i mean i've been there i get it and uh and so i think that you know it's a tough it's this is the million dollar question right you know patience how do you motivate them to make a change other than just saying oh you need to exercise and you have a healthy diet see you later see you next time it's it they feel fine and so they they think i'm okay i feel fine you know i'm all right no nothing really wrong i'm not diagnosed technically with any disease and you know so i i must be all right um it's it's a scary thing it almost when you think about where you're headed and so i don't i'm not on board with scaring people into doing things but you know if you look at the future and you think well you know you might have and you might be you know more susceptible to developing things like Alzheimer's disease for instance maybe in your 60s nobody wants to be there and and we've all been probably touched by Alzheimer's disease in some way and you know you see the the horrible you know it's a pernicious disease and and uh what a burden you know for for family friends you know how care providers it brings other people you know way down it's really hard and so nobody wants that nobody wants macular degeneration uh certainly diabetes um so yeah that's uh that's maybe a strategy is to you know illustrate to people like here's you know for somebody you know if they don't do anything in in your instance you know you maybe putting yourself at risk for developing these diseases now mind you it might not be until 10 15 20 years down the road but it's these are bad things to happen to a person yeah yeah and you don't want to sugarcoat it and also you don't want to abandon them you know it's like it's like i'll be here to help you help you when when that happens and i hope it doesn't but you know these are these are the things that we can change now because i think you know if you think about it like like smoking cessation on the risk of AMD onset and progression you know basically your risk becomes the same as it as it was had you never smoked after 20 years so that means that you know if you're 50 years old and you want to make a change by the time you're 70 if you've if you've really made a change you still can i mean there's a lot of life left after 70 if you've lived it well absolutely yeah and and say thing to say at 30 you know maybe you haven't done things well at 30 and okay so i know we're talking about smoking but but i'm i think you could probably apply the same sort of reasoning of you know if we if you commit to something whatever that lifestyle is for a period of time five 10 20 years you probably can undo a lot of what you've done uh up to a certain point yeah you absolutely can and i've seen this with my own eyes and i i'm sure you have as well you know in the chairs and optometrists and you know you see changes maybe in the retina you see changes in you know for in my case visual performance and also personally i mean we've had folks you know in my family that uh you know my wife's grandmother who was diagnosed with AMD in her family uh early 60s and her mother you know bilateral went blind you know in her late 60s and so this was you know in her early 60s started her supplementing with the macular carotenoids you know loutineses isanthan and i was very early in my career and i said oh gosh you know we have to do something about this these can help and so consistently you know she has taken these over the past you know 25 or 30 years and she's 91 now and she switched ophthalmologists because uh her you know doctor retired and her new ophthalmologist said well uh you know you were diagnosed with macular degeneration you know dry form uh back in 1980 something and uh and she said yep yep i've got macular degenerate i take my you know my eye pills and it's all good and he goes well if you know i was to examine you today i would not diagnose you with AMD you don't have retinal signs of AMD anymore and that's 30 years i mean that's that's pretty amazing and you know given the genetic you know the family history and all that so you know i've seen all of this from all different angles athletes who are at the top of their game get better because of you know performance advantages enhancing you know from the carotenoids from omegas and so there there are things you can do that are relatively easy actually uh you talk about getting the right nutrients the ones that have been studied really carefully these macular carotenoids the omegas there are other in nutrients that have effects on lipid metabolism on glucose metabolism as well very well studied the history goes back and and again it takes a little bit of work if you're going to eat the food for sure a little easier if you've got you know some really high quality supplements and you can realize these effects and they do like you say have these dramatic effects just like cigarette smoking cessation uh you you're talking about all of these you know direct effects antioxidant anti-inflammatory but also you're switching on these factors that that lead to cleaning up of the system uh it cleaning up debris in the retina in the brain improving you know blood flow out to you know capillary beds you know all of this stuff the epigenetic effects turning on these circuits that you know are healthy and signal basically it's a useful function uh so we all want to you know act more youthful that's certainly a good way to do it so you can have a huge huge impact uh with with just nutrition but you know of course we're talking a little bit about exercise as well here but you know uh well i want to get into the nutrition in a in a second i actually want to get into some of the specifics because you mentioned some things about um about changing some of the way that your