#888 Iron Deficiency Anemia with Dr. Pelcovits

April 16, 2023Scott Benner

Ari R. Pelcovits, MD has type 1 diabetes and is on the show to talk about iron deficiency and ferritin.

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Scott Benner 0:00
Hello friends. Welcome back to the Juicebox Podcast. Today, we're going to be listening to Episode 888.

I was so excited to make this episode. I've got a doctor on, he's got type one diabetes, that's how I found him. But that's not why he's here. Today we're gonna be talking about anemia, and low ferritin. Now before you say, Oh, I don't have anemia, I don't have to listen, please trust me, just check this episode out. Anemia low ferritin. And its impacts are very, very, very much under diagnosed. While you're listening today, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. We're becoming bold with insulin. Couple quick things. If you have type one diabetes, and you're a US resident, or you're the caregiver of someone with type one, please complete the survey AT T one D exchange.org. Forward slash juice box. It will help diabetes research to help you and it'll help me t one D exchange.org. Forward slash juice box. If you'd like to get 35% off your entire order at cozy earth.com. Just use the offer code juice box at checkout. And to save 10% On your first month of therapy. Go to betterhelp.com forward slash juicebox. This episode of The Juicebox Podcast is sponsored by touched by type one touched by type one wants to elevate awareness of type one diabetes by raising funds to find a cure and inspire those with diabetes to thrive, touched by type one.org. And I'm going to take this opportunity to talk about the podcast just for a second before we start. So sort of an ad for the podcast. A lot of the management stuff is broken up into series defining diabetes defining thyroid, the diabetes Pro Tip series, the bold beginning series, there's an entire collection of algorithm pumping episodes, ask Scott and Jenny, just episode upon episode of listener questions answered by myself and Jenny Smith. There's the diabetes variable series, the mental wellness collection, how we eat, and very new to the podcast, a type two series for people who are struggling to understand what their Type Two diabetes means or how they can get started with helping themselves. And of course, the after dark series, which has a long list of interviews with people living with diabetes, and their stories that let's just say don't usually see the light of day, you can search for the series within your podcast app, like you could say defining diabetes juice box and it would come right up. Or you can go to juicebox podcast.com. And there's links at the top of the page in the menu section that will allow you to see every episode that's in every series and collection and then you can just go to that episode as you please. And if you're in the private Facebook group, and please I hope you are in the featured tab. There's a tab at the top that's called featured. There's lists of all of these series and collections there for you as well.

Ari R. Pelcovits, MD 3:29
I'm already Palca that recently diagnosed type one diabetic and also a Hematologist Oncologist in Rhode Island. And happy to be here today.

Scott Benner 3:40
Good morning. How are you? I'm doing well. This is one of these odd situations. You ever hear somebody say I have x disorder and I can't wait for someone famous to get it so that they pay attention.

Ari R. Pelcovits, MD 3:54
Yeah, no. Yes. Yes. That is sometimes the best thing that can happen to any disease and someone famous getting that.

Scott Benner 3:59
So for my situation and what I'm trying to accomplish a hematologist getting type one is perfect. Sorry for your trouble, but I'm looking forward to picking your Yeah. Well tell me first How old were you when you were diagnosed?

Ari R. Pelcovits, MD 4:16
So I just got diagnosed about five months ago, and I'm 36 now so I was 35. Okay,

Scott Benner 4:22
is there a history of autoimmune in your family?

Ari R. Pelcovits, MD 4:24
You know, really little, my mom has Hashimotos which I feel like, you know, a lot of people too, but outside of that, I was sure I was gonna get cancer. I mean, that's kind of why I wanted to be in hematology oncology. And so it was it was a nice surprise. When I got this diagnosis.

Scott Benner 4:39
We wait You thought you're gonna get cancer. So you became a hematologist? Tell me about that. Exactly.

Ari R. Pelcovits, MD 4:43
Yeah. Well, you know, my mom have had breast cancer, which he's doing great from, and my brother when I was a kid had lymphoma, also, he's doing great. So just a lot of life experiences that I think led me down the path towards oncology, and then always in the back. I mean, I don't know if it's true every doctor but I think a lot of doctors are hypochondriacs and assume they're gonna get almost every disease, but most likely also assume the ones they treat they're gonna get because they see it all the time.

Scott Benner 5:13
Well, I can tell you this, that a lot of people who need therapy become therapists. I don't know why that

Ari R. Pelcovits, MD 5:20
Exactly, exactly. Yeah. Although my endocrinologist told me other day that maybe I should take my endocrinology boards now just for fun.

Scott Benner 5:28
Well, you're a, you're a well educated man, you certainly went to a good medical school and tell people where you went and what you're doing now.

Ari R. Pelcovits, MD 5:36
I went to medical school at the University of Maryland where I grew up. And then I came up to Rhode Island and did my residency and fellowship at Brown University. And now I've stayed on and I treat patients with both cancerous and non cancerous blood conditions.

Scott Benner 5:51
And that explains why your internet stinks. Okay.

Ari R. Pelcovits, MD 5:55
That's exactly.

Scott Benner 5:57
Alright, well, I will not go down the rabbit hole of Rhode Island. I'll skip right over that. That's fine. And, and just say how long you've been practicing?

Ari R. Pelcovits, MD 6:07
Well, so actually, I'm just out of out of training. So you know, medical training, just to be fun takes forever. So my training was seven years, and now I'm about six months or no longer nine months out of training. So I'm almost finishing my first year in training.

Scott Benner 6:20
Wow, that's insane. Well, I appreciate all the effort you put into it. It's really, really something honestly, may you live long enough to pay off your debt?

Ari R. Pelcovits, MD 6:32
Make it worth it? Yeah. Okay.

Scott Benner 6:33
So tell me a little bit about how you manage your type on. Yeah, so

Ari R. Pelcovits, MD 6:37
I currently am on a pump. I'm on the tandem T slim. And I have Dexcom, which I was able to get pretty quickly, I think, was on MDI just for a couple months after diagnosis, and then got on a pump, maybe about two months ago or so. And it's been pretty awesome with the pump since then.

Scott Benner 6:57
Are you using control? Like you? Yeah. How do you find it?

Ari R. Pelcovits, MD 7:03
You know, I find it overall good. I eat I wouldn't call myself like a low carb person. But I definitely changed my diet since diagnosis and much more of a low carb on the end of the low carb things. So I think, you know, I stay pretty steady from that perspective. And I don't think control IQ has to do a ton of work. It is interesting where I didn't notice, like I think with Lantis you know, I kind of knew what was on board always. And with the control IQ the way it's kind of adjusting things. It can have some impacts where you know, some days I have more insulin on board than others just because for whatever I've been doing, it's decided

Scott Benner 7:40
I needed more. Yeah, you're using Lantis out the box. Yeah,

Ari R. Pelcovits, MD 7:44
I started on Lantus and fast acting with with males.

