Is Obesity a Willpower Problem? The Biology of Weight, Diets, and GLP-1s

0:00 [SPEAKER_01]: Picture a stage, stadium lights, a live studio audience, and a scale built right into the floor. [SPEAKER_01]: It's the finale of the biggest loser, and a guy named Danny K. Hill has just won it. [SPEAKER_01]: He walked out of that show at 430 pounds, but standing up there at the finale, he's 239 pounds lighter.

0:15 [SPEAKER_01]: He didn't maybe the hardest thing that show has ever asked of anybody. [SPEAKER_01]: In front of the whole world, and everybody watching, chalked it up to one thing. [SPEAKER_01]: Willpower. [SPEAKER_01]: Here's what the cameras didn't stick around for. [SPEAKER_01]: Over the next six years, Danny's body pulled almost all of that weight back on.

0:31 [SPEAKER_01]: Not because he stopped trying, but because his body was fighting in the whole time, and your body doesn't get tired, biology is undefeated. [SPEAKER_01]: So today we're finally doing the Willpower episode. [SPEAKER_01]: The idea that what you weigh comes down to yourself control, and whether that holds up, or whether it's one of the most expensive myths in health and fitness.

0:48 [SPEAKER_01]: I'm Dr. Jordan Fagginbaum, and this is the part of our medicine podcast. [SPEAKER_01]: And with me, as always, it's the second most handsome Dr. North America, Dr. Austin Baraki, but Austin, we finally are going to do the Willpower episode, the one where we go after the idea that your weight comes down to self-control.

1:16 [SPEAKER_01]: But before we start, let's pin down what we even mean by Willpower, because we need to be talking about the same thing. [SPEAKER_01]: Now, the textbook version is that Willpower is the ability to override an impulse in the moment, like a craving, [SPEAKER_01]: or something like that to serve some bigger goal down the line, resisting the short-term temptation so you hit the long-term target.

1:37 [SPEAKER_01]: So people will say things like self-control, delay gratification, or use willpower to describe the same thing. [SPEAKER_01]: So when someone looks at a person with obesity and calls it a willpower problem, [SPEAKER_01]: The claim underneath is that this person keeps losing that in the moment fight day after day for years due to a process that they're consciously choosing and that last little piece I think that's like the operative phrase does that how you kind of understand this will power argument I think so but I will also say that the more I do this now having you know worked with [SPEAKER_00]: probably thousands of folks working through this challenge while there are a number of often common themes that I hear in what people's experiences like especially for those who have struggled with obesity any time since they were children or adolescents or

2:29 [SPEAKER_00]: Maybe from around the time they started having kids or maybe around menopause like each each you know distinct kind of life stage that can be a common in in people's journey. [SPEAKER_00]: I also have come to appreciate that like people also arrive at this if we call it an end point. [SPEAKER_00]: in different ways.

2:49 [SPEAKER_00]: So to kind of restate what I'm getting at there. [SPEAKER_00]: Although there are many common themes in people's experiences, each person's journey is somewhat individual in somewhat unique. [SPEAKER_00]: And so I think this raises problems when we make either over broad claims in arguing with people on social media where it's like, [SPEAKER_00]: You know, this is, you know, so heavily influenced by genetics and people say what so like no one has any role in like their choice or their decision making.

3:15 [SPEAKER_00]: It's like, well, not exactly either and there are certainly some folks, you know, there I think you were then is commonly appreciated who genuinely have never really tried to, you know, [SPEAKER_00]: put forth effort in this endeavor, but those are also people for whom it's like, well, maybe if they did, it would work, but for a larger proportion of people, doesn't work out quite as well, especially over the long term.

3:41 [SPEAKER_00]: And so I think that painting with an over-broad brush leads people to talk past one another to not have productive conversations in this space. [SPEAKER_00]: I think that our role here is [SPEAKER_00]: to channel this bread of like clinical experience of like what has it been like talking with people working with people guiding them through this journey day after day, month after month, the after year, hundreds, thousands of times, what are the useful take-home conclusions that we can use to better understand people's experience to validate their experience, but also to not, you know, [SPEAKER_00]: inappropriately take away from their agency in this process, because that's something that people do have to some degree.

4:20 [SPEAKER_00]: I'll say to varying degrees depending on the nature of their underlying disease process, if that makes sense. [SPEAKER_01]: Yeah, yeah, I think that's the the biggest pushback is when you say that something has a large genetic component to it or or other unmodifiable factor for talking about another condition, then people say also just can't do anything about it, like we'll know, but maybe we shift those efforts to actual modifiable levers, for example, but yeah, you're exactly right that online.

4:49 [SPEAKER_01]: I don't think that a lot of people are having thoughtful discourse about some of these questions that have a broader impact on society, one of them being obesity. [SPEAKER_01]: For example, on threads recently, this person made the claim that look obesity is just due to overeating, not genetics and not your metabolism.

5:07 [SPEAKER_01]: And I'm like, if you had me in the first half, on the one hand, it is true that at some point there needs to be an energy imbalance and energy surplus. [SPEAKER_01]: However, when you added. [SPEAKER_01]: the part about it not being related to genetics. [SPEAKER_01]: I'm like, well, now you lost me.

5:25 [SPEAKER_01]: We can say, yeah, metabolism isn't really different. [SPEAKER_01]: You know, but we can't really say that genetics aren't involved. [SPEAKER_01]: And we're going to talk about that here. [SPEAKER_01]: We're also going to talk about the role of the environment. [SPEAKER_01]: We're going to talk about what sets your weight, why the body fights so hard to hang on to that weight.

