Kerry 0:29

All right. Hi everybody Welcome back to the Get Healthy Tampa Bay podcast I'm your host Dr Kerry Reller. Today we have Dr Sara Trigero she is a board certified internal medicine and obesity medicine physician based in Reno Nevada she's the founder of Achieve Health Nevada and also teaches internal medicine residents at the University of Nevada Reno And she combines evidencebased medicine with a highly personalized approach to care, helping patients better understand body composition, metabolic health, obesity medicine, and sustainable lifestyle change. Well welcome to the podcast. We'll stop there. Yeah so tell us I mean I did a little brief introduction, but tell us a little about who you are and what you do.

Sara 1:10

So born and raised here in Reno, Nevada. But I had to move away d- you know for all my training and get like used to I don't know different areas different demographics and stuff. So I I did all my training out of state but moved back about gosh now it's been 12 years ago. And for a long time I was working at the the VA actually and so that was really fun and exciting until we opened up this new practice. But very much you know started internal medicine and so taking care of adults you know obviously at the VA like very complex conditions and that kind of thing but over time just really got interested in other aspects especially about metabolic health and so pursued obesity medicine. And I think it's really cool just this overlap of things like primary care obesity medicine metabolic health you know and then also just recently got certified in lifestyle medicine and so really kind of the same concepts right? Like what are all of the tools in the toolbox to really help people address their their health you know And sometimes a preventative way sometimes a treatment way right and kind of following across their lifespan and you know the different stages that are about that I think you know in my own family and then of course in my own health like sometimes there you know those like things pop up right Or you have certain risk factors or certain conditions that might make something a little bit more challenging And so I think it's great to be able to have tools in the toolbox to able to address all of that and fig figure out what is the right thing for the person So I love lifestyle medicine too like healthy things are healthy but of course like as an internist I use drugs too And just kind of figuring out what's right for for the person So that's been kind of a fun fun journey for us in figuring out who who fits which bucket I guess

Kerry 3:07

Did you have, like, a enlightening moment or cases or just really seeing everything at the VA that you realized some, you know, you need this extra... Like, what's going on Why are we you know just using medicine or anything like that or what else is out there Like how did you come across, you know, obesity and lifestyle medicine, I guess, is kind of my question.

Sara 3:27

Yeah I would say you know combination right on one hand we were treating a lot of patients that had you know high blood pressure high cholesterol heart disease diabetes You know like I mean they just had this huge gambit of medical conditions and a lot of the underpinning etiology from that was probably excess weight and obesity And I think it was happening in like we're You know this was just becoming so prevalent that these conversations about trying to reduce weight at a time that I was also maybe struggling a little bit myself I've never personally fallen into like the BMI category of obesity but I was struggling with weight I have PCOS or the new you know term for that so and so I was struggling myself. And despite, you know, having this education and everything about, you know that we would give recommendations to our patients about I was struggling And so despite education Mm-hmm despite maybe some privilege as well you know I was like What Like Why am I not being successful. And if I'm struggling to be successful how are my patients gonna be successful with that too? So it was it was kind of like a combination of recognizing that in my in myself and then also seeing need Mm-hmm for so many of my patients So yeah.

Kerry 4:54

Yeah think a lot of people providers doctors whatever we all have you know our own struggles and journeys as well And I think when you're realizing that hey you're having your own experience with it and you like you said the word privilege right We should know everything You should know what to do right So why can't you do it yourself right It's so hard. And it's you know it's not fair cause you're put on this you know pedestal that, everything should be perfect. But you know I think just being there for the patients and realizing you're a human being as well I guess it's a big deal I don't know. But you mentioned you know PCOS I thought it'd be fun to cause that new I don't know if you know the full name but they changed the name of it and I just wanted you to just comment on you know your journey with that and why you think they changed the name of it