Scott Benner 7:48
Okay. Hey, are you did you put on a headset with a microphone? I did you just move it a little farther away from now from your popping a little bit? Yeah. Is that better? Yeah, we'll find out. So okay, all right. Well, I don't want to skip over your diabetes, but I have a lot to ask you. So yeah, that's fine. We can come back to my diabetes. Okay. Where does this begin? Where does my obsession with understanding people's iron and ferritin levels begin? I guess, if I look back over my life, I was a person who was tired all the time. I didn't know it. If I came to your house to watch a movie, you know, back when people rented videotape, so if you remember that. Yeah. I would be asleep halfway through the film. It was a joke. We go to a theater. Scott be asleep. Come to the house. Scott's gonna fall asleep. I have fallen asleep. Driving a car. Oh, gosh. Okay. I mean, in in moments when you probably shouldn't just, it just became a thing. Sort of just like, and it was always put on me. By the way, there it was. It always was. I was always treated sort of like, oh, like he can't even stay awake. Like it was nobody ever thought anything medical. They were just, you know, anyway, 80s 90s. I don't know if people realize how much more the world's come along because of the internet and things like that. But back then somebody made a snap decision about you. And that was it for the rest of your life. Right? You were sleepy. So I'd go through bouts of it where it was terrible. And then it would get a little better go back. I'd get used to it. I was good at pushing through it. I guess one day, I just said to my wife. I feel like I'm going to die. And I didn't know another way to put it. I was like, I'm like if if this isn't what dying feels like then you know, I don't know. So I went to a battery of different doctors. And my ferritin level comes back very low. I think like 13 Maybe. And, of course, like I didn't realize it at the time, but everybody in the room looked at me like oh poor guys got cancer. like that, that's now I look back. I know that was the look I was. Yeah. And how old were you then? Oh God in my 40s, my mid 40s Okay, you know, and then the battery of tests, we're gonna put it through, we're gonna put a camera up your ass, we're gonna put a camera down your throat here swallow this giant pill, it's got a camera in it, like, like, all that stuff. Come back. And the answer is, huh, there's nothing wrong. I was like, okay, so any reason you can think that you would have blood loss? And I said, I've had one pesky hemorrhoid my whole life, but I don't know that it's bleeding that much. You know, like, meanwhile? I don't know. Like already. I don't know. Like how much blood loss is blood loss? Right? You know? No, yeah,

Ari R. Pelcovits, MD 10:49
you what looks what looks terrifying to you sometimes in a toilet bowl is actually kind of mild compared to what will really drive your numbers down.

Scott Benner 10:56
What a nice thing to say. And it's so anyway, then some tests come back. I have something called Berets. Okay, and maybe you're not absorbing iron correctly, Scott. You know, I don't have celiac. I don't have like, you know, like that. All that. So I'm like, Okay, so what's this Berets? And then you might be able to explain it better than it was explained to me. But it's been. I kind of assume it's like a precursor to a can a soft to cancer. But

Ari R. Pelcovits, MD 11:28
yeah, doesn't necessarily have a GL was the word I think you were holding back on.

Scott Benner 11:32
Thank you. Because I wasn't certain. So cursor, esophageal cancer, but doesn't have to be that and, and take this thing and keep, you know, keep your stomach acid down? Well, at that moment, I was like, Well, I'm just going to change the way I eat. If, if that's it, because I didn't, I did have heartburn, like throughout, maybe not throughout my life, but it was getting worse. So I cut out like oils. It's a strange thing. But I cut all oils out. I stopped eating later at night, like little things like that. And I was actually able to deal with it on my own.

Ari R. Pelcovits, MD 12:06
Without any sort of medicine for the heartburn. Yeah, I

Scott Benner 12:08
used the medication in the beginning, but then I got away from it. And I still keep like a, I don't know, like an acid like a chewable by my bed in case something happens, because I've learned not to ignore it. But I mean, I might be used those. I don't know, once every six weeks, something like that. So and that's and

Ari R. Pelcovits, MD 12:27
you're still getting iron infusions now or you sort of got it and you're done. Oh, no,

Scott Benner 12:31
I get the iron infusion. I feel like a million bucks. Six, eight months later, I start tailing off again. And then I gotta get him again. Yeah, I've had iron infusions. I've lost track. Now. Honestly, over the last couple of years, I've probably had 10 of them. And I, you know, I take my biggest my biggest leap was that the doctor kept saying, Well, maybe it'll hold on. And then one time after an infusion, he retested my iron in my heart and was so high that he was like, Oh, good, you don't need to take a supplement anymore. And then I was like, Oh, I'm good. And then I didn't take the supplement. And then of course, eventually, it dropped back. Right?

Ari R. Pelcovits, MD 13:12
I mean, your story that your story is so classic for the type of patient I see with iron deficiency. It just the number of people I see who go down that same path of, you know, where's the blood going? Where's the iron going? We can't find it. But clearly, something's going on here. And they need iron to feel better. Yeah, I'd be happy to kind of run through, you know, why we think that process and you know, what are sort of when someone comes in with low iron, what we're thinking about and why they thought you had cancer? If that would be helpful, please do. Yeah. Yeah. So you know, well, the main thing is that we need iron to make make our blood and that's why we care about it. And so oftentimes, if you don't have enough iron, you also then won't be able to make make enough red blood cells. And that's when we use the word anemia, so become anemic. And I think for a long time, people thought that it was only if you became anemic, that you would start feeling crummy. But clearly, there's tons of people like yourself who just having low iron makes them feel awful, tired fatigue, no energy. And the way we can sort of not have enough iron in our bodies is usually one of two mechanisms, which is either we're losing it in the blood, because the iron that's in our body is mostly in blood. So whenever we bleed the iron in there, it gets lost. And then our body uses up whatever sort of iron stores we have. Or we're not absorbing enough iron. And so and someone who's over the age of you know, we used to say 50. But now with this happening younger, probably even over the age of 40. If you come in and especially if you're a man and don't have any other reason to be losing blood, we certainly worry could this be a cancer in the GI tract or colon cancer, cancer higher up that's causing you to lose blood and that's why you have low iron

Scott Benner 15:00
Oh, to say that I don't feel well. By the time I was able to tuck a hematologist into giving me an infusion. And it was really like I had to bang on people's heads, because the last thing they made me do was eat. Even though I didn't have any signs from testing of celiac, they made me eat a gluten free diet for a month. Oh, interesting. And so I'm eating a gluten free diet. And one day, I'm in my kitchen, and I just bend over to pick something off the floor. And I almost went headfirst into the floor. Like I was diving into the floor on purpose. I just couldn't hold myself up anymore. I was at the point that no matter how long I slept, and when I got up by 1pm, I couldn't function anymore. And I took myself to the emergency room.

Ari R. Pelcovits, MD 15:53
And were you were you? Did they make you go on iron pills first?

Scott Benner 15:56
Oh, I had to do everything. Everything that everyone knew wasn't going to work I had to

Ari R. Pelcovits, MD 16:01
write did you get the bad constipation from the iron pills? No, because

Scott Benner 16:04
I used a really good formulation to do it. I used I use the thorn labs iron I mixed it with a their vitamin C brand and I didn't have any trouble with that. I've also learned by trial and see works really well. Okay, but point being I wasn't just didn't feel well, like I was shutting off. And, and so I went to I went to the emergency room. I because the doctor still wouldn't give it to me I hadn't completed all the things I had to do. I told my wife, I'm like, I'm not gonna make it to the end of what he needs to do. And I explained everything to the ER and some lovely doctor in the ER gave me a small iron infusion not nearly enough, right? And it was that enough to like, Let me hold on until until the doctor was fine. Then they put in that first infusion waited a week gave me a second one. And I'm gonna say that in a month, maybe six weeks? i It changed my life, like I was just met. And is that because you have to remake red blood cells with the new iron in your system? Is that right? Yeah. So