5:42 [SPEAKER_01]: And the one number in my estimation that [SPEAKER_01]: obesity in this country is roughly triple in the last 40 to 50 years, nobody's genes have changed during that time. [SPEAKER_01]: And so when you know that, you're like, okay, well, what did change? [SPEAKER_01]: Well, nobody got lazier or the society at a population level didn't get lazier or [SPEAKER_01]: And we've alluded this, kind of be to round the bush, we even have some episodes on this in the past.

6:14 [SPEAKER_01]: We're going to nail it down in this particular episode. [SPEAKER_01]: So watch or listen all the way to the end, it might be transformative. [SPEAKER_01]: So let's start off with a question I think's germane to this topic. [SPEAKER_01]: What actually determines your weight? [SPEAKER_01]: And I want to start back further than most people usually do.

6:31 [SPEAKER_01]: Forget about why you gained the last 10 pounds back that you tried to lose it before. [SPEAKER_01]: The real question is, [SPEAKER_01]: Why does your body act like it has a number? [SPEAKER_01]: It's dead, set on maintaining no matter what you do. [SPEAKER_01]: And this kind of goes right to the heart of the genetic question.

6:47 [SPEAKER_01]: So the thing researchers want to settle is the same question that everyone argues about when the family gets together for Thanksgiving. [SPEAKER_01]: A kid grows up with obesity, for example, is it due to the genes that they're born with or is due to their parents, the house they grew up in, the food and the fridge, all of it?

7:04 [SPEAKER_01]: One of the best ways to separate these two factors is adoption studies. [SPEAKER_01]: And in 1986, a group led by Dr. Snunkard did this. [SPEAKER_01]: It was published in the New England Journal of Medicine. [SPEAKER_01]: They pulled 540 adults out of the adoption registry in Denmark and sorted them into four weight classes, then two obese.

7:24 [SPEAKER_01]: Now, this design works because an adopted adult shares their genes with their biological parents, they never live with, and shares their kitchen and their habits, the environment with their adoptive parents who actually raised them. [SPEAKER_01]: So, you ask one question, which set of parents does the grown adult, does their weight match match it to the biological parents?

7:44 [SPEAKER_01]: That points to genes, that matches the adoptive parents that would point to the environment and the house they were raised in. [SPEAKER_01]: It wasn't even close. [SPEAKER_01]: The adoptees weight tracked their biological parents. [SPEAKER_01]: The adoptive parents, the people who fed them dinner every night for 18 years or more, had basically no relationship to the weight these adults ended up at.

8:06 [SPEAKER_01]: Then the harder test, the same research group in 1990 was also published in the New England Journal of Medicine. [SPEAKER_01]: They took 93 pairs of identical twins that were separated as kids and raised in different homes. [SPEAKER_01]: So they had the same genes, but different households.

8:19 [SPEAKER_01]: And you can score how closely their adult weights matched, where 1.0 is a perfect match and 0 is no match. [SPEAKER_01]: This came in around 0.7. [SPEAKER_01]: Identical twins raised in the same house coming in around 0.74. [SPEAKER_01]: So splitting them up basically does nothing. [SPEAKER_01]: The numbers the same.

8:36 [SPEAKER_01]: You put those two claims together and then the idea that obesity has like a 40 to 70% genetic basis that seems to hold up. [SPEAKER_01]: You take genetically identical people. [SPEAKER_01]: You scatter them in a different homes and they still end up at nearly the same weight. [SPEAKER_01]: Now, to your point earlier, heritable or genetic doesn't mean fixed.

8:56 [SPEAKER_01]: Your genes kind of set how susceptible you are. [SPEAKER_01]: It also doesn't mean that your weight is 70% genes and 30% your fault. [SPEAKER_01]: Whether that susceptibility ever shows up in our opinion is mostly due to the environment. [SPEAKER_01]: In the early 1960s, about 13% of American adults had obesity.

9:13 [SPEAKER_01]: It's around 40% today in a peak near 43% a few years ago. [SPEAKER_01]: So obesity tripled in about 40, 40 years or so. [SPEAKER_01]: Genetics can't move that fast. [SPEAKER_01]: So two generations is nowhere near enough time for a population's genes to shift like that. [SPEAKER_01]: So whatever did this, it wasn't in the DNA.

9:34 [SPEAKER_01]: We're gonna keep that in the back of your mind throughout this episode. [SPEAKER_01]: I think I can safely say that this idea that there's a single set point is probably wrong. [SPEAKER_01]: Your body isn't guarding this sort of one exact number down to the ounce. [SPEAKER_01]: What fits the data, and again, this is still controversial, is that there's a defended range, sort of upper guardrail and a lower one with some space in between.

9:57 [SPEAKER_01]: Now, both the lower and upper guard rails are kind of set individually, they're not conserved across the entire population. [SPEAKER_01]: But inside that range, your environment mostly decides where you sit. [SPEAKER_01]: You push past a guard rail and biology will drag you back. [SPEAKER_01]: One way or the other, we think that the upper guard rail used to exist or be defended against due to like [SPEAKER_01]: and the lower guard rail would protect against you becoming too frail to reproduce.

10:27 [SPEAKER_01]: Both of these things would be problematic for passing your genes on and so there's some evolutionary argument there. [SPEAKER_01]: All right, so jeans may be build these guardrails. [SPEAKER_01]: That's that's kind of our current position. [SPEAKER_01]: And the environment moves you around inside them.

10:38 [SPEAKER_01]: And over the last 40 to 50 years, that is mostly moved everyone. [SPEAKER_00]: I think that this paradigm is so useful to understand how so many things manifest in the real world. [SPEAKER_00]: This idea of a gene and environment mismatch, the idea that [SPEAKER_00]: genes will establish a predisposition or a susceptibility to something and that could be good or bad.

11:02 [SPEAKER_00]: And then the environment is the thing that either rewards or incentivizes or leads to the kind of apparent manifestation of that sort of thing. [SPEAKER_00]: You can observe this in other contexts. [SPEAKER_00]: You could draw other sorts of analogies like Imagine, for example, I always like, you know, using competitive sports as like many microcosms of like human evolutions.

