“Please never doubt the light you bring to my life. I am a new garden and you are the sun that gives me my reason for blooming.” –JPG“Darling, there is no tomorrow without you. If I ever lost you, I would live forever in all the days I had with you.” –JPG“Oh how great is the depth of my wanting for you.” –JPG
What do the words in these images do for you, friends? What do they bring forth?
If you are not already acquainted, I highly recommend finding and following Josh Greene, @typewrittenlovenotes on Instagram and on his Substack. His writing is thoughtful and evocative, keenly astute to all things human. He engages his audience with the most admirable integration of openness, earnestness, and appropriate boundaries.
I read the three expressions of his post above and commented, “Wondering… what are the day to day actions that go along with these words? It’s lovely to imagine.” Two avenues of reflection emerged from the question:
How do I walk the talk? If I tell you how much I love you, care about you, and value you, how do I show you in our everyday interactions? What does it mean to live these words? How do I treat you such that you believe me when I say them? It makes me wonder which people in my life feel a gap between what I profess and how I behave. How do I delude myself, believing my words and actions are fully aligned when they are not? What needs to happen for those who feel the gap to tell me so I may correct, either the words or the actions? It’s so easy (for some of us) to say the flowery words. They make everybody feel good with instant gratification. When things are harmonious it’s easy to act lovingly. How do I show up when it’s hard? Do I live up to my own standards of integrity, compassion, and self-regulation? Perfection is not possible. But how much is good enough? How do I keep myself accountable?
What words/stories drive my actions off track? I make generous assumptions about most people most of the time; I place myself pretty far on the right side of the curve compared to the general population here. And yet, there are those for whom I hold only sparse generosity. I justify my attitude and seek validation for it. Thankfully, I have dear friends who will provide that emotional validation, remind me of my own standards of conduct, and challenge me to reconcile my actions accordingly. I come back to the words. How do I label these people and thus prime myself for disconnection rather than connection, the exact opposite of what I always say I want most in life and relationships? It’s an uncomfortable and humbling irony, and one that I am grateful occurs only occasionally. So I am determined to suck all possible learning from each occurrence, in hopes of prevention in future. Disconnect will always happen of course, but my high dream is to look back and see that I did my best to present my best self whenever possible. What do I need for that to happen more reliably?
These questions feel important, but not necessarily urgent. I’m reminded of Rilke’s admonishment to ‘live the questions‘, to simply be alive to them, let the answers reveal themselves over time. I have trained my observation and reflection muscles well; they are tone and strong. So I don’t fear the heavy self-awareness lifts when they cross my path. I can slow down, take a breath, and assess. I get to decide whether and how to approach, detour, confront, or take other action. I’ll know when I need to know, and I am well supported with excellent counsel.
So let’s live some good questions, shall we? The world needs us all to speak and act more thoughtfully and reflectively, and be much better self-regulated.
“I think we could all encourage one another to acknowledge and articulate our gifts more. That could make the world better.” I wrote this to JP Greene, @typewrittenlovenotes, in response to his story reel describing his gift of acute and specific memory.
I traveled to Portugal this past week to attend the wedding of two of my favorite young people. What a gift and privilege, and a memory I will treasure lifelong. Not only did I get to spend enough quality time with both bride and groom, but I got to meet their and their parents’ dear and loving friends, and came home having made a bunch of new friends myself.
The event included multiple opportunities to reminisce and reflect on the newlyweds’ roots, personalities, and relationships. The ceremony and vows represented them both so earnestly and exquisitely. Their honest and authentic natures clearly present to us all right up front and consistently, as every description of them from the best mates to parents were exactly the people we all know and love, all why every one of us was willing to fly over an ocean to celebrate their marriage.
How often do you hear from others about your gifts? How often do you exercise them in both confidence and humility?
How often do you express your appreciation of others’ gifts to them? How often do you notice yet stay silent?
When we reflect others’ gifts and impact back to them, specifically and in real time, we reinforce what we love most about them. We validate and strengthen their self-awareness and self-worth. When we notice someone making a positive difference in the world, acknowledging it amplifies the effect and helps us all absorb and integrate that energy better. I believe we are more likely ourselves to act in kind thereafter–it’s a win-win.
This week, I challenge us to practice.
Articulate our admiration with assertive positivity. To be clear, we must be genuine and honest–actively responsive in and to our observations. It need not be effusive, per se, just earnest and direct. If it feels uncomfortable, may we muster the boldness to overcome the discomfort (maybe explore it?) and connect despite it. Sincere compliments make us generous on the receiving end; they can someone’s day, which brightens our own day. I think we consistently underestimate the vast and beneficial ripple effects of a few kind and encouraging words.