Ari R. Pelcovits, MD 17:15
it depends. So if you if you're also anemic, so we sometimes use these words interchangeably, and it can get kind of confusing. And I think especially if people go and donate blood a lot, they'll sort of say things like oh, your your iron is good today when they're actually not testing your iron. So you know, you have your your hemoglobin and your red blood cells. And when those are low, really the word is anemic or anemia. And then you have your iron. And you can have low iron and ferritin is a what we use to measure sort of how much iron you've got kind of stored up in your body that's available for use, if you have or

Scott Benner 17:55
just a quick reminder to go to touched by type one.org. And to find them on Instagram and Facebook. At touched by type one.org You go to programs. And then you can scroll down to see everything that's going on the annual conference, an awareness campaign, a dance program, dancing for diabetes, they have a D box program, a golfing event, and other stuff, videos and pictures what they're doing links to get started. And by the way, that annual conference, let me click on it and see if there's a date listed yet. Because I'm going to be speaking at it. Oh, it still says Stay tuned for 2023 announcement date. What we're getting close. And I think I know the date. So go check it out. It's a great event in Orlando. And by the way to say it's a great event is an understatement. Beautiful facility, wonderful staff, great speakers. And I mean, I'm going to be there so touched by type one. dotwork Hey, if you're feeling overwhelmed, and you'd like to have some talk therapy, you can get 10% off your first month of therapy at better help.com forward slash juicebox just signing up at that link saves you 10% off your first month. Again, you can save 35% off your entire order at cozy earth.com By using the offer code juice box at checkout and athletic greens athletic greens.com forward slash juice box I think you get free. Yeah, vitamin D for a year and five free travel packs with your first order at my link athletic greens.com forward slash juicebox. And don't forget juicebox podcast.com To find the series and the collections. And please subscribe and follow in an audio app like Apple podcasts Spotify or wherever you get your audio I hate to say that

Ari R. Pelcovits, MD 19:54
you disagree. First thing that has to happen is you've got to make my red blood cell sorry

Scott Benner 19:57
I'm sorry you disappeared again but we're on a good day. Yeah, so let's keep going ferritin from there,

Ari R. Pelcovits, MD 20:03
yeah, so ferritin is a measure of how much iron you have left in your body sort of leftover for you to use. And so if you also have anemia, if you don't have enough red blood cells, when you get an iron infusion, your body first sort of takes that iron to make new red blood cells. And so if part of the reason you're feeling so crummy and fatigued is because of the low red blood cells, then it's going to take a little time for those to get made. But then you're also going to need to sort of replenish those iron stores. And sometimes it's just redistribution of what's been put in your body, and everyone's going to be different. And I know I think you're like the ideal patient your response. And you know, when I see people for this reason, I often try to caution them and say, Look, you know, lots of different things can cause people to feel terrible. Clearly, the only thing we found right now that's doing it is low iron. And so I'm gonna give you this IV iron, and my hope is that you have the Scot response. And, you know, four to six weeks from now you feel like a different person. Yeah. It doesn't work that way for everyone. You know, some people will get okay, I feel a little better, but something else is happening. Some people, especially when it's just low iron, and they're not anemic, I give them the iron and they really don't feel any different. But and not not the question, sort of the care you are getting, you know, IV iron is a pretty safe medicine, they probably talk to you about this, the sort of the main side effect we worry about is very few number of people can have an allergic reaction to it. Yeah. Outside of that, you know, cost and things like that you certainly want to think about but I'm pretty liberal and who will at least give it a shot with it too. You know, and if you're someone where I give you the IV iron and you have no response, you know, you don't feel any better. And there's nothing dangerous about your numbers. Well, then sometimes I'll say okay, we'll give it a try. And clearly this is something else.

Scott Benner 21:53
No, for sure. i And to your point about perhaps having a reaction. I think the first two times they gave it to me, they gave me IV Benadryl to and then after you don't have a reaction a couple times, I'm like, I'm gonna say no to the Benadryl.

Ari R. Pelcovits, MD 22:09
Yeah, that was the right thing to do.

Scott Benner 22:12
This is ruining an entire day of my life. And I don't use the Benadryl anymore. As a matter of fact, I go in there, I'll tell you, one of the most difficult things about getting an iron infusion for me, is that I walk into an infusion center, where everyone has cancer. Yes, and I I roll in 20 years younger than them, probably looking like a million bucks. And I'm like, What's up everybody, I'm here for my butt. So I keep it very, I keep my head down, I walk in very solemnly, it seems like a very, it's almost seems like a religious setting. I don't know another way to say it, you know, and, and I walk in, I keep my head down, I get my iron and I keep my mouth shut. And I leave, just try to be respectful to everybody. But the, the response I have is insane. Like, like, it just happened again, where it was four weeks ago. And I said to Kelly, I'm like, Oh my God, my iron slow. And we were getting ready to go on a trip where I was gonna have to drive to, you know, the East Coast, I was going to drive from Jersey to Atlanta. And then in like, and then back again, like 10 days later. And so and so I got went through the whole process, I knew my insurance company was going to say, okay, because you know, we've gone through it before, and I just got on the phone with them, like, I need this before I leave, I grow my iron won't kill me, I'm gonna have a car accident, you know. So I'm like, I have to go on this trip. So they were able to sneak one in before I left. And about three days into my trip, I said to Kelly, I'm like, I'm starting to feel a little better, like, and then it progressively got better. I got back, I took another infusion. Now it's been maybe two weeks since the second infusion. And then so many things like little things in my body get better my muscle tone picks up. My GI tract works better. You know, energy all that's right back again, my mental clarity is back. Like there are episodes of this podcast where you guys won't know it. But I'll think around words, like I'll be making the podcast. And I don't know how other people's brains work when they're, I can I can feel what I'm going to say before I'm saying it. And I can look ahead at my sentence and go I can't find that word. And then I'll talk around needing the word. And that happens when my arms lower too.

Ari R. Pelcovits, MD 24:32
So not not to talk too much about diabetes. But what I will say is that since getting diagnosed, I think one of the lessons as a as a doctor I've tried to take from my experience is listening to the patient. And this has been true both from my own experience, but also kind of listening to the podcasts and on the Facebook group. And just, you know we have our textbooks and we have what we're taught. And certainly you don't want to just run away from those and start practice. The same, you know, crazy medicine just for the fun of it. But it's clear that that's not going to capture every patient experience. And the people, you know, and this has been said over and over again. But the the people who are the best experts in any condition are the people who have it. And so kind of what you're describing with this, you know, your response to IV iron is, I mean, could I find every every symptom? You just said in a textbook? No, but but why would I deny what you're?

Scott Benner 25:31
I'm assuming you're just going to come back in a second.

Ari R. Pelcovits, MD 25:33
Iron? And could you give me an iron infusion? Well, I'm not going to go kind of try to do that, because that wouldn't make any sense. But, but listening to people and sort of saying, Look, you're having this experience, I have a medicine that can make you better that I think within the risks and benefits of what's safe and appropriate, and within sort of what we consider appropriate medical practice, you know, listening to the patient is really important.