metabolism is for you know your lipid metabolism and some of those other things i want to get into more specifics there about about the specific nutrients because that's interesting to me um but before i do that there's one other kind of thought process i wanted to go down because you know in a lot of these patients that i see you know a lot of ocular surface disease patients um and i wanted to go down the the uh course of you know how much does the ocular or the oxidative stress of metabolic disease impact inflammation systemically but also inflammation inside or on the anterior surface of the eye so low grade inflammation inside of the eye but also like ocular surface dysfunction uh where we see inflammation as a primary driver my suspicion is largely that if patients cleaned up their diets and cleaned up their i mean i think a lot of it is also just other factors you know the type of things that we do we're not blinking but like how much of that could be controlled by like better diets better uh you know exercise habits so can you talk a little bit about you know inflammatory process within metabolic diseases yeah absolutely and i can confirm your suspicions that you know if you were to clean up have a less inflammatory oxidative you know sort of situation diet wise uh you know the eyes are you know these markers uh for you know all sorts of health as you know is an eye doctor uh you know and systemic inflammation can be seen on ocular surface that inflammation is influenced by that certainly you can have a window to the brain by looking at the retina uh cardiovascular health is also you know sort of you get a window into that you know from the eyes uh diabetes is a extremely pro-inflammatory condition and hyperglycemia if it's uncontrolled sugar levels uh that's also highly oxidative and so you you end up producing these hydroxyl radicals um and then that triggers an immune response these uh macrophages and neutrophils which use you know reactive oxygen species as their inflammatory response it's a cycle so oxidation begets inflammation and that begets more oxidation and then you cycle and it's not just speculation now we have tons of hard data that show that for instance we're talking about carotenoids the lutein's azanthin measal's azanthin in the eye controlling all things uh diet uh BMI everything if you have a diabetic versus a non-diabetic patient the macular pigment is nearly three times as high in the non-diabetic as it is the diabetic patient so what that is is indicating is that these carotenoids even if you're eating them are getting used up systemically in an attempt the body's trying to use these really powerful nutrients systemically they don't just go directly to the eye they're in the body and then if whatever's left over it gets to target tissues like the eye and the brain skin cardiovascular system um and so they're being used up uh ahead of time. They're being used up primarily as an antioxidant that's right systemically and and so you're you're depleting that store and then which means less gets to tissues like the retina and so and we know you know because of the pro-inflammatory state uh systemically that's going to impact you know all tissues of the body uh whether directly or indirectly uh in the you know the case of the cornea as well the ocular surface you've got you know a relationship between certain pro-inflammatory cytokines systemically and those that are found on the ocular surface you know IL 17 RA I know is certainly one of those um you know but there's a again a vast literature that indicates this you know pro-inflammatory state systemically how that impacts uh the eye not only you know sort of anterior but you know posterior as well segment and you know retina clear through to the front and in the cornea so well it's hard because because a lot of the things you're talking about are these even low grade inflammatory processes where they're not they're what might be called subclinical you know like you might have a patient that um has so I a patient with you know bilateral anterior uveitis and I had a patient like this over the last three months that we've been we've been managing and um and so you know you you get some you get kind of these standard lab tests there's just kind of battery of lab tests that you're suspicious when you have that occur you're pretty suspicious that there's something systemic going on but you know in your gut I mean I'm sitting back and I always think like well 50 percent of the time there's a there's a cause that we can identify the other 50 percent of the time we will not be able to identify it so the first lab test that the patient got through our kind of general lab was like positive for everything you know positive for showgrins positive for um rheumatoid factor positive for aa and a and so then you know that allows us to get her in with um with a rheumatologist right the rheumatologist comes and and they do the same labs they repeat them and uh and everything comes back normal right comes back negative now this patient is is she she doesn't look I mean she's 70 years old she doesn't look like she's um super overweight probably because that's what we've become used to but she's she's definitely obese definitely obese um and so it you know then then the diagnosis becomes well the the original lab work that was done through the hospital system was all false positives our new lab work that we use is all the accurate one that's what the rheumatologist tells her and I'm left thinking like how do we get how do we get a hospital based lab that gets everything false positive because it was repeated it was negative or could it have just been that whatever the amount of inflammation because at that time you know we had it we had it