May we make one another feel seen and appreciated, my friends. May we openheartedly point out others’ gifts to them, and help them self-acknowledge. Far from stoking egoism and arrogance, I think we will simply call forth our best selves for one another and for the world. Imagine what a better society we could build this way?
Caption from the Medscape Instagram post in the photo, which I re-shared on my stories: “Patients who use gray-market retatrutide seemed to achieve roughly half the expected weight-loss benefit relative to Eli Lilly’s clinical trials of the drug, while still experiencing high rates of cardiovascular effects, researchers reported in a preprint study. “At this time, retatrutide isn’t approved by the FDA and is in phase 3 clinical trials. The company has announced plans to submit for drug approval in first quarter 2027. However, demand for the triple-agonist has surged. Read more about the research by tapping the link in our bio.” Read the Medscape article itself.
Ooo, lots to discuss here friends! Let’s see if I can be thoughtful, informative and concise! I’ll give a brief summary of the Instagram post referenced above, implications I see as a physician, and my conversation with Friend who actually tried retatrutide from the gray market.
Retatrutide represents the next generation of medication for metabolic conditions like diabetes and obesity, and it shows tremendous effectiveness for the latter. In a phase 2 trial published in 2023, the vast majority of study participants lost at 10-15% of their body weight on the highest doses. Interestingly, about a quarter of patients taking placebo also lost 10%, and also experienced a noticeable amount of side effects–but that’s for another post. One phase 3 trial showed just under 2% decrease in hemoblobin A1c (the three month average blood glucose test, which we follow in patients with diabetes, and 2% change is significant) and 15% decrease in body weight at the highest dose.
The study (yet unpublished) referenced in Medscape is fascinating: nference, an AI company that works with clinical entities to convert medical records to de-identified data, mined clinical notes for signs that patients were using retatrutide, even though it’s not FDA approved and cannot be formally prescribed (and thus not yet monitored or tracked in any accountable way). Some exerpts:
“Unlike most retrospective observational studies, which start from a prescription or pharmacy claim, the researchers used large language models and de-identified electronic health records (EHRs) from US academic medical centers and health systems to capture the complete clinical note history of patients taking retatrutide.
“’Retatrutide isn’t an approved product, so it has no national drug code, no pharmacy claim, and no structured prescription record anywhere in the health system,’ Soundararajan explained. ‘Evidence about who is taking it exists only in the physician narrative in the form of free text in clinical notes.’
“Using the nference AI platform, the researchers retrieved the full clinical-note history for every patient whose record mentioned the drug and adjudicated three outcomes: whether the patient actually took the drug; where they obtained the drug; and when they started taking the drug. A clinician manually re-reviewed 320 randomly sampled extractions against the source notes. Exposure classification was 99.8% accurate and supply route was roughly 90% accurate.
“Analyses showed a rapidly increasing use of nontrial products purported to contain retatrutide, with a 1.8-fold increase per quarter from October 2023 through March 2026.
“Weight loss among the 89 retatrutide trial participants was 15.5% at 6-12 months, closely approaching the observed 16.9% mean weight loss across the retatrutide and placebo arms at 80 weeks after treatment initiation in TRIUMPH-1-4 (weighted average).
“In contrast, compounded retatrutide users lost 7.2% body weight at 6-12 months, less than the 15.5% observed in the retatrutide trial cohort and comparable to the weight-loss achieved among matched tirzepatide users (7.7%).
“A significant increase in heart rate was observed at 3 months for both the retatrutide trial cohort (+4.3 beats per minute [bpm]) and the compounded retatrutide cohort (+2.5 bpm), which was not seen in the matched semaglutide or tirzepatide cohorts.
“The retatrutide trial cohort also showed numerically higher, but not statistically significant, rates of three-point major adverse coronary events (MACEs) vs matched tirzepatide users (relative risk [RR], 1.77) and semaglutide users (RR, 1.02), with similar findings for expanded MACE vs tirzepatide (RR, 2.03) and semaglutide (RR, 1.25).
“Limitations included the observational nature of the study, which precludes proof of cause; short and uneven follow-up (median roughly 3 months in the retatrutide arms vs 6 months in comparators); and index dates derived from notes rather than dispensing records.”
See below for screen snips of results from my Google search, “get retatrutide online.” Online pharmacies like HIMS and Ro, which provide compounded versions of FDA approved weight loss drugs, do not provide retatrutide. Most of the hits were peptide sellers, though platforms like Ro and Midi look like they give information on how to seek the medication through research trials.