Scott Benner 25:55
Is it? Or is it that? Is that that low iron can't cause some of the things? Or is it that just historically, and traditionally, you don't attach? Like muscle tone to that as an insult? Yeah, I

Ari R. Pelcovits, MD 26:12
mean, I think it would probably be that, well, here's what I would say, taking a step back, I think the reason anemia, the reason when your red blood cells, your hemoglobin gets a low, you feel tired, kind of makes sense from a scientific perspective. So your red blood cells carry the oxygen all around your body. So when that gets low, you know, on some level, you kind of, you know, make sense that you're probably not delivering enough oxygen to all the tissues, and so you're going to feel tired, weak, etc. The reason that when your iron is low, you also feel that way is not quite as clear. Because you would think that if your red blood cells are high enough, then okay, so you don't have enough iron in your bank. But I'm still getting all the oxygen I need everywhere it needs to go. But again, it's so clear, and this is not controversial, that there are people who have these symptoms when their iron is low, yeah, without anemia.

Scott Benner 27:05
And I'll tell you that I've now met so many people because of the podcast. And that, and I, and I'm thinking too, because all is this? I mean, can you step back and imagine that this isn't crazy that my daughter has type one diabetes, my son has Hashimotos and I have trouble with iron. Is that is that somehow connected? Because why am I meeting so many people who either have type one, or kids have Type One, who are also talking about the same symptoms, and have the same test lab results around their iron in their ferritin?

Ari R. Pelcovits, MD 27:41
Yeah, I mean, I think the main way you would want to tie it all together would be celiac, because that would be the sort of other autoimmune condition that you know, would run in the family and would cause low iron. So outside of celiac or Crohn's disease, ulcerative colitis, these other autoimmune conditions that impact your gut absorption, I can't say there's a clear way I can connect it probably it's more coincidence than just that iron deficiency is really common. But I mean, you know, maybe there's something there that

Scott Benner 28:12
we need to investigate. Why do you think iron deficiency is very common?

Ari R. Pelcovits, MD 28:16
Well, so when, in young women, almost any woman who's having her period will have some amount of iron deficiency. So, you know, you test that anyone, you know, between the ages of, you know, when they have their first period until their last, they're gonna be probably, you know, a good chunk of those people are gonna be iron deficient. And then we have, you know, again, I think it's more that is symptomatic iron deficiency as common as just iron deficiency. So sometimes we end things in medicine, we go looking for them, and we find them. And it's, but does that necessarily mean there's a problem there? And some of that is sort of the test with treatment. So do we give a treatment? And do people feel better? And there's a lot of people who, who aren't like you who like I said, Well, we'll only have a little bit of low iron there, you know, hemoglobin will be normal, and I give them some IV iron, and they really don't feel any better. And so those are the people where I say, Look, we found this by accident on bloodwork, I don't want to sort of give you extra medical bills, extra visits, just to sort of solve a number, if it's not really making you feel any better.

Scott Benner 29:11
Well, I know it makes me feel better. There was a day where I needed an infusion. And they're like, we can't we don't have a chair and I said, I'll drink it. And she said, and she laughed, I said, I'll do it in the parking lot. And she laughed again. I said, if you think it'll help, you can stick it up my ass. Because I need this future. And, and they laughed and found a way and I'll tell you this too, a number of years ago, probably four years ago now. My son had a lot of the symptoms. And he was a college athlete. He was like killing himself, you know, and we got him some blood work in his part and came back very low. And we got him an infusion and it changed things for him but now he just takes a supplement. And it's he seems to be fine

Ari R. Pelcovits, MD 29:59
and they never found because in his case, well, no,

Scott Benner 30:01
but about two years later, he was diagnosed with Hashimotos.

Ari R. Pelcovits, MD 30:05
Okay. Okay, so that definitely could have been playing a role. Yeah. So

Scott Benner 30:08
now he just takes a supplement, you know. And I'm actually I don't know the name of it, but I just started seeing an endocrinologist. So I went into the doctor, I was like, Look, I and I'm telling you this to see if you see a connection to my body is always carried extra weight. I say all the time on here, and anybody who will listen, I am the fattest guy who doesn't eat that you'll ever meet in your life. And so I do not consume food, commiserate to my body. And so I went to this Endo, and I'm like, Alright, look, the kids are gone. Like God bless them. Hopefully, they'll live but it's time for me to try to stay alive. You know what I mean? And battery of tests, and she comes back and says people would kill for your bloodwork. And I was like, I wanted to be happy. And I was like, Alright, great, but no answer there. You know, like, Why does my arm keep falling? So she wants to put me on something a little stronger as far as iron goes than what I'm taking now. And I said, Well, what about the weight? And and to give you some context already, like I stood in front, I've known this woman a long time. She's been on the podcast, actually. And I'm going to bring up something that she told me in a second to see what you think about it. But I so I know her. You know what I mean? Like, we're not we're not friendly. But we know each other very well. I stood up in her office, and I said, How much do you think I weigh? I was like, be honest. Just I mean, you look at people all the time, what do I weigh? And she goes, I think about 175 pounds. And I said, Yeah, I'm 233. I'm like, I'm like, what, like, so that's part of the problem, too, is I carry it well enough. That like, I don't personally look at myself and go, I have to lose weight. Like, do you know what I mean? Like, it's that kind of feeling. So she's like, What do you really? And I was like, yes, she examined me. And she goes, I'm gonna put you on Wigo v. And I said, okay, like, right on. So yesterday was my second injection, I'm still not on a therapeutic level of it yet. I'm taking, I don't know, whatever. This is, like point two, five milligrams, I'm down seven pounds. Wow. And so I got to the point where I'm like, I'm 51. I don't even care why anymore. I just, I don't want to have a heart attack. You know, like, like that. That's that, like, you know, so I'm, I'm getting out of this anyway. I can.

Ari R. Pelcovits, MD 32:32
Yeah. But so. So yeah, so obesity? And weight? Oh, man, you know, you could do and you maybe already have, and I haven't seen it, but you could, you could do, you know, podcast upon podcast about that. And it's certainly not my area of expertise. But, you know, what I would share is sort of a few things. I think, like many things in life, you know, I think there's probably extremes, and then there's the truth somewhere in the middle. So, you know, there clearly is, you know, we call it sort of, you know, an obesity epidemic, or whatever term you want to use it, there has been a rise over the last several decades in, you know, people's weight and obesity. There's also clearly, you know, some link between weight and bad outcomes in healthcare. So, as your weight increases your risk of certain things like heart attacks, and some cancers goes up. But, you know, at what point that happens, exactly. So, you know, at what point do you cross the threshold where, you know, if I weigh this amount, now I'm at risk for a heart attack is is a bit unclear. And, you know, there's probably some amount of being slightly overweight, that's not quite as bad for you, as maybe we've been sort of led to believe in our general culture of thinness. Sure. It doesn't mean that, you know, living a healthy lifestyle isn't important. But I think it's like, how do we focus on the numbers? The other thing is, there's certainly some data about where your weight is as important. So probably carrying your weight in different places in your body can lead to different outcomes. And that's not a choice you can make. That's just the way your body is

Scott Benner 34:05
right. Yeah. And I'm carrying it in the wrong places because it my arms, my legs, my ass, I looked like I weigh 175 pounds. So not great. And, and so, you know, that's but do you see any? Is there any relationship to carrying extra weight and anemia or low iron or low ferritin?

Ari R. Pelcovits, MD 34:27
No, not particularly. I wouldn't think I mean, again, you know, maybe you could, you could sort of try to connect things where, you know, the low ferritin the anemia is making you, you know, more tired and weak and so you're living a less active lifestyle. But again, the sort of science of weight loss and weight gain is, I think, so complex. And, you know, I think what these medicines like what Goby have taught us is, every everything before this where we've tried to get people to lose weight by restricting what they eat and you know, putting them on intensive exercise regimens, never works, and the majority of people can't keep that weight off, or a lot To people doesn't even work. And so there's something about these medicines that are working in an entirely different way. But yeah, I couldn't I couldn't say that just being overweight is going to lead to low iron.

