Heather Lee (Host): Hi there, everyone. Thanks so much for listening to this latest episode of Medically Speaking. I'm your host, Heather Lee. And joining me today is Dr. Ashley Bernotas, who is the Director of Obesity Medicine for Kaleida Health. Thanks so much for being here.

Dr. Ashley Bernotas: Thank you for having me.

Host: We had chatted previously on the phone, sort of getting gearing up for today. We did an event together. And I feel like I could listen to you talk for hours. You just have so much great information about obesity medicine. However, you did the transition to this. This was not always your primary focus.

Dr. Ashley Bernotas: Yeah. So, I was primary care. I trained in primary care for my practice for about seven years before getting into this. I was feeling burnout in primary care as many of my primary care colleagues are and have been. And I thought how could I impact patient care and enjoy what I do and get the fulfillment out of it that I wanted to when I joined, when I started going to medical school? And so, I looked into it and I found there was a pathway into obesity medicine, which I didn't even know existed. But it's an important field for me and a passion of mine, because I struggle with it and I have my entire life as have my family members. And so, I figured I have some insight into it, some basic knowledge, and lets me expand on that knowledge actually for personal reasons, and then I thought I could bring it to my patients.

Host: Yeah. Before we dive into what you do now, when you were debating whether or not like do I take this path or this path? Especially being a doctor, did you ever feel that-- as women, we feel like this pressure to be what everybody thinks we are.

Dr. Ashley Bernotas: And you don't really listen to ourselves and what we want to do career wise and what's best for us. And I think that every physician-- I know at least from my physician friends and myself, every physician questions themself almost daily.

Host: But I feel like you don't want to admit that to other people.

Dr. Ashley Bernotas: No.

Host: You know, I'm hoping that we have more talks around this and that we bring it up as a topic, because there's a lot of imposter syndrome out there, or people questioning their decisions. And I feel as though there's something that's guiding you into this. You know, you're meant to be a healer. You're meant to be here. And if you're not happy at where you're at, there's a way out and you could figure something. You could find a pathway that you enjoy.

Dr. Ashley Bernotas: I feel like that's great advice, you know, in the medical field or not.

Host: And every aspect of life. I think there's always a way out. You deserve to be happy.

Dr. Ashley Bernotas: Yeah, exactly. And bet on yourself and trust your gut.

Host: So, you found this passion, this calling. You're relatively new to Kaleida. Walk me through the steps of how you landed with us and we're so happy that you landed with us.

Dr. Ashley Bernotas: Well, thank you. Yeah. So, I'm originally from Toronto and we decided to move. I completed my residency in Plattsburgh, New York, close to the Vermont and Montreal area. And then, we decided to move to Buffalo to be closer to my family in Toronto. And so, when I was joining-- well actually, I was just putting out some feelers for jobs, and I reached out to GPPC and I said, you know, "I'm a primary care physician looking for employment. Do you guys have any openings?" So, I interviewed with them. I was going to start with them at their Maplemere new office. And that same week, they had a job posting for the Director of Obesity Medicine. And they said, "So, bells are going off and we might have to take a little detour." I remember the recruiter saying, "Do you want to pursue this? You're dual board certified in both of these things that we need." And I said, "Absolutely, let's go for it." And that's how I got the job.

Host: And I know that you said that this is something that you personally have dealt with family members. But what about obesity medicine just really drew you to caring for your patients? And how, I guess, do you use your personal experience to shape the care that you give for others? Because I feel like there's something comforting about knowing somebody who has walked in your shoes or understands where you're coming from, as opposed to being told, "This is what you're doing wrong," "This is what you should have been doing," you know, sort of an outsider looking in.

Dr. Ashley Bernotas: Yeah. And I feel like that that experience that I have allows me, like you said, to understand patients where they're coming from and meet them where they're at instead of telling them how to do-- you know, I say, "I understand. This is how it is." And, you know, oftentimes they're in my office saying, "How'd you know this? Like, you're reading my mind." And I'm like, "Yes, because I live it too." And my patients, countless of my patients live it too. But I think that initially it actually intimidated me, struggling with my weight. And then, I'm like, "How am I going to guide these people with weight loss when I struggle with this myself?"