Sara 5:39

I mean it's new enough that I'm still gonna have to like remember what it actually stands for But it's basically like polyendocrine metabolic ovarian syndrome I think is what it is yeah. that's what I heard So it's PMOS now Yeah And so no I think that this is good And there's been some discussion about why they wanted to it Mmhmm And I think part of it is because many people with PCOS are underdiagnosed and I think that's a challenge because this really does have a lot of important consequences for women that have PCOS or PMOS And I'm gonna have to get used to actually using the new term cause it's so new But you know and I I think that being able to highlight I think more what this condition is about is is good. Obviously you know with With women I think one of the main components that you know when we were using the word PCOS that we were really focusing on was probably a lot of the ovarian function so fertility being a big part of it and so women tend to have irregular periods and you know problems with fertility cause they're not ovulating as regularly and we might see multiple cysts kind of from this like immature follicle development that happens with PCOS but it's funny cause there's you know like the criteria for this right And it you know the other component of PCOS is that people can have like excess androgens and have other things going on like facial hair hirsutism like that kind of thing that also can play a role. Acne. And really, it's like you need two of three of those things, irregular periods, facial hair or cysts, to be diagnosed with PCOS. And I think that really also didn't acknowledge, you know, a some of the other stuff that was going on. Like, probably one of the biggest things being, like, insulin resistance ...and sort of this predisposition towards pre-diabetes and diabetes, and then also the weight challenges that go ...along with PCOS. PCOS. And so I think this idea of kind of talking about that there's really kind of some global metabolic dysfunction might help us to sort of be more cognizant of people that are struggling with that, to identify them and help them because those metabolic consequences have, you know, big im- implications, I think, over somebody's lifespan towards cardiovascular risk or, you know, risk for maybe some different cancers and stuff like that too. So it's, I think, helpful to sort of really make sure that we're identifying people to give them the help and support that they need. So I, I think it's- Good. You know? But it is a change, so we have to remember it and think about it Yeah Yeah. Do you think it's gonna change, like, treatment for it at all Yeah You know I think that you know focusing more on the preventative health part about it I I do hope will be good right So it's not just about fertility and regular periods it's also about reducing risk of cardiovascular events I think that's probably a big part of it and hopefully really acknowledging that struggle too so that we don't just give trite recommendations about lose weight. You know like an understanding that it might be different for that person where they they probably really will need more support with that, ...Because there's metabolic dysfunction

Kerry 9:14

Right. I mean we know that even like with any like there's some line of insulin resistance like you said and there's we know that it's harder for patients with insulin resistance or prediabetes and diabetes as well to lose weight. So if it's harder to do that then it's harder to you know, control their other condition that's related to it So you know I think you're you're Right I think it can I think labeling it more in a metabolic issue you know allows people like you to use your lifestyle and obesity medicine certifications and knowledge and tools that you've mentioned to you know better treat the patient as a whole rather than you know maybe what we might have been doing previously. Like it's more encompassing I think which is which is hopefully where we're headed We don't really know cause they just did this. But yeah it's just I thought it'd be fun to you know, kind of touch upon that new name just to really reflect more on what the actual condition is. It's not just about, you know ovarian cysts right? It's like an, a misnomer kind of thing.

Sara 10:10

Right, And I think, like, you know, sometimes people think about that cyst problem and it's like you know maybe focusing more on things like pelvic pain and which if if that is going on for a person you know would be important but a lot of people with this condition don't necessarily have those kinds of symptoms. They have other symptoms right. Mmhmm mmhmm And so I think being able to really capture those folks will be helpful. So yeah I'm excited ...but it's gonna take time for it to trickle through I think too Yes Yeah All new things

Kerry 10:43

So I mean some of the other things that I think that you wanted to talk about that is important in lifestyle and obesity medicine is also you know about The weight and what it means and maybe why the scale number is not so important. Can you comment more on that and discuss that? Yeah Hmm,

Sara 11:02

I think you know It's so funny because like right we have BMI and that has remained such a huge aspect I guess of how we diagnose obesity or classify obesity and stuff. But at the end of the day this is all just a number right and depending on the person right how that number is viewed it's you know can be different. So I think obviously like men compared to women and and those kinds of things are we expect different different weights for you know at the same height even but we also know that people can develop some of the complications of excess weight even within a normal BMI. And so it's tough, right, with all of these things. So I think th- I think that's where sometimes people get a little bit, I don't know, like they ha- they can have a hard time, right? Like maybe that person with PMOS, right, this new PCOS term, right, where they're struggling even within that normal range, and so they might be having some of these metabolic consequences, even if their weight isn't wildly abnormal So you know for us here at our clinic we've been using body composition testing to sort of help us with patients and of course to like monitor them over time. But sometimes we can see some of those things, where your weight is a certain number, but that doesn't necessarily mean that you have a great body composition. Maybe you have excess fat within a normal BMI range and so for some people a BMI of 24 I mean they could still start to experience know some of the metabolic consequences of of their weight so I think that's been really helpful for us you know, to sort of look beyond weight as just a number right And to sort of be able to pair somebody's symptoms or what's going on in their experience around weight with some little bit better data about their body. I think you know, there's probably more to this still in some ways. Like, you know some people that have excess weight, like will also have higher muscle mass because they're carrying around excess weight right? Right but doesn't necessarily mean just because there is that quantity that it's like functioning perfectly too. So a- again, I mean, even with body composition, it's still just a number, but I think it's a little bit better number than than weight alone. And so that's been helpful for us to kind of be able to see and then trend over time and make sure that as we're working on things that hopefully we can kind of get to that better- body composition sometimes if we tell people to lose weight you know without kind of monitoring that people might find themselves losing muscle mass or other types of weight that might not always be healthy weight loss. And so I've really appreciated being able to, to trend that over time you know, with our patients. So I, love that e- extra piece of information that we get Yeah,