Scott Benner 35:10
No, no, but could low iron lead to weight retention?

Ari R. Pelcovits, MD 35:14
I think the only way I would imagine is sort of through a sort of decreased exercise type of situation where you're just a less, you're being less active because you have less energy. Well, I'm sharing

Scott Benner 35:24
it and bringing it up, because I don't know I just, if it helps somebody just to put, you know, connect some dots for themselves, then that's it. I mean, the amount of people who after I, I talked on the podcast about having my iron below, the amount of people that reached out is stunning. Like, like, really, really stunning. It's almost like thyroid and you know, oh, you're in range. So we won't give you the hormone. But but, you know, once they heard me say, I, you know, we manage Arden's thyroid, to under two, like, that's the goal, like her TSH needs to be under two, that's how we're managing. They're like, Oh, but mine's four, and I have all the symptoms, and my doctor won't blah, blah, blah, and like, that just happens over and over and over again, there's got to be some sort of a metabolic balance to your body. And that if it's too far out of whack, I just, I think things just can't work. And, you know, I have no medical experience, but I can tell you that I have a number of little things wrong with me. And once I, once I put them in a better situation, things improve that there's no connection to I mean, because of Arden's trouble with food, and digestion, probably from type one, I started taking a digestive enzyme with my meals, and it's really improved my life. So what the hell who cares? Why I don't even

Ari R. Pelcovits, MD 36:49
exactly know. I mean, I think that goes back to this sort of what I was saying before about, you know, listening to patients, but also the humility of practicing medicine. So, you know, don't try not to come into, you know, when I meet a new patient, not trying to come in thinking I have this ego that I know more than them, but really listening. And like you said, when you encounter something that's making someone feel better, you know, make sure you don't harm someone, don't tell someone to do something that's going to hurt them. But listen to people and believe them when they're feeling better. And like you said, if we can't explain it, but it's it's overall leading to better outcomes. And sometimes that's what's most important.

Scott Benner 37:22
Yeah. Okay. So Dr. BENITO came on did a long episode about thyroid. And in the middle of it, we talked about iron on ferritin, a little bit. And she said, her patients, a woman of a menstruating age, she thinks of a ferritin of 70, as absolutely minimum. And I wondered what you thought about that?

Ari R. Pelcovits, MD 37:48
You know, that's a little higher than I would, again, well, that means taking a step back again, I think it's what do we mean by by low and not just treating the numbers? So, you know, going back to this concept of iron deficiency and anemia? I think it depends on what's going on, and why the I'm seeing the person. So if someone's been referred to me, because someone checked the ferritin level, and it came back at 25. But this person feels fantastic. They're not anemic, you know, they're running marathons, then I say, just look, just watch it. Right, I don't think there's been any clear evidence that simply pushing that number higher necessarily is going to, you know, make things better for them, right, where simply that same person could walk in with that ferritin. But if they're feeling crummy, then I might say, let's give this a shot and treat it. So I think the number itself, although certainly, you know, there are going to be normal values. It's going to depend a little bit also on how that person is feeling. Yeah.

Scott Benner 38:48
No, I agree. And I don't think she meant, you know, if everything's happy, go lucky. And you're 70 I need to give you more iron. But I but I think she means for people who are, are complaining of these issues, that she still thinks of 70 is as lower. And I mean, I don't know, this woman is an integrative endocrinologist. She's helped my family significantly. She's managed thyroid levels when other people wouldn't have touched them. She's just been like, she's just a little. She's not crunchy. Like, it's all very scientific. But right, but, but she's just seems to be on the bleeding edge of what she's doing. Right. Right. And

Ari R. Pelcovits, MD 39:32
yeah, I mean, again, I think that I would, you probably have to twist my arm a little bit to get me to treat someone just for Farrington. You know, if you came in and you were labs look pristine otherwise, and you're feeling crummy, but your ferritin was 60. I don't think I would be rushed into to give that person you know, IV iron.

Scott Benner 39:50
So when you give it to them orally, though, is there really a chance of it helping? And do you think this is going to be a two prong question? Like, is, is the state of our food? The reason for this? Like, are we just not eating iron rich foods?

Ari R. Pelcovits, MD 40:09
That's a good question. You know, I don't, the what we can absorb through food is somewhat limited. So if you get into an iron deficient state, so if you have some sort of bleeding event, right, let's say you've never had iron deficiency before, but you get an ulcer in your stomach and it gushes out blood, it's hard to get your numbers back to normal without some amount of supplementation through pills, or IV, you know, just eating a lot of steak isn't going to always do it. So but on the other side, it's a little not impossible, it's hard to become iron deficient, just by you know, being a vegetarian. Again, oftentimes, when I see people probably like yourself, where we can't find the exact reason, it's probably a combination of things. So it's, you know, they've not been eating a lot of iron rich foods, maybe they've got a little bit of bleeding, we can't find, or I have more that's been bothering them for 30 years, they might be on a medication that's blocking some amount of iron absorption. So it's maybe not one thing alone. But all of these things added together. To be honest, we probably eat too much red meat as a society. So I can't say that we're not eating quite enough iron, although, you know, we have iron and a lot of other foods as well.

Scott Benner 41:20
I do my part on red meat and helped me at all. And so is it. Does it make sense to you that about every eight months I, I just deplete?

Ari R. Pelcovits, MD 41:31
Yeah, so you're probably having my guests if you know, is you're probably having some amount of small amount of bleeding. That's ongoing. And so it's, it's slow, and it's small. So it's not enough that they're going to catch it on any sort of colonoscopy or endoscopy or any camera looking anywhere. But it's persistent enough that every eight months you kind of start running out a little bit.

Scott Benner 41:55
And stuff. Do you think supplementing could stay ahead of it? Like, should I like, double down on supplementing? And do it?

Ari R. Pelcovits, MD 42:02
Like you mean with like taking pills orally? Yes. Yeah. So it depends, it depends on the dose you're at, there's actually a point where the oral medication can kind of start backfiring if you take too much. So we used to recommend people take these like massive loads of oral iron, you know, they would take pills three times a day. And what we found was that it was it was probably confusing the body. And the body's sensors in the gut would see all this iron coming in, and would start being like, Oh, God, we must be getting too much iron. And we'd really shut things down, and it would stop working. And so that's why we now recommend you take it every day or even every other day. So there's sort of a limit to what you're gonna be able to accomplish through pills.

Scott Benner 42:43
Do you talk much about gut health? It's such a weird thing to talk about with doctors, because I feel like it's unknown, to a large extent, but absorption happens there. Right? So yeah. Are there things people can do to make their stomach a more hospitable place to absorb things?

Ari R. Pelcovits, MD 43:02
I mean, you know, I think certainly there are going to be some medications that get in the way of absorption. There are some really good doctors actually at our hospital who do a lot on sort of Gi you know, the biodiversity of your GI system and gi health. I will plead guilty that I probably don't do a good enough job like all doctors and talking about nutrition and what's going on in your gut. But but they exist out there.

Scott Benner 43:28
I'm suffering for the word, I can't come up with it. When I take a medication like keep stomach acid down, what is that? It's a something inhibitor, h2 blocker or a proton pump inhibitor, proton pump inhibitor, they also slow down iron.