11:23 [SPEAKER_00]: So to speak, and it's like Imagine that, you know, the NBA started out with a basketball hoop that was like two feet off the floor. [SPEAKER_00]: what would be the prevalence of we'll call it over height in the population, meaning people who were over seven feet tall in a league where the basketball hoop was two feet off the floor.

11:40 [SPEAKER_00]: It would not be terribly high because that would not be a significantly like, you know, selected for or incentivized sort of thing. [SPEAKER_00]: But if the over the course of 40 years, 50 or 60 years, that basketball hoop gradually went higher and higher and higher by the time it's six feet, seven feet, eight feet, 10 feet, 15 feet, [SPEAKER_00]: Then the prevalence of those who are very, very, very tall is going to overwhelm and increase and gradually dominate the space, just because that is kind of what is essentially being selected for.

12:08 [SPEAKER_00]: In that set of particular environmental conditions, and this is the case in so many other things. [SPEAKER_00]: You look at literally any sport and it selects for a particular phenotype, and if you were to change the rules of that sport, then it would change the phenotype that it selects for.

12:21 [SPEAKER_00]: In the same way that if we change the environment that we lived in, it would essentially [SPEAKER_00]: a different sort of phenotype and those with different genetic predispositions might be a little bit more favored and others still might become a little bit more disfavored or disadvantaged in that in that particular environment and you know and that comes back to you know times of great nutritional scarcity in you know the course of human history to now at least in some parts of the world areas of great nutritional over abundance and there are downstream [SPEAKER_01]: Yeah, yeah, if we shout out one of our favorite mutual favorite authors, David Epstein, who wrote the course gene and range, and I think it's got a new book coming out as well.

13:09 [SPEAKER_01]: He had this transformative to me anyway, paper, the big bang of athletic bodies. [SPEAKER_01]: Like it was originally thought that the best athlete, [SPEAKER_01]: would have very neutral proportions, not too heavy, not too light, not too tall, not too short, no like freaky, you know, anthropometry, for example, which is obviously not the case when you look across all different sports in basketball to use your example.

13:33 [SPEAKER_01]: If you're a man, [SPEAKER_01]: who lives in the United States and you're between the ages of 18 and 45. [SPEAKER_01]: And you're over 70, no joke, you're seven footer. [SPEAKER_01]: It's like a 20% or 18% chance that you're in the NBA right now. [SPEAKER_01]: Because this is so like selected for, and that's kind of what we see play out here with the susceptibility for OPC, for example, and the modern environment.

13:56 [SPEAKER_01]: Now, to put a like clinical bow on this, this is a question I wanted to ask you, Dr. Barackie, imagine a patient who comes in, they seek their seeking weight loss. [SPEAKER_01]: And when you ask them hey, what do we try before, what's what's been your experience, you know, try to build some rapport as you would.

14:10 [SPEAKER_01]: They say, hey, look, I've been big my whole life, my whole family's been big and they sort of kind of say it flabbly. [SPEAKER_01]: What do you do in that sort of situation? [SPEAKER_00]: I have this conversation very frequently and because I'm always taking a white history and I've heard some stories that really hit me.

14:25 [SPEAKER_00]: Sometimes they can become quite emotional when I listen to what it was like for this person to grow up and they have vivid memories. [SPEAKER_00]: So many folks where they're like, I remember when I was eight years old and I was sent to fat camp or and I was, you know, [SPEAKER_00]: less under ten years old and my mom took me to my first white watchers class and they have these kind of like scarring incidents from their early childhood that kind of set them on this life course of essentially having this almost antagonistic relationship with their own body and viewing it negatively from from the very start and that has been a throughline of their entire existence and it's something that is really really you know

15:05 [SPEAKER_00]: heavy to hear. [SPEAKER_00]: And certainly when it comes to the conversation of like, okay, we'll now we're in, you know, middle age or even older and we're having this conversation about what we do about it, it might certainly have felt like a life sentence to them so far. [SPEAKER_00]: And particularly to this point, because so many of the [SPEAKER_00]: interventions that have been available over time, short of very atric surgery have not been terribly effective or at least offered durable efficacy.

15:33 [SPEAKER_00]: Because when I take the next history of tell me about the things you've tried, very often for people in that situation, it could be I could just ask that question and shut my mouth and listen for the next half hour and listen to all of the things that have been [SPEAKER_00]: tried whether diets or exercise programs or nutritional supplement told shake programs or one gym or the other or this guru, that guru, you know, various named diets and all sorts of things, as well as maybe even some of the medicines over time.

16:03 [SPEAKER_00]: And maybe they've had some early success with many of them as many people do because pretty much everyone, and this is a conversation I've often, everyone can lose weight, but of course the challenge is the durability of that weight loss, because most of these folks have, and sometimes people have told me, I've lost thousands of pounds in my life, but the problem is that they have tended to come back inevitably over time, and that's that kind of [SPEAKER_00]: almost magnetic gravitational pull of biology back to what you have described as almost like what feels like a set point to people and particularly punctuated by these certain life events.

16:39 [SPEAKER_00]: And so I'm not there in that conversation too. [SPEAKER_00]: obviously discount their experience, but rather to promote or to to get a sense of what is their, you know, stage of change, we're in that whole behavior change model, and are they willing to try something different that they might not have tried before?

16:55 [SPEAKER_00]: Because the reality is now we have more potent, more effective tools than ever to address that underlying biology, rather than telling [SPEAKER_00]: you just have never tried hard enough in your life. [SPEAKER_00]: That would be preposterous of me to ever even suggest to some of these folks, because I've even had some who are like ultra endurance athletes.