controlled we had it with control with topical medications maybe the only place that we were seeing it was anterior you know anterior chamber reaction um but the thing I think about is like well how much how many of these things just and that was a significant one like but it it just was significant enough at that time to create an anterior chamber reaction in both eyes come back positive on all these tests but we controlled it or it just ran its course and the inflammation sort of cycled down and when it was checked again it was all fine like these are the sort of clinical questions that I have a lot where it's like and now it's now it was just like up it's idiopathic we don't know what's causing it well well really the thing that it leaves me thinking is like you know could we just have her you know she's 70 but could she walk every day could she change her diet could she like can we make it a bigger impact because her blood her blood sugar is spiking and anyway what's your reaction to that I mean that's sort of does that seem reasonable Cooper vision and the AOA have joined forces in a ground breaking initiative to transform how optometrist treat children with myopia the myopia collective aims to unite our profession and its allies to challenge the status quo and elevate the standard of care for children with myopia everyone is invited to become a member of the collective by joining you pledge to act in slowing childhood myopia progression membership includes regular updates and information about the collective's efforts access to educational opportunities and resources and insights from the ambassador optometrist who advocate for community policy and changes supporting a collective's mission click the link in the show notes to join the collective today we've been partnering with SLOR LEXOTICA 360 for a while now and it helps us in three areas first they use social media campaigns to highlight products that we believe in and prescribe to our patients and they deliver those patients back to our practice second SLOR LEXOTICA 360 enhances our patient experience through staff training tools to help us simplify and streamline the way we communicate about our products and services lastly but for my practice most importantly it helps us make good business decisions related to our optical offerings we will systematically and objectively analyze what our patients are purchasing and what they like and removing products that our patients are not really using or not really drawn to this along with additional rebates and immediate savings helps us continue to deliver high quality products and services to our patients and keeps our practice resilient check out SLOR LEXOTICA 360 for yourself by visiting SLOR LEXOTICA 360 dot com yeah oh it does and that's an interesting case and you're not alone I mean this kind of thing happens occasionally and you know there was a basis for that if there's some kind of a flare up for instance you know that that'll occur occasionally and some folks you know you'll have a flare up and you'll get you know maybe some you'll see it on the skin you know eczema psoriasis or something it's related to you know systemic inflammation certainly the eye and maybe that was what was going on there another related sort of phenomenon I think that's that's important just from a big picture perspective in medicine is you know what what do we base where are the norms now you know so you you do test and you see like okay so the norm and by the way these norms have shifted significantly over the past 50 years like what's normal for you know like cholesterol is a good example but but you know what's normal for you know blood lipids what's normal for you know I love to talk about cholesterol we should talk about that sometime you know yeah no kidding so you know there's been a little bit of a moving target but but my point is that you know these things are shifting to the direction of you know to where it's like well acceptable what's what's the average person and is that average person healthy anymore you know like I wonder about that certainly we have you know vitamin levels that we we know are kind of vitamin and essential minerals and stuff like that that are you know we know kind of where they're supposed to be but I wonder you know if you're you know you're you're moving that needle out to unhealthy and if we're saying okay you're okay when in fact it's like well we really need to work it back down to the the healthy range what used to be maybe considered normal and so I worry about that word sometimes that normal what does that mean so this process yeah so so the the changes that we see since 1984 within the CDC data and the numbers that you that you arrive at there's no other conclusion but well what would be there's no other reasonable conclusion outside of diet and sedentary lifestyle is that accurate I think that's that's accurate you can drill down a little farther and look at things like processed foods the you know ultra processing of foods and those kinds of things but we're still on food you know what what you're eating and and it's you know activity levels and when you look at activity it's little things in the 1980s you know you would have to get off the couch to turn the channel on TV for instance I mean little things like that it sounds ridiculous and silly but you know I think it's it's easy now to say well everybody walks around with their phone and and you know it's you sit with your phone and it's you're looking at things instead of maybe going out and and doing something going for a walk but but it's it's not like you have to go to the gym for three hours a day I think it's it's a little additive you know bits of of exercise just getting up and going and standing as opposed