And then, coming to terms with the fact that it's a chronic disease that I did not have all the say in. And it is a largely genetic disease, kind of relieved me of some of that pressure and talking to my patients. And receiving their feedback on, you know, "It's nice to speak to someone who understands me and gets me" is wonderful. And I think that, you know, there's a lack of knowledge with obesity medicine in medicine in general. And I think that we're now finally talking about it, which is wonderful. But I think that for the longest time people are just told these simple things, eat less, exercise more, and they're just kind of brushed off. And I like to delve into that and help them and support them.

Host: You were talking about people saying, "Oh, well, you know, eat less, exercise more to a certain extent." There's obviously the genetic component. But what other things or advices being thrown out there that is maybe not so sage?

Dr. Ashley Bernotas: Not so sage? Okay. Yes. So, that makes sense. So, I think that the perception that a patient suffering with obesity or overweight is unhealthy is incorrect. And I often will have patients who have pristine blood work better than some of my thinner patients who will come in with large amounts of muscle mass and lower amounts of body fat mass than some of my "thinner" patients.

And I think that that big misconception leads to a lot of bias within our society. And most of my patients are like, you know, "I eat salads. I don't eat fast food. I'm not eating this junk food that people are-- I'm not lazy. You know, I'm trying to exercise. I'm trying my best." And I think that we need to be kinder to each other. I think that we all need to understand that we all have different things going on in our lives. And as a busy parent, it's really hard to exercise. It's really hard. My exercise is chasing my toddler around my house or getting outside in the summer months, but we're in Buffalo. The winter is a little bit harder.

Host: Yeah, it's real life.

Dr. Ashley Bernotas: It is.

Host: I think that's the biggest thing. You get some people that say, you know, "You're making excuses." And I'm like, "Okay. Sometimes. Sure." But other times, it's real life. There's work, there's family, there's so many factors, that go into it. And then, again, the genetics. You know, I've come to the terms, you know, that I'm not going to be stick skinny, right? Nobody in my family is stick skinny. So when you look at these pictures on social media, you wonder like, "Well, why can't I look like that?" I don't think I was destined to ever be that person.

Dr. Ashley Bernotas: Exactly. And I like how you said, you make excuses. And I don't really love the term excuses. I think that we're too hard on ourselves. And I think that we're just explaining where we're at in life, you know? And my patients come to me, like I said, very busy. They're either in school or society, and our work-life balance was not made for us to exercise four hours a day, to eat these, you know, super organic, healthy foods. Like, yes, you look at the cost of food, you look at food accessibility in a lot of parts of the country.

Host: I look at my lunch break and I'm busy today.

Dr. Ashley Bernotas: You skip lunch.

Host: You skip lunch.

Dr. Ashley Bernotas: You skip breakfast, because you're rushing to a meeting. And you get home and you're just nonstop and you're finally sitting down to eat at 8:00 at night and you're going to bed an hour later, right? And so, I think that society is just not meant for us to slow down, work on yourself and exercise. They're like, "Let's just pile everything on.

Host: Yeah. If exercising four hours a day was the only thing that we had to do, we'd all probably be in a much different state. But there's work, there's life. At what point does somebody pick up the phone and give you a call and say, "You know what? I might need some help from you"? Are there certain thresholds? Is there certain challenges they might be facing? Who can contact you and your team?

Dr. Ashley Bernotas: So really, I'd be happy with anyone doing it. I don't think that there's ever a wrong situation where you would reach out to us. I feel as though if you feel like you need help with your weight, then we are here for you and I can at least talk to you and guide you, you know, on different options based on your actual weight, what the insurance is going to cover. You know, there are many aspects that play into that, but I think that anyone who's struggling, anyone who has questions about it can make an appointment and we can at least chat about it.