I spend an increasing proportion of my practice discussing and dispelling medical misinformation. It eats all kinds of time, but I welcome it because I learn so much, and my practice is sturctured such that I have the time, which most doctors do not. I learn what my patients are seeing, hearing, and thinking. We look up evidence together, and I get to explain how I vet information: sources, physiology, rationale, conflicts of interest, meaningful outcomes, and the balance of benefit, cost, and risk. We learn together and I earn trust. My perspective shifts and I gain flexibility while hewing close to strong medical ethics and high academic and public health standards. I was both interested in and validated by Dr. Karl Nadolsky’s Instagram story, so I shared it.
My gym friend commented, “Let’s chat about this,” and now blog readers and I all get to benefit from the follow up. Friend has agreed for me to share our conversation with a few key quotes here.
Friend: “I tried grey market Reta and had zero results. zero. 16 weeks, titrated up doses. Actually gained weight and body fat. Mentioned it in a few body building and CrossFit forums and others had similar results with the Chinese labs products like Reta. Turns out, from those who sent the products out for lab testing, that there’s enough of the product in the vials to show that the actual chemical formula is present, but it’s severely underdosed to what they’re selling… The TRT [testosterone replacement therapy] clinics are selling Reta for over $300 for a 3ml vial of 15mg/ml. That’s down from $750 a few months ago. The Chinese grey market sells them for $35-$50 per vial. So gym bros, who are already spending on memberships, protein, supplements, and testosterone see the cheap prices and jump on them… One of the more popular online forums for gym bros is called “steroid source talk”, and there is where thousands of contributors share results and product reviews. There’s even links to vendors that have proven to have decent quality product.”
Let’s take a moment here. What do we notice in ourselves when we read this? What assumptions do we make, and what do we judge, especially?
Whenever I talk with a patient or friend about these things, especially someone with first hand experience, my attitude softens significantly. It’s not unlike my conversations with Red voting friends. I have my biases and convictions about public health, evidence-based medicine, affordable healthcare, etc., and they have theirs. I also care a lot about connection and relationship, which only occurs with openness, curiosity, and humility on both sides.
I messaged my friend, “It’s all so fascinating. I’m so interested in the motivation, the drive to seek these things. What’s at the heart and bottom of it, what need does it meet? Our culture is evolving so fast and so much of it feels mindless and numbing to me, like the worst of human nature is behind the wheel (collectively) too often.”
He answered, “Follow the marketing, in my opinion. It targets a specific demographic. Middle aged men, who work out tirelessly, are fathers, business owners, husbands, and are simply frustrated and aggravated with their current progress or results. They’re lifting weights constantly and not getting stronger. They’re dieting daily, tracking macros, eating whole organic foods, but are still appearing soft, and aren’t shedding stubborn fat that would come off easily in their 20s or 30s. The marketing is targeting a specific population demographic that has a ‘problem’, …self-perceived or not, and offering a ‘solution.’ …These men… are essentially desperate to see better progress, and (the companies) prey on that vulnerability. One of the most successful clinics in Chicago uses the phrase ‘get your mojo back’ on all their ads.”
Me: “…I’m thinking it’s similar for women…cultural expectations and pressures to stay young, beautiful, etc. *sigh*” [And now that I re-read, this intersects with last week’s post about pathologizing the normal, making women expect that they should not have to feel or experience the changes of menopause, that it can somehow be eradicated…] “I think our culture really fears aging and losing function. This intersects with how we don’t value our elderly, as if they have nothing to contribute. It’s all very complex and ties into our individualist, money-driven culture traits, too—very American, or at least Western. I often find myself comparing and contrasting this mindset with how I experience Chinese and Eastern culture, which is very much more respectful of elders and, in my observation, a lot less fearful of aging.”
In the end, my friends, what is truly worth our time, money, and energy? What do we want and what are we willing to spend, sacrifice, and risk to get it? At the end of life, what will really have mattered, and what will we look back on and wish we had let go or held onto better? What fears does the culture amplify for others’ (financial) benefit? How can we each and collectively resist such nefarious actors, and be ourselves agents of integrity, connection, wellness, self-efficacy, and grace?
I never expected that sharing an Instagram story would provoke such a dive into emerging pharmaceuticals and their ‘gray market’. But I’m not at all surprised that it opened a respectful and connecting conversation with a new friend. It reinforces to me the possibility and potential for connection in any forum, on any platform, if we are willing to engage humbly as fellow humans. Let’s spend our precious time, energy, and resources more intentionally on one another, yes?