to sitting for instance you know doing a little bit of exercise every day adds up a lot the food aspect of it is is huge as well again what's easy it things that and things that taste really good now you know salt sweet and fat wow you know that used to be rare back in the day you know hundreds of years ago we didn't have that too much of that and so we developed these cravings we need some of that certainly to function some but not as much as we're getting generally today so yeah I think you're right I mean the the reasonable conclusion is that this is an environmental thing this is all you know what we put in our bodies and and what we're doing with our bodies you're a cautious guy Jim but I'm gonna and I'm generally cautious too but I'm going to sort of open a little bit of a can of worms you know so we talked a little bit about behavior and feeling like you know again if we've medicalized this and geneticized it where it doesn't need to be medicalized and geneticized then if those are even words then what about things like the GLP1 agonists that are available now that have gotten tons of you know tons of I've most many of my patients whether they have diabetes or don't have diabetes or taking these on a regular basis and if you talk to them most of them sort of say yeah I don't think I want to be on this forever but boy it's really giving me some good results so there's this there's this sort of underlying like thought that like yeah it's probably not good for me to be on a medication constantly to suppress my appetite and maybe I'll be able to change but you've already said like it's processing food it's the food we take in I can't help but think you know this bigger this bigger scale of like okay well you know our our food companies and our pharmacy you know pharmaceutical companies you know I think I think it's a little too far maybe I'm not ready to go there yet that it's nefarious but like they're finding a they're finding solutions to problems those relatively simple solutions for people and and why are people so and I don't think that's necessarily nefarious and so much as it's it's just like hey we can find a fix and we can make a lot of money on this fix and so we'd rather just give you the fix yeah how do you impact that this the the semagluetide osmemic etc and I don't mean to you know of course slander anything or anybody this is wow it's a it's a huge issue from a lot of different angles and you know our metric for health in this case is what it's weight right it's how much you weigh and so it's not are you healthy it's I mean there is a healthy weight right and and I get it generally speaking you know if you're if you're a hundred pounds overweight you need some help get you know down certainly I'm not going to the grudge you for that you know that's that's good you know to lose the weight how it works it's an appetite suppressant effectively right and so you eat less and that you know generally you might think well that's a good thing well what what are you eating and typically they're still the same foods that they would eat just less so you're talking about french fries chicken nuggets and I mean I don't mean to generalize too much but it's probably not the healthiest food and so you're starting to see cases that I've seen reported now it's been out long enough to where you've got nutrient deficiency yeah in these folks and they're you know like precariously deficient in in really good nutrients because they're not a not eating a lot of food and then what they are eating isn't really nutrient-dense so it's it's pretty empty calories and so and then another point on this is you know I mentioned easy you know what what's easy and this is easy right I mean yeah wow you don't have to be crisp wolf you know running five miles ten miles a day whatever you do uh you know to stay in shape you can take a pill get an injection you know and um that's you know that mean heck that's appealing right you don't have to necessarily exercise to lose weight um you don't have to you know cognitively limit your intake and so and and all of this is pretty unnatural so and and you know I am well known for saying you know nature always wins uh you know you can't trick nature and so now we're starting to see some reports come out of you know the effectiveness length the period of effectiveness of these drugs is you know maybe six or seven months and so then you start to see it where off the body is I mean the magical magical part of the human body or really any biological entity is its ability to adapt so it it adapts it changes and this allows us to adapt to all sorts of different conditions I mean environmental internal food you know what we put in the body what we don't put in the body uh you're able to adapt and and overcome you know certain circumstances that's a magical part of the human body so it's not a one plus one equals two it's you know it's a one plus one equals something and it depends on what the body how the body reacts to it and so it looks like at least preliminarily like this drug will not last forever in terms of its effect where do we go from here um and you know folks I worry about them yo-yoing you know going yeah you know off and going back and then up and down and that's not healthy that's not good for the body at all in terms again of this massive inflammatory cascade and then you know you settle back down and then do that over and over it's it's not healthy so um yeah I worry about malnutrition with with this drug I know folks are very excited about using it and losing the weight and I mean heck I would be too for sure because that's what's been held over people's heads for so long is you know you need to meet your target weight you need to lose weight and if that's