Host: Yeah. Let's go back to the genetics for a second. How much of it is genetics? How much of it is, you know, personal life choices and activity levels and all of that? Is there a one-size-fits-all percentage? Or does it vary from person to person?

Dr. Ashley Bernotas: This is a great question. So, I think that it's largely genetic. I would say about 70-80% genetic.

Host: Wow.

Dr. Ashley Bernotas: I always tell my patients it's about 70-80% genetic, and the rest is hormonal. Because when they studied these medications that are out, they studied them against diet and exercise alone. And what they found is that the average weight loss with diet and exercise alone was 3%. The medications can get up to 23%, which means there's a whole other 20% there that is untapped that we can't control. And society has made it so it's put all the pressure on us, and said you can control this through diet and exercise. And if you're not controlling it, you're lazy, you're not working hard enough, you don't have enough motivation, willpower. You know, all these words that are, you know, just putting a lot of ownership on us when actually it's our hormones playing a huge role, which is what these medications tap into.

So in addition to our genetics, and of course, there is some environmental factors, you know what you're eating when you're younger and, you know, your family life and those stressors that plays a role into it and can actually modify your genetics throughout your life. But the hormones that we're now tapping into with the treatments is a great-- I guess I would say that now it's nice that we can actually act on these hormones that we can't improve on our own or change on our own.

Host: There are always going to be those people that they hear of, you know, the different weight loss medications. And they're going to go, "You're just trying to push medicine on me. You're trying to take the easy way out." What's your answer to that? Especially when you're talking about, you know, 70-80% genetics. But there are always going to be the naysayers that are always going to say you're not doing enough.

Dr. Ashley Bernotas: I would say to them that there's no easy way out. You know, surgery is not an easy way out. Taking a medication every week and injecting yourself with something is not an easy way out. The easy way out would be to do nothing. And I don't even think that's the easy way out because you'll be suffering, you know. And I think that we never, ever tell patients with asthma, "You're taking the easy way out by using your inhaler. Just exercise, lose some weight, reduce your your environmental stressors or, you know, move yourself away from anything that triggers your asthma." You know, similar to don't eat those carbs, eat more protein. And, you know, same thing with blood pressure medications. You're not taking the easy way out. People don't often look at, you know, obesity as a disease. That's also a big misconception and a big issue that we're trying to educate people. It is a chronic disease. We found that there's, you know, chronicity to it, which is why we can't cure it. And if it was cured, these large companies that make a lot of money off of dieting would no longer be in business, right? Because we'd find some way to cure it.

Host: Let's talk social media for a second. You know, I'm guilty. You scroll through, you see the influencers, the people who are into fitness and fads and diets and all of the things. It can get frustrating sometimes, because, again, I'm guilty of it. You compare yourself to other people. How do you guide your patients through that aspect of it? Because I feel like it's in my head, you know, even though I know better and there's the part of me that is reasonable, there's the part that is unreasonable.

Dr. Ashley Bernotas: Yes. And it's hard to control that. It's in our environment every day. And we are hearing about the success stories, much like, you know, they say often people who post on social media don't post in their darkest moments. They're posting at the height of their--

Host: It's the highlight reel.

Dr. Ashley Bernotas: It's the highlight reel. Exactly. And so, I think that, you know, obviously taking that into account, but also distancing yourself from, you know, following certain people who don't fit into how you want to live your life. And I find that those who I follow are mostly physicians who are, you know, teaching obesity medicine and who have struggled with their weight their whole lives too. And so, I feel like that that is my club. That's where I belong. And I feel like I can understand their situation, their progress, and theirs matches mine a little bit more. So, I think just isolating those who don't really fit into how you feel about your body would be helpful.

Host: Yeah. Because it can be frustrating, you know, and discouraging too, because if you're not seeing the same losses or the same gains as, you know, depending on how you look at it, I feel like it could be a setback. Well, what's the point? You know, if I've only lost one pound when I want to lose 40, what's the point?