17:13 [SPEAKER_00]: I've had some very memorable conversations recently of people who are ultra-runners, who have struggled with their weight or ultra-swimmers, who have struggled with their weight. [SPEAKER_00]: And it's like, far be it for me to say that you've not tried because those are things that I am generally not willing to do those types of activities.

17:32 [SPEAKER_00]: So really, it's validating their experience, but also offering potentially a novel in different path that actually treats the underlying biology more effectively than ever. [SPEAKER_00]: Now, I still have to caveat it by saying, like, hey, this works for many more people than it has in the past, but still I have some poke folks who I use these modern therapies for, and they still get a their hyporesponders, or less than optimal.

17:51 [SPEAKER_00]: This field is rapidly evolving, still growing. [SPEAKER_00]: Sometimes we do combination treatments of one medicine with another. [SPEAKER_00]: We have some exciting agents on the horizon. [SPEAKER_00]: Sometimes we combine it with surgery, and it can be be effective. [SPEAKER_00]: So there are often still tools and strategies and reasons for optimism in the future.

18:10 [SPEAKER_00]: But really, it's a matter of trying to understand their journey to this point, what led them to have a conversation with me and trying to break out of the mindset of like, this is not, this is just effectively not modifiable ever for any reason. [SPEAKER_00]: If you would like to, or if you're open to trying something different, as many people these days are, the more and more popular, our modern agents get, then I'm happy to support them through that journey.

18:34 [SPEAKER_00]: But definitely tough conversations and ones that I'm having daily at this point. [SPEAKER_01]: Yeah, I mean, the average individual with obesity will try to lose weight at least eight times in their lifetime. [SPEAKER_01]: But generally, they don't find success. [SPEAKER_01]: We think it's about one in 10.

18:52 [SPEAKER_01]: People will achieve clinically significant weight loss if we define as losing more than 5% of your starting weight and then at your point this durable efficacy how long does that last can you maintain it? [SPEAKER_01]: To your point, everybody can lose weight, right? [SPEAKER_01]: But whether it's enough, [SPEAKER_01]: And if it's sustainable, that is the key question, and unfortunately prior to this modern era of medicine, we just didn't really have that many good options available for folks, and so things are changing.

19:19 [SPEAKER_01]: I agree. [SPEAKER_01]: Yeah. [SPEAKER_01]: All right, so look, if genetics and the environment set the sort of range of weights that a person will experience in their adult life, the next question is, what does your body do when you try to go outside this range? [SPEAKER_01]: So losing weight and then keeping it off for two different problems, you let's say you decide to drop below your sort of that lower guard rail and your body answers from two directions at once your appetite tends to go up and the amount of energy or calories that you burned most predominantly at rest goes down we're going to tackle them one at a time let's start with appetite or hunger.

19:58 [SPEAKER_01]: Because everyone assumes that the change in hunger and appetite is temporary. [SPEAKER_01]: Now, I want to make clear that appetite and hunger are related, but not necessarily the same thing. [SPEAKER_01]: Appetite is a sort of biological drive for food seeking behaviors or what I like to say food seeking practices.

20:15 [SPEAKER_01]: Hunger is your sort of conscious experience of that. [SPEAKER_01]: I implore you to try and be less hungry. [SPEAKER_01]: Just decide to be less hungry. [SPEAKER_01]: And you'll see that that's kind of sorely. [SPEAKER_01]: Or it's like try to be less thirsty. [SPEAKER_01]: Try that too.

20:28 [SPEAKER_00]: Good luck. [SPEAKER_01]: Yeah. [SPEAKER_01]: So the thought here is that look, you're going to go on a diet. [SPEAKER_01]: You might get hungrier in the short term, but you just need to tough it out for the first few weeks. [SPEAKER_01]: And your appetite's just going to reset when you get to this new lower body weight.

20:44 [SPEAKER_01]: In 2011, a study in the New England Journal of Medicine led by Priya Sumithrin tested that directly. [SPEAKER_01]: It took 50 people with over way to obesity and ran them through a pretty extreme diet. [SPEAKER_01]: I think by all, in terms of overall, the terms of purposes is pretty extreme.

20:59 [SPEAKER_01]: It's a 10-week diet, 500 to 550 calories per day. [SPEAKER_01]: Not a deficit, but very low energy diet. [SPEAKER_01]: As an aside, when people ask, hey, what's the fastest way to lose weight? [SPEAKER_01]: You just say, well, you just don't eat, the fastest way to lose weight. [SPEAKER_01]: Is that the best way to lose weight?

21:14 [SPEAKER_01]: That's a different question. [SPEAKER_01]: In any case, everyone in the study lost weight about 13 and a half kilos on average, that's about 30 pounds in 10 weeks. [SPEAKER_01]: All right. [SPEAKER_01]: So instead of just asking the people do they feel hungry, so subjective ratings. [SPEAKER_01]: They also drew blood and measured some of the biological hormones that we know are associated with appetite, hunger, and satiety.

21:35 [SPEAKER_01]: They measured it at three different points, one directly before the diet to directly after, so this 10 week period and then a full year later. [SPEAKER_01]: Now, if this were just a short-term transient rough patch, you got a white knuckle through, those hormones should have come back to baseline at about a year.

21:52 [SPEAKER_01]: But a year later, all of the hunger hormones were still elevated. [SPEAKER_01]: and the fullness hormones were still down. [SPEAKER_01]: And by their own ratings, people were measurably hungrier than before when they lost a single pound. [SPEAKER_01]: The body turned the appetite up and left it there.

22:06 [SPEAKER_01]: So this sort of nails down that the hunger that these folks are fighting a year later is real and measurable and isn't the sort of short-lived temporary thing you just got to again, white knuckle it through. [SPEAKER_01]: Um, so some of the hormones that we're talking about here are are Grellen and left in those are probably the two best known in the space.