the goal then this does it but you know healthy you know what is healthy and that's a really should be our concern that should be you know top of the page well that's what we you know that's what we where we started was weight right BMI and and so that's where we started the conversation and it's a it's a metric and and that can kind of get that number down but like all the other intrinsic things that come from so I'll tell you like I think I've said it before I if I have a struggle it's I love ice cream I love ice cream and I love ice cream at night time like the worst time to have ice cream and you know my wife is smart enough for me I got home the other day actually it was it must have been a Monday it was must been Monday night and you know I got home weight dinner and I I've um I've been fasting five days a week where I would I had fast for basically like a 22-hour period so I have like a two-hour to two and a half hour eating window and I've done this for since July and only it's it's awesome because one like I feel my GI system feels way better but also it allows me to have periods where I don't have to like if we're going to have pasta and grains and you know sit down with a big meal on the weekends like I can still have fun with food I don't feel like I'm I'm challenged by it now that's worked for me it doesn't work for everybody but it's been you know I I can say listen I'm gonna fast and I can have a great meal at dinner but the thing I love and the thing I really want is a pint of ice cream you know at at 8.30 at night and I know it's not good but but Jamie but so Jamie um I think I got home and I was like why don't you have she had you know the groceries came and I said why don't you ever get ice cream like why don't you ever have ice cream I always got to go buy my own ice cream and and she she was kind of like you know she she sort of played it off a little bit but I think she was she's I know she's smart enough to know that they're like I just keep it out it's so now I got to make a trip to the store and so it's like another behavior right it's another behavior like if I can just withhold it and I don't I haven't had any ice cream this week because it has been inconvenient for me to go to the store she's making it hard for you yeah exactly so it's not not easy yeah yes it's so so like I say all that to say like well we've sort of adapted these these things in place and we're not perfect by any means I like I said but it makes me think like well could the semagletudes could the jail p1 agonists could they actually serve as a way to get people on track like you know could we actually put it in place and implement it where where like the way we use it the way we prescribe it is I'm going to prescribe this for you but I'm also going to get you in contact with a personal trainer or with a you know like we've got to get because it's only going to last six months or seven months I'm really cynical that that that that we're going to actually have active movement toward that but that's where I think there's a ton of opportunity you know there's a ton of opportunity with it to to sort of ignite this lifestyle change but that means that there's going to be hard after right we can we can ignite this but there's going to be hard after that's I that's what I worry about with this with this medication yeah for sure I agree I think that if you were able to you know as part of the prescription you know certainly recommend and get folks on you know at some form of exercise program some form of you know like hey let's evaluate your diet and you know if you can you know condition if you can connect the exercise aspect obviously you're taking the semaglutide drug but you know the exercise aspect with the weight loss and you're kind of grooved on it and like you know I have noted once or twice in this podcast you know it's a habit it becomes a habit your exercise you recognize that okay I'm feeling better when I exercise I feel great when I eat better I feel better and so you hope I mean that's an optimistic viewpoint but you hope that that takes hold and it's not sort of like well I'm doing my olympic and it's you know I've lost all this weight and people are losing a lot of weight and that's great but then you know it becomes ineffective or you are taken off of the drug and then what do you do well you revert back to your old habits and so you've got to form some new habits I think and and that you know if you can groove those again part of this is psychology a big part of it and you know totally you know connect the two you know like I'm exercising yeah the drug is is happening but I'm going to maintain this because this feels good being lighter it feels good when I exercise it it feels good when I put healthy stuff and you know food in my body you know if you can hit that that's like the trifecta and you know you're in good shape going forward but you know again I you know I'm skeptical you know people tend to gravitate back to the couch and so you know that the easy way out you know they don't want to have to drive to the store to get their pint of ice cream but you know it's yeah let alone have to walk to the store what if I had a walk to the store right like there'd be a point there's like a whole piece of car key yeah now I now I could even just which I'm sure I would having a thought about this maybe I should but like I could door-dash it you know like I know but yeah you know like your easy thing oh my gosh yeah well and you and you and you uh and I plan to that see now I'm gonna think about it yeah but the the the the thing that all of this you brought up health and then you also brought up um you know mistaking wait for health and and one of the things that that all of this stuff does is