And that's largely the complaint that I get with patients who come in who have exercised and dieted and, you know, they're like, "I gave up on exercise because I'm doing all this work, putting in all of this stuff." Especially women as they approach menopause, it's almost like the body just doesn't want to get rid of that fat.

Dr. Ashley Bernotas: Yeah. It fires back at us. The menopause transition is one of the hardest things that women go through, and I think that it needs to be talked about a lot more. And I could also talk about that for days, but I would say that it's the time in their life when it doesn't budge. They can exercise, they can do all these things. And finally, these medications do come in and allow them to continue exercising and eating healthy, but actually losing the weight and seeing results that they want.

Host: And 18-year-old me is not, you know, me today. That's 10 years ago, I'm not the same person. But I think, again, it's the reality of it and there's the reasonable side, and then there's the irrational side that sometimes can't process all of that. You said that we need to change decades of thinking when it comes to treating chronic disease and obesity with short term solutions. Again, what are we doing wrong and what do we need to change and do better?

Dr. Ashley Bernotas: So, as I said, it's a chronic disease. It doesn't respond to short term solutions. These fad diets that we've been dealing with since I would say like the '80s, you know?

Host: Oh gosh.

Dr. Ashley Bernotas: The Jazzercise.

Host: The Cabbage diet.

Dr. Ashley Bernotas: The Zone Diet, the Nutrisystem, the Weight Watchers. You know, all of these diets are not going to solve our problem. Sure, they can guide you, but it needs to be something that fits into your life. And if it is too unrealistic, if you are eating what I call astronaut food, you know, if you're eating these like freeze dried meals, you know...

Host: You're not enjoying yourself.

Dr. Ashley Bernotas: And you're not enjoying life. Not going to be able to sustain it, and it's not going to be continued. And so, I tell patients, I'm like, "We at our clinic meet you where you're at." So, we want to know how you eat, what your lifestyle looks like. Are you a soccer mom going to soccer practice three days a week? Are you a single mom? Are you not a parent and you have a lot of free time in the evening? You love to cook, you know, and then we find out what your preferences are, go based off of that and try to help you increase your protein, decrease your carbs, and work on your macros so that you can actually go out to a restaurant, you know, go somewhere and not feel like you can't eat any food and make it realistic and easier.

Host: On that note, if somebody uses a weight loss medication, you know, we talked about it's not the easy way out, because it's not a free for all. It's not you get a shot and then you can just do whatever, eat whatever. It's part of a bigger picture, right?

Dr. Ashley Bernotas: Yes, yes. And I definitely could tell if a patient is not necessarily adhering to a healthier lifestyle. And we talk about it. You know, sometimes things happen and life has its ups and downs and stressors. And sometimes patients will be like, "Yeah, you know, I lost my mother. I'm really not coping well. I haven't been able to follow the diet." And I'm like, "It's okay. That's okay, because life happens." And we need to be able to understand that that happens. And then, we'll get on track when you're ready.

Host: Is there a particular BMI weight percentage? How do you factor who's a good candidate for one of the-- before we get to that, can we just talk to about BMI for a second?

Dr. Ashley Bernotas: We could talk about BMI.

Host: I'm 5′2″. I'm not going to give my weight. It's probably not where I want it to be or perhaps where it should be. But I feel like I've been obese since I was four years old, because the calculations and I think about my body type and all of these things. You see that number. That is discouraging.

Dr. Ashley Bernotas: It is. I want to correct you on one thing. I don't love the term when you said you're obese. What we like to use is actually person-first language, which is we're trying to shift and say, you know, "I have obesity," right? So, actually, we've been misusing that term too. Like, "I'm diabetic." You're not diabetic, you have diabetes. You know, you have these diseases. That's not who you are. It doesn't define you.

Host: That's interesting because, again, it's trying to shape that conversation and shift the conversation.

Dr. Ashley Bernotas: And shift the stigma and, like, remove the stigma, right? And so, you are Heather. You're not obese. You know what I mean? You have obesity, you know, as do I, but--

Host: But the BMI, is it outdated?

Dr. Ashley Bernotas: Yes.