Ari R. Pelcovits, MD 43:43
They do. Yeah. So there's a little bit of controversy about exactly how much but I think they certainly, again on that sort of, you've got a couple things on the scale. You know, that alone probably isn't enough to make you iron deficient. But it's certainly in combination with other things. Well,

Scott Benner 43:57
yeah, but when you're me, and they're like, Hey, take iron and take this for stomach acid. I was like, wait a minute how I know. Yeah. They gotta fight with each other. And but anyway, okay, so let's talk a little bit about how to get people help. So they have first of all, what do you see as the classic signs, signs of low iron? Losartan?

Ari R. Pelcovits, MD 44:19
Yeah, so I think there's the ones that are the most generic and then can be anything. So that's the fatigue, tired, low energy, just feeling kind of off and not not quite like yourself, but that can be 100 million different things. The one that's the most classic that we have a fun medical term for is called pica, which technically meets eating things that are sort of not foods. So the classic example in the old textbooks would be like eating dirt or clay, but the way it typically manifests is ice craving. So my wife who had low iron this was like her most classic symptoms, she would just chew and listen mounds of ice that drove me insane. And then she finally got an iron infusion once and it was like, you know, within a few weeks, she just like, suddenly one day was drinking a glass of iced water and went, Oh my God, I don't want to eat this ice anymore. Yeah. So that's almost, we have a fun word for that. pathognomonic which is, you know, if you're sitting there chowing down on ice, and you can't stop, it's almost certain that you're gonna go find your, your irons low. The problem is a lot of these other symptoms are really nonspecific. And so it takes, you know, your doctor as part of their battery of tests, including that iron level to check.

Scott Benner 45:32
So I, before I realized I had a problem with my iron, I actually bought my own icemaker because it was, I had to chew the ice. I was hydrating myself through ice, I believe. Yeah. And my hydration has gotten worse since my irons gotten better.

Ari R. Pelcovits, MD 45:51
Yeah, no, no, that's literally my wife said the exact same thing. Yeah, like, I don't drink water anymore.

Scott Benner 45:55
And then when my iron came up, not only did I not want to chew ice, but chewing ice, like turned me off. Like it almost sicken me a little bit. I was like, Oh, I don't want like, this is not a thing I would do if I wasn't getting that drive. Do you understand the? Like, what's the functionality behind that?

Ari R. Pelcovits, MD 46:13
very unclear. You know, one of these things go it's funny, right? When when we feel like something's unclear. We're okay with it if it's coming from the doctor side, but yeah, so So, so, so pretty unclear why you got this craving whether, you know, I think there's probably if I remember back to what I was taught that the thought about like, these, like clay, your dirt cravings was like you literally were trying to search out the iron there. But certainly that makes no sense with ice. So who knows?

Scott Benner 46:38
Yeah, it's I can tell you it's as real as could be, though. I know. Yeah. It was for me. Alright, so if people are having the symptoms, right, they're there, they can't get rested, no matter how much they sleep, they're weak. They are dizzy. Brain fog, chewing ice. I mean, if you please, if you're out there chewing dirt in your backyard, please give us

Ari R. Pelcovits, MD 46:59
a lot of maybe a few other things we did to work.

Scott Benner 47:01
Yeah, go see a doctor. And, but And so anyway, I go to the doctor and they run. The first thing I've learned that you have to be careful is you have to ask for a full iron panel. Is that right? And?

Ari R. Pelcovits, MD 47:13
Yeah, so there's lots of different values, there's sort of five and particularly we look at and I would say the ferritin is by far the most important. So if they're going to take check one thing, it would be the burden. But all of them together can be helpful to sort of really make sure we have a full picture.

Scott Benner 47:27
What is iron binding capacity?

Ari R. Pelcovits, MD 47:30
Yeah. So that is a way for us to measure sort of how hungry your body is for iron. So typically, when you're when your iron is low, your iron binding capacity is going to be high. So it means you know, your your capacity to have more iron, your desire for more iron is hot, you want more,

Scott Benner 47:48
okay? Because I because that always confused me. They're like your iron binding capacity is high. And I'm like, Well, hi. Seems good, don't we? Right? Right. Right, right, right.

Ari R. Pelcovits, MD 47:57
Where these things can be helpful is sort of your ferritin. Other things can impact it. And the most common thing is sort of inflammation. So some people's ferritin might be what we call falsely elevated. So it looks it looks normal, or it's even a little high. But really, they are iron deficient. And so these other numbers can help us sort of tease that

Scott Benner 48:16
out. I think that's a another thing, especially for people with auto immune, that's important for, for your doctor to understand. Because if you're sitting there at a fair ton of 25, and it may be higher than it actually is, you probably are in trouble as far as needing more. And I'll tell you, mine has been as low as seven. Like that's when I was falling over. It's seven. Yeah, yeah. The last one, I think was 13. And I was I was on my way to not doing well. But it's funny how it's almost like it's almost like driving a car and running out of gas. Meaning your tank can be completely low. But as long as the hose leading to the motor still full, you're running like everything's great. And then when it's gone, it's gone. And that's that's how I feel like I imagined if I looked back, and I very carefully looked, I might see it coming on, but it doesn't, but it comes on so creeping really slow. That is just like I'm fine. You know, I feel a little tired. And you know what, for me, it's like, why are my nails breaking? And then boom, I'm shutting off what they see the nails breaking. I'm calling the doctor like, hell do

Ari R. Pelcovits, MD 49:27
you have do you have like scheduled lab work that you do? Or is it you just wait until you're feeling this way? Yeah,

Scott Benner 49:32
so we just started talking about that. Because it looked like it was gonna you know, at one point he was very hopeful that you know, supplementing was going to be okay, but at this point now, I'm just gonna get it drawn every six months. Yeah, and see where I am at the problem ends up being his insurance. So you know, you want to be again the people say this about the American healthcare system all the time, right, like, like you want to be pre emptive but the insurance is like no, get the lab values lower and then we can do it. Right So after I feel like I'm gonna fall on my head, then we'll get right to it. Thanks a lot. But we are going to, we are trying to push them in that direction. So we'll see what happens with that.

Ari R. Pelcovits, MD 50:13
Yeah, that's good. That's what I try to do. I try to keep you know, especially people early on where I'm not sure was this sort of like a one off bleeding event or something happened that decreased your absorption, and then we're going to be fine. After we take you up. You know, let's check bloodwork every three to six months. And then we can see how you're starting to drift. You know, let's get ahead of this. Because I know how bad you felt. Let me let you get all the way down. Yeah.