when it's all connected and it's working well I mean for me it's my you know it's my prayer life it's my it's my family life it's my uh physical life it's my professional life when those are firing on all cylinders it's not just that you know my physique looks okay um or that my GI system feels good it's like my life feels like it's aligned right like it feels like things are just in tune and in sync and if any of those things get out of whack then then things sort of tilt and and and jumble and and that's I think the like the the ultimate thing of and and that happens to me right it totally happens to me where I if my prayer like again if I my prayer life is not is not good then I sort of be focused on other things and internally my um you know like I'll think about something that might be a little bit I'm not I'm not settled on or I haven't identified how I'm going to fix that problem or well how about and like I'll just get this little like sort of anxiety in my stomach right but if it's if it's or if if you know my wife and I are just a little out of sync or my kids and I are just a little out of sync then then I'm much more anxious right I'm much more um like when I think about it's not it's not even related but like think about the practice or like how am I going to handle this or the new buildings coming on you know I've got this big big office expense that we're going to have like you just get a little pit in your stomach right it's a it makes you more anxious as opposed to like when those things are aligned and all and and I'm and that's what I've learned that's why I'm so disciplined it's like I can be disciplined because I know like almost everything that I'll think about stuff I'm like oh this would make me really anxious if if all of those things if I wasn't staying focused on all of those things that thought would make me anxious but when it's all aligned it's like no I can have that thought I can consider it I can internalize it I can process it I can actively think about it but everything's kind of in sync and so I don't know I don't know whatever that means but it I think that's what you're looking for in health right you're looking for that sort of reaction to health yeah no absolutely I think that makes a lot of sense it really does I mean I can certainly relate to that you know having this you know sort of homeostasis in in your life I love that word holistically you know all everything's in balance and and you know when you're firing on all cylinders how great that feels I mean it's like everything is lined up and great and you know and you want that for everybody you want to grab your patience say come inside my body here and feel this you know and this is where we want to be you know in your in a health it may be a little bit of a disarray and you know so we need to you know kind of restore balance and you know physiologically we can do that nutrition plays a huge role you know you can kind of reset push the reset button just introducing you know certain compounds even these corrupt nights for instance you know latencies let's talk about that let's round out this discussion with that yeah I mean those those compounds you know they're they're like a positive shock to the system so I've done you know numerous intervention studies and when I was at the University of Georgia we did a study and and my my wife's part of the research team the brains of the operation and I know I just do the heavy lifting she's probably the looks too Jim yeah if we're being honest oh absolutely yeah and then my kids thankfully got got hurt anyway but yeah so so we she did a lot of the blood work and assessed you know pro-inflammatory cytokines antioxidant potential was the most interesting finding to me I mean granted we found you know significantly lowered inflammation versus placebo and this is just what the carotenoids you know loutineses azanthin meses azanthin and just over a six-month period in healthy right healthy young adults these are college age students from 18 to 25 years old and one of the really really the strongest finding we found in in the blood there were other benefits certainly visual performance cognitive performance but but in the blood was this antioxidant potential it was dramatically the bar was huge compared to placebo and the higher that potential that means the the higher systemically your body's able to you know quench free radicals and this is all kinds of radicals lipid radicals lipid-based peroxidation radicals nitrogen hydroxyl radical all of these and so that's a very good thing as you might imagine so you know in these students we're having observations you know most of them were like well my vision at night is a lot better and my memory is too sharper and I don't have brain fog and these kinds of things but I can't help but think well that's that's related to this systemic like reset button push you know there you go all of this stuff is mopped up you know all of that oxidation that would otherwise lead to inflammation that would you know lead to you know the body kind of panicking a little bit because you're damaging you know blood blood vessels you're you know potentially raising up in in areas that use a lot of oxygen for metabolism like the retina or the brain you know there's less protection there you can't quench those those radical oxygen species and you know we need a little bit of of the free radical the singlet oxygen the body uses it but it gets again out of homeostatic balance and you're down the road to you know oxidative stress and and that's not a good thing you know this leads to that anxiety of stress we've studied that as well and and you know how that actually plays a role so so that would actually create more anxiety as well like there's