Host: Okay.

Dr. Ashley Bernotas: So, the BMI was used really for a simple calculation to try to put people into categories. And for whatever reason, insurance loves it because it's easy. You can easily replicate it with a very inexpensive method of just the scale and your height.

What it comes down to, for instance, I had a patient with a BMI in the 30s. And this is not obesity medicine. This patient was more athletically built. So, BMI in the low 30s and had a body fat percentage of about 7%, was a bodybuilder. And so, that muscle mass just brought the scale up. And based on their height and their weight, their BMI put them in the obesity category. But realistically, the patient was extremely healthy and had like more lean mass than fat mass.

Host: Okay. Yeah. Let's go with that, we're muscular.

Dr. Ashley Bernotas: Yeah. Just say you're muscular. You know, you can come to my office and get on that body composition scale. It'll really tell you--

Host: And then, give you the real breakdown.

Dr. Ashley Bernotas: That's what I care mostly about is your body fat percentage, because that's a dictator of your health status, is your actual body fat percentage versus just the three-digit number on the scale. So, I tell everyone, if you're going to buy a scale, don't bother with the three-digit normal one. Try to look for a body composition scale that fits in your budget.

Host: Yeah. Because the visceral fat and the percentages of fat, that's where you can run into other health issues, right?

Dr. Ashley Bernotas: Exactly. So mostly visceral fat, which is the fat that is wrapped around our organs. That is the most significant. And one of the biggest telltale signs of how bad that is, is your abdominal fat. So ironically, our thigh fat is not as bad for us as our abdominal fat. So, it's a win for a lot of women.

Host: That is a huge win.

Dr. Ashley Bernotas: I mean, I'm not going to, you know, get into nitty gritty details, but there are two different types of fat. There's white fat and there's brown fat. And brown fat creates energy, and it creates heat. So in fact, it's protective and that is what is mostly in our thighs. And the white fat that we don't want that is unhealthy is mostly around our abdomen, which represents mostly what's inside, on our organs.

Host: I'm going to start saying that I am full of brown fat, I am muscular, and my thighs are okay.

Dr. Ashley Bernotas: That's it.

Host: Yeah, exactly. So, somebody comes into your office, you sit with them, you work with them. At what point do you say, "You know what? You're a good candidate for perhaps one of these weight loss drugs?"

Dr. Ashley Bernotas: Yeah. So, the FDA approved the medication starting at a BMI of 27 for patients. BMI of 27 with at least one medical comorbidity. So, that's diabetes, high blood pressure, cholesterol issues, asthma, PCOS.

Host: So, it's not like you're just walking in there and saying, you know, "I have a little weight to lose. Give me a shot, and I'm good to go."

Dr. Ashley Bernotas: Yeah. No. And obviously, I don't prescribe below the FDA limit. So, I do have some patients who don't quite meet that. However, let's say they've met it in the past. So, I do have some patients who've had bariatric surgery. And they're starting to creep back up. So then, we talk about, "Okay, well, their BMI was 43." They may be at like, you know, 26.9. I say, "Okay, come back. We're going to keep on monitoring you. If it gets into higher than 27, then we'll talk about medications, if that's what you really want," because they do want to maintain a lower body fat percentage and kind of a lower BMI.

Host: We hear all of the different names, the different brand names. I always wonder what is the difference between them. I see the commercial for this one, the commercial for that one, and I'm like, I know a friend who's on this one. Somebody else is talking about that. How do you know which one to go with? How do you prescribe, you know, one shot versus another, or one dose versus another?

Dr. Ashley Bernotas: Yeah. I would say the best medications out there currently are the injectables. Bariatric surgery is still the number one form of weight loss. And then, second to that are the injectables, and then we get into the oral medications. And so, I tell patients really, "If your insurance will cover the injectables, that is your best bet." That is the once-a-week injection, fewest side effects, and the largest amount of weight loss. And there are four main ones. I call them sisters and cousins. So, Ozempic and Wegovy are sisters. They're the exact same medication. They just have different names. Ozempic is for patients with diabetes and Wegovy is for patients without diabetes.