Scott Benner 50:33
Oh, it is my goal not to feel that way ever again. Like I tried to stay ahead of it. Because I also don't know what else it's impacting. And yeah, there should be other stuff. And you know, you brought up I brought up earlier, like I said, like, I don't want to have a heart attack. But I am adopted, but I know very little about my birth mother. But here's something I know about her. became depressed after she was kind of forced to give me away by her family was morbidly obese after a number of maybe 1520 years and died of a heart attack trying to have bariatric surgery. Oh, God. So terrible outcome, obviously. But I just like I'm not, I am trying to avoid that, you know, and by the way, I'm not. I guess by the charts, my BMI is high enough that my insurance company was like we go over. Sure. No problem. But But visually, I don't think you'd see me that way. Yeah, and I am. So I don't know if I'm carrying it, some of it under my muscle. Like, I don't know what it is. But I just I'm not doing that. Like, I don't know, I've worked too hard to get this far. Like, I'd like to get to the end where I get to poop on like nurses in a home. And that's your goal. They have to smile and be like, It's okay, Mr. Banner, and so that they have a story to tell when they're 30. They're like, Oh, my God, I had a job when I was 18. Holy Hell, let me tell you about it. I'm trying to build resistance in the younger people already. That's but But seriously, like, I'm just trying to, you know, I've had a real, like, kind of renaissance in my thinking about age, because my mom got cancer. And she's doing well, but she got it at 79 years old. And some will argue that 79 is pretty old to begin with. But I've seen it, I saw how it kind of added 10 years to her, you know, name Yeah. Oh, yeah. And, and I just started thinking, like, you know, when we, at our age, think about living forever. I'm like, I'll probably lived on 8590 years old. But you imagine yourself as 85 now, like how you are now but that is not how it goes. And so what I told my wife is after I watched my mom with her cancer, I said, I'm going to I'm going to live like these next 15 years for the last 15 years I'm getting. And I don't imagine I'm dying at 65. I hope I don't. But I don't know where I'm going to start declining after that. And I'm like, I'm not going to just, I'm not just going to keep living now, like these other years are promised to me. But in the shape I'm in now, which by the way, I think we've just discussed for the last hour, it's not. It's not optimal. Right? So I don't know, I'm just trying to I raise my No, I

Ari R. Pelcovits, MD 53:22
think the privilege of being a doctor is that even at a young age, you get exposed to a lot of morbidity and mortality, you see a lot of people who are sick, and a lot of people die. And a lot of people who who gets to be you know, old and live well. And in it, it forces you to think about a lot of this and try to prepare yourself in different ways for that sort of, you know, outcome because I think some of it, like you're saying is, is how can I live the best I can now to be as healthy as I can at that point in my life. But the other is that, you know, it's an inevitability and not to be too depressing, but it's how do I psychologically come to terms with the fact that no matter what I do and how well I live, even if I get to 95 or 105, there's going to be a moment where my body will give up on me. And what do you do with that knowledge?

Scott Benner 54:12
I'm some days I'm stunned. I'm this old. I mean, seriously, you know? And yet, it's funny. As ridiculous as this sounds, aside of the things that I've shared here today, my vitality is like terrific. And like my mic when my iron is fine. My clarity is crazy. I am one of those people I wake up I am me from the second I opened my eyes to the second I go to sleep, like I don't know, you know what I mean? Like

Ari R. Pelcovits, MD 54:39
and you know, and I think that's the other thing that's important when you're going to the doctor and you're kind of trying to figure out you know, how to how to get worked up for these symptoms and treated you know, the other thing we sometimes do that's not great is you know, when I meet someone, this is the only time I'm ever gonna see them that are that first time is that first moment in their life. I'm meeting them and so you know, I sort of trying to make it clear what your sort of normal baseline is like you're coming in and you're saying you're sick, but I don't know what a good day is. And sort of highlighting like, no, look, I can I can be running constantly, when I'm feeling well, like this is abnormal for me. And trying to make that clear, can I think help sort of get some urgency or make people think like, well, we got to figure out what's going on. I don't want to just sort of blame this on, you know, you're just getting older or, you know, yep, some days, you know, you feel kind of down. Because I think it's easy to do that and harder to maybe think a little more and try to figure out what could be happening.

Scott Benner 55:33
Well, I'm very glad you brought this up, because it was going to be my next question. So how do people come to there? First of all, you're gonna end up at your GP first with these complaints, right? And then you're gonna see, you're gonna see the iron, or the ferritin, or the iron binding capacity, you're gonna know a little bit because you listen to this journey back. Oh, that's not right. Your GP is going to be like, that's fine. Because you don't know, or she don't know, doesn't matter. And so I tell people all the time, I'm like, stop banging your head against the wall with your general practitioner and find a hematologist. Now, it's hard to get in with a hematologist. Yeah, you know, and so don't delay. But then once I finally get in that office, what do I tell them so that we actually start moving forward from there? And I don't get ignored? Like, what would? What would really pique your interest?

Ari R. Pelcovits, MD 56:24
Yeah, so I think that what would make me convinced that we should try something is, if I can be, if I can hear that, you went from feeling good to not feeling good. So there was a change in your symptoms. And that the only thing we now can ascribe this to is this lab finding that your iron is low, or you're anemic? You know, I think what makes people sometimes they'd be hesitant is, you know, you know, I've kind of felt this way for 40 years now, certainly, it could be because your iron has been over 40 years, and nothing's happened to it. But usually, what's going to push them over the edge is that this is new, you know, in different than what I felt like before, how can I now kind of try to feel better?

Scott Benner 57:05
Yeah, I also think that there's more light bulb moments for people because of the way information is getting shared now, like, you know, because of something like this, like, somebody's gonna listen to this and be like, Oh, holy hell, I felt like Scott my whole life, I didn't know, you know, what you mean, like that is going to happen, and you have to just be able to come in to the doctor, you know, my finding is, you come in, you'll lay yourself out, you know what happened, I like to write it down. Because you can get in there and start telling stories. And that's not helpful. And the doctors looking at you, like, you got eight minutes to get to this, because I'm out of here, you know, and like, you need to be able to come in and say things, like, you know, I'm noticing this and this and this, and this and this, and then let them ask you a question. Because if you lay it out, well, then you've laid out, Hey, I think I'm anemic. Or I think my heart is low. And it's really, it's impacting me, then let them ask a couple of questions, answer them. And, and then for my money. I think you say it out loud. You say, I have been supplementing orally and it's not working. I really would like you to consider an iron fusion for me.

Ari R. Pelcovits, MD 58:19
Yeah. No, no, I think that's key. Also, sort of, if you've done the work of I've been on an iron pill for, you know, 234 or five months and look, my numbers haven't changed. This isn't working. You know, I will say there are some general practitioners who can schedule iron infusions. So we do see that sometimes. And unfortunately, probably, although I know you were just supportive of getting us over to specialists and as a hematologist, I should support that. But you know, I think you know, some more you know, well versed primary care doctors probably feel comfortable doing this themselves saying, you know, let's try the oral iron for a little bit. Let's refer you to the gastroenterologist to make sure you're not bleeding. And then you know, this isn't working let's try IV iron I can find the clinic and get get the order in for you.

Scott Benner 59:03
Oh, listen, I first of all, I would take that I would take that order from any doctor who was my dentist would write it for me I would have been like, that's cool. Let's go you know, I am I am interested by the progression though. Because I come in like and I tell you, hey, my iron bla bla bla bla bla, especially for me, this has been happening my whole life. Like, you think I've got the kind of cancer that doesn't kill you in 25 years. You know what I mean? Like, just give me a I look back on that initial situation. They could have turned me around in two weeks with an iron infusion and then gone and looked up my ass if they wanted to. But like Why leave me on death's door to do it. That I never

Ari R. Pelcovits, MD 59:48
again not knowing the specific not not not wanting to you know, totally speak speak ill of my colleagues. But I think you're right. There's no reason those things can't happen simultaneously. So if I see someone for low iron, you know, anemia And they haven't seen a gastroenterologist yet. We'll do that. But it doesn't mean I won't give them IV iron. In the meantime, well,

Scott Benner 1:00:06
I got a little I stopped seeing the the one gastro doctor because I was like, just give me an infusion. Like, I figured this out already. I tried to explain to him, I'm a very, very popular podcaster. And I've already picked I've already picked through this, and I know what's wrong. But there's part of me that thought like, hey, oh, man, I can't bill you. For an iron infusion. The way I can bill you for a scope. So like, I didn't get that feeling a little bit. I was like, Yeah,

Ari R. Pelcovits, MD 1:00:32
I think that. Luckily, for the most part, we're sort of a lot of doctors are shielded from those sort of financial outcomes. So like, for me, for instance, like, I don't get paid more if I give you IV iron or iron pills, or refer you to 10 doctors or one doctor, like I get a salary. And you know, that that's so whatever I do in my clinic doesn't matter. And more people are moving towards that. Which is by far the best on some level to avoid these sorts of conflicts of interest.