actually i i guess i didn't really i didn't even think about the oxidative stress and inflammatory process being linked to kind of another anxious process isn't that's true yeah that the psychological to you raise up these levels and you know any insult to the body uh is you know in terms of stress is viewed the same way so you might be worried about relationship or or money uh or you might get hit on the leg with a stick uh you know any kind of stress the body what does it do it you know it dumps cortisol into the system you know uh you know this is a adrenal glands and boom there you go and it's off to the races there's an upregulate there's immune system response uh there's you know psychological effects the body's all connected you know and and so if there's excessive oxidative stress in the body then that's going to rise to the level of you know cognition of of psychology of of anxiety and stress and then you know you lose sleep that's a stress or sleep deprivation you know you know you can't sleep because you're not sleeping and uh you know all of these things and so and we see so much of that in society again all of it's connected um you know all of these things uh you you watch the evening news and you see commercials for you know all the pharmaceutical drugs that are treating issues that are all related to inflammation and oxidation and and you know all of this you know the outcomes uh that are that are you know out that crop out from all of the the precursor the oxidative stress and inflammation including you know lack of sleep so it's a do you have do you have the so you know it's pretty rare I would think and I I'm not I can't do this but but like how many people do you think or or do you think people can actually when they start feeling that that in additional anxiety or or stress wherever it's coming from them like how many people do you actually think and say I can step back and be like all right well first thing I'm going to do is I'm going to call myself down and know like tomorrow's going to be better and second I'm going to really figure out well what what got out of balance did I have too many beers this weekend or too much wine or did I eat too many pies of ice cream like like you seem to me that or did I you know I like it would seem to me that if you could be that in tune with with sort of the way that your body is telling you um and and your you know spiritual life as well is like telling you what's going on man like how empowered could you be yeah I think when you look at it sounds like you Chris you know you've got to handle on a lot of things and and you're you know have a level of awareness of fooling a lot of people well yeah maybe so but someday they're gonna figure it out the discipline aspect of all of this is huge and so you know if you're a very disciplined person and and you're really paying attention to your body you know I mean like I've worked with you know many super high level athletes and and they're an interesting group because they know when even a little twinge of something's not quite right in their body something's not quite right with you know mentally or you know physically with their with their physical body and and so they're they're very in tune with that and that's because they're in fantastic shape they know exactly what's going into their body what's going out how much energy you know what they can do in the gym at times if they're running you know whatever they know exactly what's going on they know all the metrics and and so if something's off slightly they they can say what's up and you know they can it can evaluate okay what did I do this weekend like you say you know ice cream beers whatever and so I think that you know for folks that might be really you know kind of in terms of a state of health not in good shape you know they're they're pretty far gone and that ability to be refined in their thinking about health about you know diet what's going on with their body that's lost in a lot of noise I think and so you again you want folks to get to a position where you know they've got a handle on that and certainly people know what it feels like to feel good they know what it feels like to possibly even when they were children you know to be in pretty good physical shape to be able to do things you know I used to be able to do 10 pull-ups or whatever and and maybe not so much anymore you know but but you know they know it and so you want them to get back to that point where you know and again it it comes it comes with being in a state of of generally good health easier said than done but but I think that you know that's that's where we want our patients to be and and yeah what a magical thing to be able to say oh wow yeah I didn't really eat many you know colored fruits and vegetables or leafy greens last couple weeks maybe that's part of it and then you know you realize that you you get on that and it's not a immediate you can't eat a salad and then be like woo Superman you know but you can you know go a couple of weeks beating healthfully and you notice effects I mean it's you know even even me you know I I'm captain vegetable or whatever and I you know I tend to eat well but you know I fall off the wagon a little bit and then but I come back on and it's like ah that's what it was you know and clarity of thought even you know and and just you know the ability you know I'm going to run and it's like some days you're just like wammo I'm like you know on top of the world I can run all day other days it's like oh man my legs are not they feel like they're twice as heavy as they used to be yeah and you know I'm sure you experience that too and it's like I do you know that what's going on there well you can usually derive back you know to you