Host: Okay.

Dr. Ashley Bernotas: And then, there's their cousin, Mounjaro and Zepbound. And Mounjaro is for patients with diabetes and Zepbound is for patients without diabetes. And so, those are the four injectables that are on the market currently.

Host: You mentioned side effects. What are we talking in terms of side effects?

Dr. Ashley Bernotas: So, I actually find that the side effects aren't as bad as people say, and I don't know if that's just, you know, patient dependent. My patients don't seem to have a lot of side effects.

Host: Yeah. We always focus on the negative too.

Dr. Ashley Bernotas: We do, but I don't increase very quickly. I increase based on how the patient feels, and I'm not just increasing without talking to the patient and seeing how they're feeling on the medication. So, I think that helps as well. But the biggest side effect is nausea. The second one would be constipation. And those are pretty much the top two that I hear of. Sometimes patients will get these sulfur burps that they talk about as they get higher on the doses of medications, and they do go away. It's very dose dependent. Some people don't get them at all. You know, it's very interesting.

Host: And that's why they communicate with you because then you can adjust where needed, right?

Dr. Ashley Bernotas: Exactly.

Host: Long-term side effects. You know, I'm the type of person that I listen to the drug commercials. And immediately, you go to the negative and they run down the list of, you know, all of the possible things that it could cause, you know, for X, Y, Z medication, you know, and/or including death. And I feel like we focus on the worst of the worst. I hear cancer, thyroid cancer, with some of these medications. What is the actual risk when it comes to the injectables and some of the more serious things?

Dr. Ashley Bernotas: So, the injectables actually reduce the risk of overall cancer.

Host: Wow.

Dr. Ashley Bernotas: Yes. So there are a lot of weight-related cancers, especially women. There's breast cancer, uterine cancer.

Host: Colon cancer.

Dr. Ashley Bernotas: Yes. Colon cancer and they're all related to weight. And so, it actually will reduce those risks. The issue with the thyroid cancer is in studies done on rodents, so not on humans, they found an increased risk of a specific rare type of thyroid cancer called medullary thyroid cancer. It is a genetically tracked cancer. So, we always ask about family members who have, you know, thyroid cancer or yourself. It is extremely rare and I have not come across one patient yet in my over one year of doing this by itself.

Host: And I think that that was one of the questions or, you know, it set off that little light bulb is because my mom had thyroid issues, not thyroid cancer. But you hear thyroid and it immediately I'm like, "Ooh, I don't know about that."

Dr. Ashley Bernotas: Yeah, no, come talk to us. Because a lot of times patients will just have thyroid nodules that doctors are monitoring forever. You know, ultrasound, ultrasound. And if they're not large enough, they don't remove them, they leave them there. And those are not necessarily pre-cancerous. And it's rare that they would develop into medullary thyroid cancer. So, talk to us. And I've even had patients who have had family members who had other types of thyroid cancer or themselves had other types of thyroid cancer, and we could still put them on these medications.

Host: All right. What should we avoid? You know, I have a little note here. Random ads on social media, because it seems like this company, that company. It's none of those four that you mentioned, compounds, right?

Dr. Ashley Bernotas: Yes. So, these medications do not currently come in generic form. If they did, we'd be prescribing them, because they'd be less expensive to our patients. And we don't want to charge you a lot. Well, we don't charge you anything, but we don't want you to have to pay a large fee for these medications. If it was up to me, they'd all be free. But there was an issue with a shortage of this medication. And so during that time, pharmaceutical companies-- or sorry, rather compound pharmacies were able to make the medication in another form and sell it to consumers. A lot of people do not understand that it is extremely different, that it is not FDA regulated, and it could be very dangerous. So, we've seen some serious cases landing patients in the ICU, liver transplant lists. Very severe cases of side effects to these compound medications.

Host: Because the doses can be different, right? Depending on who's mixing them.