Scott Benner 1:01:00
I hope so. I hope so. Because in my mind, there's a boardroom full of guys smoking cigars going our recent murder.

Ari R. Pelcovits, MD 1:01:07
Well, listen, I'm not going to be naive, there was a lot of financial overlap in the practice of medicine that leads to some just some bad bad choices from different parties. So you know, money, money plays a big role in medicine. Let's not pretend that

Scott Benner 1:01:22
isn't the case. No, of course. And I just think from a personal level, and by the way, because the audio problems, we had your overtime, are you okay?

Ari R. Pelcovits, MD 1:01:30
Yeah, I have a patient at a lab, and I just make sure they didn't decide to come early. Well, they did. But they're okay. They haven't got.

Scott Benner 1:01:39
Alright, we'll just let them sit out there a little longer, though. Because I just wanted to ask you like one last question. Well, first, I'll say what I was gonna say, they'll ask you the question. So what I was gonna say is that, you know, all these technical things, and insurance and everything aside, like, I felt terrible, I lost a significant time and quality of my life feeling like this. So anytime, as a doctor, you're letting somebody feel like that longer than they should. It kind of sucks, you know. But So my last question is, what did I not ask you that I should have asked you about that people should be hearing about this.

Ari R. Pelcovits, MD 1:02:15
You know, I think that you sort of, I think hit it right there, which is I think the job of a doctor is to help you live longer and live better. And so I think that what you have to try to hope is that you and your physician or your you know, PA or NPU, or nurse, whoever you're seeing are on the same team to accomplish that, and aren't working against each other. I think when you have a good relationship with your practitioner, that's what it feels like. And so it shouldn't be that, you know, you're fighting against each other to kind of get to these outcomes, like you said, like losing that time. I think, on some level, part of it is I think we practice a bit of defensive medicine or, you know, we're thinking like, we don't want to cause harm. So let's avoid all these things, which which is important. But we can end up causing harm by not providing people the things they need. Yeah. Not not to leave you just to I guess, you know, I will say to just sort of err the other side of why do we maybe sometimes want to avoid IV iron and probably some of my colleagues who are a bit older than me, and I've been doing this for longer, but I have seen someone have a bad outcome, like get IV iron and actually have such a bad reaction that they needed CPR. So you can you can cut them out if you want. So if you don't want to scare your listeners, no,

Scott Benner 1:03:35
I understand why you that's why they give you the Benadryl right, because you have a reaction to it, it's gonna be a bad reaction. I gotta be honest with you, though, I was gonna need CPR and a couple more weeks anyway.

Ari R. Pelcovits, MD 1:03:45
But I will say when I when I when I saw that happen, it definitely scared me for a little bit. And I am sure that after, after experiencing that, you know, I then was probably too hesitant and giving more people iron. And I think I've now come back to a better place realizing, hey, look, that was a really rare situation. And it doesn't mean that I should be letting other people suffer because

Scott Benner 1:04:06
of Yeah, listen, I would have shoved a rusty nail under my skin. If you would have told me it would have helped. Like, that's how bad off I was. I was just like, I was lost. You know, and, and I want to be clear, not just fading, like I admitted myself to an emergency room. Like, like, I was done. I was like, This is it. Here we go. Like give me iron or like it felt like my heart was gonna stop. Like when it got low enough. It was just really I don't know how to put that feeling. But I was I'm not a panicky person. I wrote it forever. I did all the things I was supposed to do. You know, I took all the steps and I was just like, my body's shutting off.

Ari R. Pelcovits, MD 1:04:43
So I wouldn't what I'd also say, though, I guess is to add and I think we did cover this before but you know, having not everyone's gonna have that dramatic response like you did. And so I think so but I think just being ready for anything, right? Like saying like, I'm going to try this. I'm hoping it's all was my problems? And if it doesn't, the answer doesn't necessarily mean you know, give me another another dose. It means that look for what else could be causing Oh, for

Scott Benner 1:05:09
sure. I mean, if you were to get an iron infusion and nothing changed in, I'm saying six weeks, what do you think the longest is this?

Ari R. Pelcovits, MD 1:05:16
Yeah, I would say it depends on the type of irons. I don't know, if you've gotten sort of these, you know, what's called in fed this sort of big large dose at once. Or the sort of other common one we use is venofer, which is smaller doses, and you got to come like once a week for four or five weeks. I

Scott Benner 1:05:29
don't I don't play them better for bullshit. I do. I do injector for twice.

Ari R. Pelcovits, MD 1:05:35
Okay. Okay. So, so yeah, so so if you get, you know, a pretty hefty dose, but you're only needing it once or twice. And when by six weeks, you should be feeling feeling the effects of it.

Scott Benner 1:05:45
Yeah, I was once on the phone with insurance company. And they were like, We're gonna give you a benefit because it's cheaper. And I'm like, No, you're not.

Ari R. Pelcovits, MD 1:05:52
Well, right now we're actually having a problem. We're having a shortage of some of the what, in fact, is what we use, which is the big dose and so we're stuck with menopur. For a lot of people.

Scott Benner 1:05:59
I have it here in the house. It's my closet full of it. That's why I can't find any of it. But yeah, just I didn't like they I think it was like six weeks and like you want me to get an infusion six weeks in a row. And I was like, come on. Yeah, I know. I pulled out of it. But anyway, this was terrific. I can't tell you how excited I was to talk to you.

Ari R. Pelcovits, MD 1:06:22
And you know what, it's not a topic that people always are super excited about talking about. So it's great to find someone who is

Scott Benner 1:06:27
you kidding me? I'm gonna have you back someday. Amazing. I again, I can't thank you enough for doing this. I really do appreciate it.

Ari R. Pelcovits, MD 1:06:35
Yeah, no, thank you so much for having me. And thanks for everything you do. It's been it's been a huge resource for me for this new diagnosis. So Oh, my appreciate it. Oh, yeah.

Scott Benner 1:06:43
If you want to say something nice about me. You can do that at the end.

Ari R. Pelcovits, MD 1:06:46
There you go. I think I think you got it. You've helped you. Yeah, yeah.

Scott Benner 1:06:50
Hold on one second for me. Okay. Sure.

Hey, how about a huge thanks to Ari for coming on the show and sharing so much great information with us about anemia and ferritin. And thanks also to touched by type one.org. Head over there and check them out touched by type one.org 10% off your first month of therapy@betterhelp.com forward slash juice box 35% off your entire order at cozy earth.com with the offer code juice box at checkout, and a free year supply of vitamin D and five free travel packs comes with your first order of ag one from athletic greens at my link athletic greens.com forward slash juice box. Go check out the private Facebook group. Thank you so much for listening. I'll be back again very soon with another episode of The Juicebox Podcast.