know what what's going on you know with with a lot of its diet and certainly you know you're asleep I mean it's all connected but but yeah health is where we should be focusing and not certainly not wait with respect to this conversation on metabolic health. So Dr. Jim Stringham you've gone on a journey with me that probably took us in places that you didn't necessarily know we were going to go and I really appreciate it because it lets my brain sort of wander in in fun ways and in ways that a lot of people aren't willing to kind of go down pathways people aren't willing to go down. So I appreciate that I also want to recognize that you know this whole entire hour that we've spent you haven't talked once I don't think about MacuHealth but but you work you work at MacuHealth and and one of the reasons that I think this is exciting for me is you know can I do something better for my patients who have metabolic disease to maybe jumpstart and have conversations with them that aren't just that aren't just going to fall on deaf ears but give them a place to start that could be as simple as some of these other things that we could compound some a larger discussion on. So tell me a little bit about what you guys are working on at MacuHealth I know you were going to go the whole episode and not talk about it but I think it's it's worth if you're willing to talk about it I'll get a platform to talk about it right here at the end. Well I appreciate it yes I am the chief scientific officer for MacuHealth I spent you know the vast majority of my career in academia as a research scientist and research professor and so what recognizing the you know massive issue there's a staggering problem that we've got here in the United States and it's really the developed world but you know specific to the United States we talked about the data 50 percent of folks with either diabetes or pre-diabetes metabolic syndrome is is a huge deal is 60 percent of individuals you know roughly by the time you're 60 years old have some form of disease or metabolic syndrome and so recognizing this issue and talking to docs over the past you know 10 or 15 years about this you know I thought well let's develop you know a formula based on science to help individuals deal with and give doctors some ammunition for their patients again the nutrients backed by you know years of replicated science this includes carotenoids omega-3s and nutrients that you know aid in glucose metabolism and lipid metabolism and and so this product we just released it fairly recently it's called MacuHealth DM for daily metabolic we we see DM in the medical field and we think diabetes diabetes of course you know technically we're not treating a disease here we're addressing issues that that are associated with these kinds of you know that the syndrome namely oxidative stress inflammation and you know glucose metabolism and so yeah macuhealth DM I'm really excited about this the potential to to help individuals again you know we want to promote you know this holistic approach to health you know that includes you know an exercise regimen you know thinking about things the right way you know moderate portions you know changing diet as well but you know these are nutrients that we don't get enough of certainly here in the United States in general and and so if you put these in your body these kinds of positive shocks to the system like I mentioned earlier can happen and and you're helping patients I mean again diabetic retinopathy helped you know there were lots and lots of studies and and maybe I can send you a few that we can make available to listeners I mean it's great the the wealth of data it's it's overwhelming it's it's really great and so we we know about this and and we can we can help folks and so that's that's very exciting to me so let's do that I'll if you can set actually if you can send this in a send that in a I can create a document that will be clickable that people can can create a web page just for that citation so we'll post that in the show notes and we'll we'll link to it on all of our other social medias and again I think what's really telling Jim that that I think is actually commendable is that we talked a whole lot about things that you had no vested interest as a company in and that shows to me that that like you view you view the bigger picture as part of a holistic approach and and I think that's that speaks a lot to to what you guys are doing and so thanks for doing it and and thanks for for you know playing a role and offering something for our patients but also thinking about it as a piece of the whole pie and I think that's that's what's challenging for a lot of us is like how from an eye care perspective how can we how can we help the whole patient more without losing sight of the eyes and so you've done a great job of articulating some of these bigger points that and where you can have can you can push the button so thanks for doing it I appreciate the conversation yeah you bet you bet thank you Chris I really appreciate the opportunity hey if you enjoyed this episode make sure to subscribe to us on apple podcast and our youtube channel both linked in the show notes now here's something exciting we're given away a one year subscription to comprehensive optometry simplified all you have to do is leave us a review on apple podcasts take a screenshot and email it to me at questions at icodeeducation.com we'll put that in the show notes as well we'll be selecting a winner on December 15th so don't miss your chance to get access to this valuable resource thanks again for listening I can't wait to see your reviews so you can get access to this video and I'll see you in the next video. 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