Kerry 14:10

I mean honestly I think every office should have one and hopefully one day they will. But I think it's great to be able to look at the visceral fat calculation that they do, look at obviously the percent body fat I think that's super important as well And you know I feel like even in my practice, like we have I all the time I'm finding people with normal BMIs that have prediabetes and things like that and I'm like What is going on? Like Let's figure out you know what why this is happening. There's something that you're doing every single day that or not doing you know that is you know contributing to this. And I mean I can think of you know one lady she's not too bad in her BMI or anything but you know she wanted to use the GLP-1s and things like that. And I'm like, "That's great," but we you know get her on the body comp and I'm like oh my gosh like the, You can do so much here The biggest thing you need to do is go like physical activity and lift weights because your BMI is fine but your your body fat mass was definitely in the obesity range. So it's kind of crazy Yeah that happens And then you know like I said day after day normal BMI will have you know prediabetes and things like that Yeah. So it's good to have these tools to be looking out for these things right Yeah. It's much it's much better care honestly So we're catching things before they get to fullblown diabetes which is one of my favorite phrases that I don't get. But

Sara 15:30

yeah, I, you know, same thing. I had a patient just the other day who- by BMI was actually underweight Mmhmm and yet has pre-diabetes, you know? And her body composition was what we would call the C shape. So the, percentage of her body weight that was contributed by body fat was higher than, you know, what sh- we would prefer, right? We would prefer her to have more muscle. If she had more muscle, maybe she would be within a normal weight category, right? And and so I think, you know, being able to have some of those discussions and stuff because by her weight alone, I mean, really, like this is somebody that you wouldn't... You're like, "You are tiny, tiny, tiny." But there were aspects I think about food choices and and those kinds of things of course that were gonna be relevant for her and her eating patterns and stuff. But also yeah like you know her metabolic engine from her muscle mass was probably too low too right. So yeah I think it's so interesting I I agree I hope that it's gonna be more prevalent right throughout medical clinics because I really feel like it adds a lot of value for a clinical assessment. And I hope too that that can also be integrated maybe in the future to, I, I mean, sometimes I think there's ways to get, maybe certain medications approved for folks. But you know there is this category of people that are within that normal weight category but prediabetic and so finding the access to some of those tools could be harder for those folks for know, using insurance and that, that of thing. Mmhmm. So maybe an InBody test would be helpful someday for that.

Kerry 17:16

Yeah I mean I think I I definitely think that it's helpful to be able to get the InBody test That's what we have at our office. You know it's interesting too cause obviously the the good ones are very expensive and we have a nice one at one office and then we have a satellite office and I tried to get one that was another version of InBody and it just I did them back to back and I was like if this saying I have 6 more fat than the other one I don't think my patients are gonna wanna get on this one So I haven't even I I took it out of the other office I'm like Just go to our main office for now because I don't want you guys to get discouraged cause if I'm discouraged they're gonna be discouraged too. But Yeah. So I mean I do think the the body composition machine is a great tool, and I think we need to be using that especially you know when we're using, like any medication or anything to help with people lose weight. But so from a from a lifestyle and obesity medicine approach how do you you know work with those patients that you're trying to help improve their body composition? Yeah.