Dr. Ashley Bernotas: Exactly. So, we don't know how much you're getting. When you're injecting yourself with, say-- I hear a lot of the compounding stories and a lot of them are in units. These medications don't come in units. You know, they come in milligrams and in milliliters. But when they're dosed with units, my patients will ask me, "What is the equivalent?" I say, "I have absolutely no idea." Because you could be getting saline, water and salt basically, or you could be getting four times the dose of the medication. And we don't know because it's not controlled. And that's what's scary because that's when side effects, you know, come about. That's when scary things happen and then patients will blame these medications that are very safe and have been FDA regulated. But in fact, it's the compounds.

Host: Do you feel like people sometimes they reach a point where they're so desperate. And they want a change so badly that it doesn't matter if it's the Facebook ad that they scroll and click on and it is out of desperation.

Dr. Ashley Bernotas: Yeah. I think a lot of it is out of desperation. And I understand, you know, these medications even out of pocket are extremely expensive. And they should not be cost-prohibitive. Everyone should be able to access them. And it's not a good situation when they can't and they're trying to do anything possible to get this weight off. But I think it is mostly out of desperation. I don't think that patients normally would go to the internet to purchase medications. I explain to patients, i'm like, "Would you buy your blood pressure medications off of something online?"

Host: No, probably not.

Dr. Ashley Bernotas: Chances are no. Unless it's like a mail order pharmacy and it's a medication that was prescribed by your doctor.

Host: You are part of a team. You are developing this incredible team of people around you, dieticians, health coach, behavioral health specialists. How do you all work in unison, and why is it important to not just write the prescription, to have this, you know, army around you that is doing the best for every patient that walks through your door? Because it's multifactorial disease, right?

Dr. Ashley Bernotas: So, it's a chronic disease that needs to be addressed from different perspectives. So of course, the medications are there, they're great. They've actually, you know, done a lot more than a lot of other things have over the years. But we still need healthy nutrition. We still want to lose fat and maintain or improve muscle, and that's really important with good nutrition. Same with exercise, you want to be able to be active. Strength exercises and resistance exercises are the top exercises that patients should be doing. And so, we have a health coach who is instructing our patients and giving them guidance. She's actually a personal trainer on the side. And she works with our patients, which is great. And then, our dieticians follow macros that are individualized for patients. So, macros are, for those who don't know, protein, carbs, and fats.

Host: And those are the three that we really should be watching.

Dr. Ashley Bernotas: The top ones, yes. There are micronutrients that are important, fiber, et cetera, which we do also talk about in the clinic. But when you're thinking of how do I eat as healthy as I can, we want higher protein, lower carb, and moderate healthy fat diet.

Host: Not no carb, you know, we still need carbohydrates. We also still need to allow ourselves to eat carbs because if we go out to a restaurant and we indulge in carbs, we'll feel like we failed, and that is not the goal. We don't want to feel like we failed.

Dr. Ashley Bernotas: There's no bad-- you have people that label good food, bad food, healthy food, unhealthy food. I feel like it's moderation and getting that balance in there too. When you label things as bad, number one, sometimes I want those more. You know, if you tell me they're completely off limits, you want them more, you crave them more. But much like you said, you know, I am not obese. Sometimes we put these labels that can derail us.

And yes, it might not be the healthiest option. But sometimes it's the only option or sometimes it's something you're craving. So, just give into it in moderation or a small bite and then go. And that's what those medications also help. So, my patients will tell me, especially those who have been on the medication for a long time, they say that food noise that went away initially is starting to come back. So, I ask them, "What does that look like for you now?" And they actually tell me, they're like, "Yeah, I'll have a sweet craving. But instead of eating a full Tim Horton's donut, i'll be able to eat one bite of a Timbit and I'm satisfied. And then, I could throw it out." So, they still have that craving for the sweet tooth that they have or the salty tooth, but they're able to control the amount of food that they're eating.

Host: So, they're still in a good place.

Dr. Ashley Bernotas: So, they're still in a good place. It is not really affecting their body fat, because their calories aren't going up and they're able to live their life.