22:24 [SPEAKER_01]: Austin, what are these hormones doing in just plain terms? [SPEAKER_00]: Yeah, there's a really kind of complex structure of the well, called the the neurobiology of of hunger or satiety of appetite. [SPEAKER_00]: Things like that. [SPEAKER_00]: And there are just to oversimplify that general categories of hormones that are broken down into the either those that are known as what was called [SPEAKER_00]: you might be familiar with the term anorexia, as the condition where people are very restrictive of their dietary intake.

22:54 [SPEAKER_00]: So there are orexogenic hormones, those that tend to promote hunger, satiety, food, seeking behavior, and calorie consumption. [SPEAKER_00]: Those are things like growland, and certain other ones like [SPEAKER_00]: neuropeptide y. [SPEAKER_00]: There's one called a goody related peptide.

23:08 [SPEAKER_00]: There's hormones called arrexins. [SPEAKER_00]: Things like that that can contribute to that arrexogenic behavior. [SPEAKER_00]: And then there are those that are an arrexogenic hormones. [SPEAKER_00]: Those that tend to promote terminating a meal, promoting feelings of fullness of satiety or not necessarily seeking food.

23:23 [SPEAKER_00]: And left in is one of those as well as others in the POMC or Proopio Melanicorton pathway and then a handful of others in that whole system. [SPEAKER_00]: And so these systems are constantly kind of epic and flowing. [SPEAKER_00]: Obviously to ideally maintain homeostasis. [SPEAKER_00]: And when this system is kind of disregulated in the context of this modern environment that we're talking about, that's where things can get kind of tilted a little bit excessively in one direction or another, [SPEAKER_00]: But to the point of a lot of our endocrinology is in our hormone signaling systems are oriented around homeostasis.

23:56 [SPEAKER_00]: That's kind of explains what we're observing here. [SPEAKER_00]: Somebody losing weight and then the body responding in a way to kind of tilt the balance of these hormones in the direction of or exigenic hormones and away from enter exigenic hormones to promote food seeking behavior, calorie intake, weight regained to restore that kind of perception [SPEAKER_01]: Yeah.

24:20 [SPEAKER_01]: Yeah. [SPEAKER_01]: So when people are saying, look, it's actually not about calories. [SPEAKER_01]: It's all about hormones. [SPEAKER_01]: I can like make a charitable argument that in many ways that that is true, but I don't think they're talking about these hormones. [SPEAKER_01]: Right.

24:32 [SPEAKER_01]: And we should also say that these hormones don't change predictably in everyone or maybe I should better phrase that they don't change the same way in everybody. [SPEAKER_01]: So maybe predictable. [SPEAKER_01]: Yes, if you lose weight, we generally think that [SPEAKER_01]: And these satiating feelings of fullness hormones will go down.

24:52 [SPEAKER_01]: But to the level they change can vary massively between individuals. [SPEAKER_01]: And so two distinct phenotypes emerge obesity sensitive and obesity resistant. [SPEAKER_01]: And so the people that are obesity sensitive generally would have a larger response here when trying to lose weight their appetite promoting hormones will go up more than somebody who's obesity resistant.

25:16 [SPEAKER_01]: Who's like, look, I'm going to do whatever is in my power to not gain weight. [SPEAKER_01]: And that's not a conscious choice. [SPEAKER_01]: That's a biological thing that's happening underneath. [SPEAKER_01]: And if you track that down to like, well, why does that happen? [SPEAKER_01]: It's like, well, it's genetics.

25:27 [SPEAKER_01]: And so then I'm like, dang it. [SPEAKER_01]: We're back to the genetics thing again, or we at hormones. [SPEAKER_01]: But anyway, so you can make a charitable case for both of those sort of arguments. [SPEAKER_01]: But the problem is their reductionist to say it's all about genetics, is reductionist to say it's all about hormones, is reductionist.

25:41 [SPEAKER_01]: It's complex to say the least. [SPEAKER_01]: Now, that's the hunger side. [SPEAKER_01]: Turned up. [SPEAKER_01]: That's only half the story here. [SPEAKER_01]: The other half is on the burning side. [SPEAKER_01]: How many calories you burn or use, expand otherwise, just existing and that tends to drop too.

25:55 [SPEAKER_01]: Now, Austin, we say something like resting metabolic rate. [SPEAKER_01]: What do we actually mean? [SPEAKER_01]: When we say that. [SPEAKER_00]: If you are purely at rest, just lying in bed not doing anything as you often describe the amount of energy that is needed to quote unquote keep the lights on in your body to operate your vital organs to keep blood flowing things like that.

26:14 [SPEAKER_00]: So just the number of the amount of energy that is required to maintain your physiology and your homeostasis purely at rest just to stay alive. [SPEAKER_00]: This amount of energy does tend to decrease in the context of weight loss and it is not exactly in alignment or what we might predict just purely based on the amount of change in body size alone or the amount of weight loss alone.

26:37 [SPEAKER_00]: And that's kind of spawned this whole conversation around the idea of quote unquote metabolic adaptation that's been, you know, I feel like a perpetual topic [SPEAKER_01]: Yeah, yeah, exactly. [SPEAKER_01]: And so, you know, people will say things like, look, if you cut calories and lose weight, your metabolic rate is gonna go down.

26:56 [SPEAKER_01]: It's like, well, your metabolic rate, which is the amount of energy you use per unit mass, right, per kilo of tissue. [SPEAKER_01]: That doesn't really change, but you have less mass. [SPEAKER_01]: So, you know, if you lost weight by definition. [SPEAKER_01]: So, yeah, your total daily energy expenditure is likely to decrease.