Sara 18:11

I mean I I would say at the end of the day of course it's like so individualized Based off Yeah of the person and I I like I think that's one of the things that is I don't know probably like underappreciated. Just like in diet culture, right? Like, it's like, "Oh, this works for everybody. Jump on board," and, you know. And so I really like being able to do like a great comprehensive assessment for folks right And really kinda understand their whole weight history. You know There are some people where they've been struggling with this their entire life or it's common in their family there are definitely those people where it's like they started a medication or something like that and that really changed their weight or they had a life stressor or something that you know kind of created a new inflection point in their curve so I think those are really great clues to see you know what's going on with that person. I think understanding their current health habits is also great too there is I think a lot of people out there where it's like they feel like they are just doing everything right you know and in a lot of ways they are and they're just not seeing the benefit of the efforts that they're putting in. And that's probably a person that feels like they have insulin resistance to me you know that feels like they've got something going on that is really like tipping the scale for them right and so they're they're just kind of really struggling against that. There is those people that like I think get a lot of like pleasure and or coping you know from different m food habits or those kinds of things too And so kind of figuring out what that that piece looks like and seeing if they need some additional support cause that's a big change. Like even if you put somebody on a GLP medication or something like that they might find benefit from it but they might struggle in different ways too Because it's sort of changing their relationship with food and if that was a kind of important coping mechanism for them like taking that away can be really hard So at the end of the day it's like really individualized I would say like you know of course lifestyle I think is always gonna be important And whether or not healthy habits are translating perfectly to a number on a scale healthy habits are healthy. So I think like we always wanna promote that and maybe especially sometimes for people struggling with obesity because there are higher risks for them for cardiovascular health heart health you know that kind of thing. And so sometimes maybe being more diligent about healthy habits is more important for them to address those risks not necessarily perfectly the scale. So I think that's where really having good expectations about stuff but it's not like we ever give up on healthy habits cause healthy habits are healthy right? And finding ways to really implement those healthy habits in ways that are sustainable hopefully joyful you know I think is also important because if things are a chore they're not probably as sustainable so I think that's another thing And also looking at how much room the person has to change you know their habits especially right now I mean I think some people right like if they have a lot of weight to lose I mean the degree of lifestyle change that they might need might be bigger And so knowing like how much of that we're probably really gonna have accessible to us I mean I think just living in the modern world sometimes is really hard And so figuring out how much people can really implement and if we need other tools on on top of that. And then if we're thinking about other tools of course like what is the most appropriate tool for that person? What is a sustainable tool for that person? Because if we start a a medication, you know like we're probably gonna wanna keep it on. So I think making sure that any intervention that you do is something that has longevity is probably one of the biggest things I think ...and that has to be individualized So yeah I would say that's a good gestalt approach I guess I don't know

Kerry 22:27

Yeah. I mean obviously you are you know treating the individual patient and making your recommendations with your expertise. What do you think are the most things that you find yourself repeating to a lot of the people? What are the most common recommendations that you're reporting? you know one of the things I would say, like, if we are kind of specifically talking about, like, food you know, certainly getting like highquality food I think is kind of a big part of it. Sometimes, you know, we really try and look at folks to see are they getting enough protein, are they getting enough fiber? And sometimes when you make those recommendations, their, like first go-to is to buy a supplement, right? Like I'm gonna put protein powder or a fiber supplement in my coffee in the morning." And and that's great, you know? But ideally like looking for those ways to kind of get it from from food And it's just funny I think how our brain works and I think that that really speaks to why it's so hard to do some of this in the modern world cause when we think about getting good protein or good fiber from our foods like that's a time commitment And so I feel like really working through what fits into the person's schedule what's something that they're gonna enjoy eating makes a lot of sense but I think when you think about protein and fiber if you think about plants or whole grains or whatever like that's probably a really good segue and something that is a little bit hidden I think from us when we when we hear those things protein or fiber. And so I think going back to like thinking about highquality foods like how do you add vegetables or fi like you know like plants into your diet that's probably like a really good first place. And then I think Like doing that instead of trying to like restrict feels really positive for a lot of my patients too. As they kind of build in healthier foods into their diet other things tend to fall off And so I think thinking about good ways to add and I think the other thing too like thinking about exercise is like really thinking about how to make that joyful right? So what is something that feels good? Again I think we have this really like regimented way that we approach caring and exercising and it's like I'm going to the gym And I have one patient who started doing like line dancing with her family and it's like amazing for her. She is doing line dancing It's like social it's connecting with her family And, it's movement I think that's like such a cool approach you know So I think being creative about it doing something that feels right for you is like you know so good And and a lot of people like wanna do walking that's great, you know? But how do you make it joyful so that you wanna do it I think is Yeah another part to that yeah I I think like for for most things that we talk about as far as like behavioral changes those are probably two that come up really often Mmhmm I mean you're totally Right Like when you tell people to get more protein more pri fiber they're trying to you know make it efficient make it easy and then they wanna reach for you know a supplement You can't blame them because that's what we're meant to do as human beings right Make it easy right? So it is I think it does make sense and there's a you know a colleague of mine who you know really focuses on getting like the fruits and vegetables maybe even whole grains into first and then starts talking about you know protein and things like that and I think that that is a great way And like you said adding things in than you know restricting and things like that and I think that's an important method too that most people are probably not getting any you know the amount of fruits and vegetables and fiber that they're supposed to be. So you know adding things in rather than restricting I think is a great way as well I would say I need to work on that to be honest but I think it's it's a great Those are really good points that you made basically is there anything else that you'd like to share And why don't you tell us a little bit about your practice because it's pretty unique out there in Nevada,