Host: Yeah. You talked about perimenopause, menopause. I know we can talk for days about that. But any tips that we should be, you know, following, things that we can be doing to combat, age, nature?

Dr. Ashley Bernotas: Yeah. So, I mean, in addition to-- so weight loss is one of the modifiable lifestyle factors to help with symptoms of menopause, so especially hot flashes. They're higher in women who carry more body fat just as we are normally warmer than some of our counterparts. But I would say, really, women who are going through the menopause transition need to talk about hormone treatment with their physicians. And I think that that's one of the major things that I counsel my patients on is have you spoken to your OB-GYN, about maybe some hormone therapy? And they're like, "Oh, I'm kind of afraid of it." Have a discussion because there's a lot more out there than we previously thought. There are a lot more options even for women who've had cancer actually. There are some non-hormonal options and even some hormonal options that are safe in certain situations. So, modulating your hormones going through menopause will help your sleep, will help your mood, will help your memory, will maybe motivate you. You'll maybe get more energy to exercise, right? And so, I think that much like obesity is treated from these four different pillars of obesity, like the multimodality things, menopause should be treated the same.

Host: Yeah. We talked about a lot. Did we miss anything? Are there major touch points that you know, you think are important for our viewers and our listeners to take away from this?

Dr. Ashley Bernotas: I would say, number one, you know, if you've struggled with weight, you're thinking about "What can I do? I've done everything," come and see us, we'll help you. We'll at least talk you through what you've done. See if there's anything else that we could add.

The other thing I would say is just be kind to others and just understand, and I tell patients, I'm like, "Be kind to others and actually be kind to yourself." And I tell my patients a lot. I say, " Look at yourself in the mirror and think about how you talk to yourself. And would you want to talk to your daughter that way? Would you want to talk--" And many people will say, "Absolutely not." You know, so why are we talking to ourselves like that?

And I think it took me becoming a parent to really realize how negatively I was talking about myself. And then, I said, "You know what? I don't want to impose this negativity on my child. I don't want them to go through what I've gone through. So, I'm going to try to change it." And I've significantly changed the way that I look at things, and it makes me understand other people better. It makes me understand myself better. And I feel as though I'm actually making more progress with like my weight challenges when I'm less strict on myself.

Host: And like you said, we would never speak to other people like that, so why would we treat ourselves like that?

Dr. Ashley Bernotas: And you only have yourself, you only have this body. And I also tell patients, I say, "Think of everything this body has brought you through. Think of all the challenges. You know, the COVID, pregnancy, loss, you know, all these life stressors that we've had, this body's brought you, carried you through that. So, be kind to it. You only have one body."

Host: You've only got one. That's it. All right. Yeah. And again, if folks are interested in speaking with you and your team, how do they go about doing that?

Dr. Ashley Bernotas: So, we have a website through the Kaleida Health general website. It's under the Kaleida Health Weight Management Center. So, you can just Google that. And there is actually a button to send in an application or some interest form, and it goes directly to our email. And our office manager will contact you and schedule you. Or you can call us at (716) 859-1168.

Host: All right. Fantastic. Thank you so much. I really enjoyed this conversation. I feel like we have a lot of important information that everybody can take away a little something.

Dr. Ashley Bernotas: I'm happy to talk about it ad nauseum.

Host: No, we thank you for having me. We love it. And we were so happy to have you as part of the Kaleida family.

Dr. Ashley Bernotas: Thank you.

Host: And we're glad that, you know, at one point you had decided I need a little bit of a change because we can tell that you're passionate about it. And your patients are really benefiting from that passion.

Dr. Ashley Bernotas: I'll tell you this, I've never loved my job as much as I love what I do currently. And I didn't know that I could ever say that I would love my job, but I actually love my job.

Host: We love to hear that.

Dr. Ashley Bernotas: Thank you.

Host: All right, Dr. Ashley Bernotas. And thanks so much for listening to this latest episode of Medically Speaking, and we'll see you again next time.