27:14 [SPEAKER_01]: Now, when that changes disproportionately, [SPEAKER_01]: to how much weight you've lost. [SPEAKER_01]: That is metabolic adaptation. [SPEAKER_01]: And so at that point, yes, the actual metabolic rate has maybe gone down. [SPEAKER_01]: And if it happens to a large enough effect, that is your effectively resisting further weight loss, via that mechanism.

27:32 [SPEAKER_01]: So yes, we tend to see, particularly in folks, who have this maybe obesity sensitive, sort of phenotype, that they're metabolic rate and their total daily energy expenditure will go down more than is predicted. [SPEAKER_01]: because again, their bodies fighting against that weight loss partner than somebody who's obesity resistant.

27:51 [SPEAKER_01]: And those folks, when you try to overfeed them, for example, they do just the opposite. [SPEAKER_01]: They're like, well, I'm going to ramp everything up because I don't want this smoke or these calories don't want that smoke, and I'm going to push back. [SPEAKER_01]: The best modern sort of look at this comes from the biggest loser competition, and so we talked about Danny K. Hill in the opener, but him and the rest of his competitors were actually followed by for six years by a team at the NIH.

28:17 [SPEAKER_01]: After the 30-week competition, their resting metabolism had fallen by about 600 calories a day. [SPEAKER_01]: six years later, when much of the weight had come back, it was still running a lower about 700 calories a day under the prediction. [SPEAKER_01]: So it persisted. [SPEAKER_01]: It was a transient.

28:34 [SPEAKER_01]: When you stack those these two things together, if you lose weight, your body raises the sort of hunger, hormones, decreases the satiety, hormones, and then on top of that, your burning less calories, because this metabolic adaptation, you can see the problem here clearly. [SPEAKER_01]: It maintaining [SPEAKER_01]: Weight loss is very, very challenging for many folks.

28:53 [SPEAKER_01]: And if that's been you, it'll lose weight and you watch it come back, while everybody may be also including you. [SPEAKER_01]: It's chalking it up to weak willpower. [SPEAKER_01]: We'd like to push back against that and reframe it as this. [SPEAKER_01]: Look, the appetite going up and the calorie burn going down, that's biology.

29:09 [SPEAKER_01]: It's not necessarily you choosing to feel hungry or the normal or consciously influencing your own metabolism when I see these things on social media. [SPEAKER_01]: You got to know about your metabolism. [SPEAKER_01]: It's like, does knowledge of the crebs cycle really inform your choices here?

29:25 [SPEAKER_01]: Uh, I think this is the most common experience when it comes to weight loss, uh, for many folks, particularly in the modern era. [SPEAKER_01]: Uh, so, so awesome to imagine this. [SPEAKER_01]: You got a patient that comes in. [SPEAKER_01]: They're 40 to 44 year old female with a BMI of 34.

29:36 [SPEAKER_01]: She's lost 40 pounds twice in her life. [SPEAKER_01]: She's regained all of it twice. [SPEAKER_01]: She convinced she's convinced she just lacks discipline and her last doctor agreed and said, look, you just got to eat less and and move more. [SPEAKER_01]: What do you actually say about why the weight came back?

29:50 [SPEAKER_01]: Do you actually go into any sort of explanation there? [SPEAKER_01]: Does that help frame your [SPEAKER_00]: Yeah, this often comes up in the course of the conversation because yeah, I know this person. [SPEAKER_00]: I know many of many of these these patients for sure. [SPEAKER_00]: And so I first just try to characterize what did it feel like to them to go through that journey.

30:06 [SPEAKER_00]: What was it like? [SPEAKER_00]: What did they perceive to be the biggest challenge for them? [SPEAKER_00]: And a lot of times it's multi-factorial, a lot of times it's I was okay when I was perfect about tracking every morsel of energy that went into my mouth and able to rigidly stick to this exercise program, non-stop every day.

30:25 [SPEAKER_00]: And it felt to me like the moment I didn't do and either of those things that it all went off the rails. [SPEAKER_00]: That was a very common sentiment that is expressed. [SPEAKER_00]: It's like unless I was [SPEAKER_00]: And whether or not that is physiologically what happened, that is what the experience feels like.

30:44 [SPEAKER_00]: And I think that that is an illustration of the power of the underlying biology in fighting back against your best conscious efforts. [SPEAKER_00]: And to be honest, we are kind of fighting at a disadvantage against our own biology in these ways, right? [SPEAKER_00]: It would be great if we were in full conscious control of all of our biology when we wanted to be.

31:06 [SPEAKER_00]: I think you would drive us crazy if we had to be, if we had to consciously decide to make sure our heart kept beating. [SPEAKER_00]: But, you know, if we had maximum control over all of these things, it would be, it would be great. [SPEAKER_00]: At the same time, because we don't have that degree of control, think about, you know, the paragons of, you know, body composition, fitness, leanness, and competitive bodybuilding.

31:26 [SPEAKER_00]: Why are so many of them using GLP1 agonist like Reda? [SPEAKER_00]: if it was the case that they're just superior beings with moral fortitude and ability to exert such perfect control, they wouldn't be using these things, but they're just like, yeah, mixed-diting ways here. [SPEAKER_00]: It's like, yes, because these tools mitigate, it puts you back in the advantageous position over that underlying biology.

31:49 [SPEAKER_00]: It ties your that that biology's like hands behind its back so that it cannot fight back quite as effectively. [SPEAKER_00]: And that's usually the way that I frame this conversation with folks is, yes, when we are able to successfully lose weight, that is a remarkable achievement, but the underlying biology, the body kind of wants to fight back.

32:06 [SPEAKER_00]: It's almost like we, we analyze it oftentimes to a a coiled spring that the further you, you know, pull it talk to them more aggressively. [SPEAKER_00]: It's going to want to snap back unless we have some additional help with something like one of these, one of these tools that can kind of put us back in the driver seat and give us a little bit more of an advantage over that biology.