Sara 26:47

Yeah I would say the other thing Yeah probably the other thing is that we look at a lot is sleep you know So I think that that's huge too right and not only is it so important for like I don't know like our own daytoday like showing up and our emotional regulation and everything but I I think it has a huge impacts too right for for weight And so, I think you know if anybody is thinking about an area that they might try and address like making sure that they're getting good quality sleep is so important. And I think the prevalence of sleep apnea as well is so huge, and we don't often Mm-hmm look at it until somebody is overweight but there's probably some bidirectional component to that. So sleep apnea driving excess weight and then excess weight driving sleep apnea so I think getting that assessed is so great too. Here at our practice we yeah we started this about Two years ago my partner and I we've I've been I was born and raised here in Reno and after completing all of my training and that stuff, I moved back, and I've been back since 2015 and we started this practice, yeah, two years ago, and I think it was really great. I feel like being able to bring high quality, like holistic care to our community has been awesome. We are a membership-based practice, so we don't bill insurance for our services and that just allows us to be really flexible with you know how we provide our care. And so we sort of follow the Direct primary care mentality and being accessible to our patients really giving them good quality time I think being able to be thoughtful about our patients and really hear about their story and helping them navigate you know some of these choices in ways that feel like it's gonna be really sustainable for them or like energy well spent you know for them if they're gonna start something feels really really good We do primary care and then we also have weight management Some people do both and since we started you know we've added different components So like really I think we've always been interested in lifestyle medicine also things like menopause for patients where that's affected But you know we've taken some of those extra steps too to get certified in those areas as well which has been I think helpful for our our patients to just feel like we were able to give really credible information to them and so that they can put their efforts where they matter most and really feel like they're making progress on their on their health. So it's been super fun different than what we were doing before but been very joyful for us too so we keep coming back to it So yeah

Kerry 29:44

well, that's good. You definitely wanna have joy in your own job and not just preach about it, right? Yeah exactly That's great. Yeah it sounds like a amazing practice. And it's nice that you obviously have a partner right And direct primary care can be a little bit lonely sometimes if you're starting on your own so I think you know doing it with someone else is great, and then you got coverage too, so that's great. Yeah ...where can people find you if they wanna, you know, follow you or work with you or anything?

Sara 30:08

Yeah so our website wwwachievehealthnvcom is a great starting point we also have a Facebook account and Instagram account if if people wanna follow us there Achieve Health NV on both of those and yeah we post about you know different aspects of our practice or different like health tips and that kind of thing too So through our website if people are interested in maybe joining the practice they can book a free meet and greet with us I think it's always important to make sure that whomever your provider is that you connect with them you know And so that's a great place to make sure that that's a good fit and that you know our philosophy is gonna meet that person's needs and our communication style and all that good stuff. So that's a great way to get to get to know us personally too

Kerry 31:02

It's always a nice touch I wish I could do that I'm an insurance model so it's like I don't think we can do meet and greets here I'd never get out the door But yeah that's awesome Well anything anything else you'd like to share with the listeners today?

Sara 31:14

Ooh yeah I would say you know I think maybe the only other thing I guess I would say is you know again like that idea of like treatment versus lifestyle right and I think they just go so much handinhand. So working on lifestyle I think is always so great and important. But I think for some people, if they're feeling like they're really struggling in an area, thinking about those other tools that are out there, I think there's many now, which is so nice. And so getting that extra support, sometimes we feel like it's a bit of a failure, you know, to have to reach for these things. And I think it would be great to like reshape that mentality a little bit mm-hmm. because addressing your health and taking, you know, action towards something that's a potential risk for you I mean I feel Like, that should never feel like a failure. You know Mmhmm taking care of yourself should always be a win. So ...I would love to promote that for people that feel like they're unsure if they should pull that trigger

Kerry 32:22

Are you referring to taking medication?

Sara 32:24

Mm-hmm. Okay Yeah, Yeah. Yeah.

Kerry 32:27

Yeah, no, I, I just wanted to clarify in case anybody was wondering. But yes I agree. It's definitely not a failure. It is a tool, and taking your, care of yourself like you said should always be a win so that's really important Yeah Yeah Love it. Yeah Awesome Well yeah Thank you so much you you said Instagram website and everything like that and you are in Reno Nevada and Achieve Health NV with your partner. And you guys, look her up if you are out there and please, everybody stay tuned next week for next week's episode, and Get Healthy Tampa bay.