32:24 [SPEAKER_01]: Yeah, yeah, I, you know, body builders are also are always, you know, are, are often anyway held up at these sort of counterfactuals, you're like, look, you're saying that people can't lose weight or difficult for them lose weight because genetics, the environment or whatever, well, look at all these body builders.

32:36 [SPEAKER_01]: And I'm like, yeah, let's look at it. [SPEAKER_01]: Generally speaking, most people who engage in competitive body building did not start out as individuals with obesity. [SPEAKER_01]: and further when they die it down, prep four, and ultimately compete, the weight changes are all short-term.

32:53 [SPEAKER_01]: Really they are. [SPEAKER_01]: Whether it's a six-month prep period and you get down a stage, wait, what happens directly after that? [SPEAKER_01]: Whoa, they gain weight, comes back in, they kind of go back to where they were before. [SPEAKER_01]: It's exactly as predicted, and so we're not saying, again, that you can't lose weight in the short-term.

33:07 [SPEAKER_01]: Certainly more than one out of 10 people when they do a diet, even with well-supported lots of resources available, a lot of coaching for lifestyle stuff. [SPEAKER_01]: Yep, more than one out of 10 people are going to lose clinically significant weight loss. [SPEAKER_01]: whether they maintain that for one year, two years, more years, well, that is the question and that's really what we're getting at at a population level.

33:29 [SPEAKER_01]: We're not saying everybody needs to go on a 16 week prep, you know, to get ready to get on stage, but yeah, let's look at body builders. [SPEAKER_01]: The best people arguably in the world for getting lean have challenges maintaining that basis and you know, again, [SPEAKER_01]: Not because they're bad people, just because one, the leanness that they're trying to achieve and maintain is below that lower guard rail.

33:50 [SPEAKER_01]: That's thing one and two biologies on this. [SPEAKER_01]: Exactly. [SPEAKER_01]: So the body defending this range is half of the story. [SPEAKER_01]: Now the other half, and we're gonna talk about this after the break, is that you're probably not choosing. [SPEAKER_01]: Nearly as much as you think you are, and that's where the triply number finally gets explained.

34:07 [SPEAKER_01]: All right, we're back here on the Barbell Medicine podcast. [SPEAKER_01]: We're gonna talk about the idea that you're choosing most of the foods that you put in your body, not only what you're eating, right, for how much you're eating. [SPEAKER_01]: This is the part that answers the number that we opened with that obesity tripled because the thing making the decisions are heavily influencing the decisions the environment changed like a rug being pulled out from underneath us so most of what you eat you don't actually decide from a conscious standpoint.

34:36 [SPEAKER_01]: We kind of envision the sort of control panel and a person just flipping switches, making calls all day, but most of the time we're actually running on autopilot on habit, and whatever is in the room or in the environment around us. [SPEAKER_01]: This isn't actually a hot take. [SPEAKER_01]: This is not like a barbell medicine.

34:52 [SPEAKER_00]: We just created this. [SPEAKER_00]: The model goes back to a 2008 paper called Eating as an Automatic Behavior. [SPEAKER_01]: And they suggest that intake is mostly triggered by the environment. [SPEAKER_01]: It's not deliberated upon, which is why nutrition lectures in this sort of try harder mantra keep losing this battle to sort of change how people are eating.

35:12 [SPEAKER_01]: the one of the best studies on this, it's almost comical to me. [SPEAKER_01]: If you serve someone more food and they eat more, they don't notice that they actually ate more. [SPEAKER_01]: This comes out of Barbara Rolls Lab, and they've been doing this for over 20 years. [SPEAKER_01]: In one study, they served the same people a plate of macaroni and cheese on different days.

35:31 [SPEAKER_01]: quietly changing only the size of the serving. [SPEAKER_01]: If you increase the portion size, the intake went up by about 30% over about 150 calories. [SPEAKER_01]: And afterward, people rated themselves just as full as the smaller portion. [SPEAKER_01]: In a restaurant version, an entree made of 50% bigger portion got people eating 43% more of it.

35:52 [SPEAKER_01]: It's the same person, same food, same hunger and satiety ratings. [SPEAKER_01]: The only thing that changed was how much food was in front of them. [SPEAKER_01]: And their eating tract, what was served to them, not their appetite. [SPEAKER_01]: Nobody at the table, quote, decided to eat more, just presented to them and they thought, yeah, I'll eat this.

36:08 [SPEAKER_01]: This also isn't a one meal novelty. [SPEAKER_01]: If we were really good at compensating, for example, you wouldn't expect this to really move the needle when it comes to weight. [SPEAKER_01]: When the same lab ran the similar type of study over 11 straight days, the people never caught on and they didn't compensate by eating less later.

36:26 [SPEAKER_01]: They just ate more the whole time in a Cochrane review on analysis of 72 trials like this. [SPEAKER_01]: They came up with the same sort of conclusion. [SPEAKER_01]: Bigger portions and packages reliably drive more eating across body weights and appetites. [SPEAKER_01]: So one of the biggest drivers of how much the whole country is eating has nothing to do with discipline.

36:47 [SPEAKER_01]: It's the size of what shows up on a plate or in a package, and that's been going up for decades. [SPEAKER_01]: When you look at the portion sizes across different foods that we commonly eat from 1970s to now, [SPEAKER_01]: Yeah, that'll blow your wig back. [SPEAKER_00]: Not honestly not surprising and I think both of us probably are people who have experienced this and we can kind of relate of like in more more often than not if we're like going out to eat.

37:11 [SPEAKER_00]: What you are served is a serving for one. [SPEAKER_00]: Almost regardless of what that serving is. [SPEAKER_00]: And further and we know this from like an adjacent concept and you know we've talked about this before this idea of like. [SPEAKER_00]: you know, food variety and sensory specific, sensory specific satiety and things like that where if you have much more variation you're ordering like, you know, five different things that come out, uh, you're going to end up, you know, bouncing between them and end up ultimately consuming more, but it's all there in front of you as well.

37:42 [SPEAKER_00]: And so I often discuss this with folks when it comes to the environment that there are. [SPEAKER_00]: sometimes in a little bit more control of. [SPEAKER_00]: I just have this conversation with the gentleman the other day who you know had had described his experience and and we came to the conclusion that look if it's in the house it's going down the hatch and so there were certain food items for him that we just decided we're probably best not to be kept in the house because again if they are they were they were going down uh [SPEAKER_01]: Yeah, I had a client a few years back and, you know, she had been struggling with weight, her entire life, right?

38:16 [SPEAKER_01]: And she's like, I'm finally motivated enough. [SPEAKER_01]: I'm gonna make these changes. [SPEAKER_01]: I'm ready. [SPEAKER_01]: And I'm like, great. [SPEAKER_01]: Can you tell me about what kind of food you keep in the house? [SPEAKER_01]: Right, and she's telling me she's like, look, me personally, I buy what you would probably consider healthy foods, but my husband, oh man, that is not the case and also he I feel like he's trying to sabotage me because he's hiding things around the house for me to find inadvertently, you know, these ultra processed foods package, you know, snacks and candies and such like that, and I'm like, well, what happens when you find them, she's like, well, I'm going to eat them because they're there and like I want to eat them, I'm like understandable, okay, I get that, but I also think.

38:53 [SPEAKER_01]: He needs to be on board with this. [SPEAKER_01]: Otherwise, it's going to be very challenging if not impossible. [SPEAKER_01]: You set me up perfectly for this because this really gets at the heart of the matter. [SPEAKER_01]: What actually changed in the environment if we zoom out to the whole food supply, the portion effect is part of that, but it's relatively small compared to what happened elsewhere.

39:12 [SPEAKER_01]: Between about 1970, 2010, the calories available per person in the US food supply went up roughly 450 calories a day. [SPEAKER_01]: ultra-process food, the engineered stuff now makes up about 58% of the calories American adult eat and about 67% for kids. [SPEAKER_01]: Now, we should say that just because something is ultra-process doesn't necessarily mean it's bad, so like way protein, Greek yogurt, whatever, that's all technically ultra-processed and can't be helped promoting, but the majority of ultra-process foods are those that have added sugar, added sodium, added fat, [SPEAKER_01]: to sort of get to this bliss point, this very tasty, mouth-foot feel that makes people eat more.

39:51 [SPEAKER_01]: And unfortunately, while it is high in calories, it's not proportionally satiating or filling. [SPEAKER_01]: So, this all changed recently, you know, over the last 40 to 50 years, and it didn't happen by accident. [SPEAKER_01]: In the 1980s, the tobacco companies Philip Morris and RJ Reynolds bought up the major food brands.

40:10 [SPEAKER_01]: Crafts, general foods, Nabisco, and brought their scientists with them to engineer food that is easy to keep eating. [SPEAKER_01]: There was an active lawsuit in San Francisco right now that we went through on the trial of big food episode. [SPEAKER_01]: That part interests you. [SPEAKER_01]: It's in the show notes below.

40:24 [SPEAKER_01]: You can go listen to that. [SPEAKER_01]: but today we only need one piece of it. [SPEAKER_01]: The food around us changed a lot in the last 40 to 50 years. [SPEAKER_01]: So did the genes change with it or not? [SPEAKER_01]: Obviously, they did not. [SPEAKER_01]: Now, some people are gonna push back and say, look, maybe some populations are just genetically susceptible, or genetically prone.

40:44 [SPEAKER_01]: And the tripling in obesity is just due to those genes finally showing up. [SPEAKER_01]: So what happens when you test this? [SPEAKER_01]: Take a group with shared genes, change the environment only, and see what happens. [SPEAKER_01]: That experiment exists, and we didn't even have to like artificially engineer it.

41:00 [SPEAKER_01]: The Pima Indians are a clean setup for this. [SPEAKER_01]: One population, common ancestry, confirmed genetically similar down to hundreds of DNA markers. [SPEAKER_01]: Some lived in Arizona in the modern American food environment and some lived in the Sierra Madre in Mexico, they were farming at eating a traditional diet.

41:17 [SPEAKER_01]: Same gene pool but two different environments. [SPEAKER_01]: The Arizona Pima are among the heaviest studied populations on earth. [SPEAKER_01]: Average BMI is in the mid-30s, obesity running from about 64% in men up to 75% in women. [SPEAKER_01]: The Mexican Pima, same ancestry, sit at a BMI in the mid-20s with obesity in the around 6% in men.

41:39 [SPEAKER_01]: Type 2 diabetes prevalence was around 38% in the Arizona Pima and you're 7% in the Mexican Pima. [SPEAKER_01]: And you can watch it happen in side individuals, not just across environmental border. [SPEAKER_01]: If you track immigrants to the US by how long they've lived here. [SPEAKER_01]: In one big analysis, obesity was about 8% among people in the country for less than a year.

42:02 [SPEAKER_01]: They live in the United States for less than a year. [SPEAKER_01]: And about 19 percent, amongst those who've been here for 15 years or more, climbing toward the US-born rate, the longer they've been in this environment. [SPEAKER_01]: The same people, they didn't swap out their genes at the border that wasn't required, the food that they were living around is what changed.

42:18 [SPEAKER_01]: Now, again, some pushback here. [SPEAKER_01]: These are cross-sectional snapshots in time, right? [SPEAKER_01]: Not the same people tracked start to finish necessarily. [SPEAKER_01]: And the two Pima groups differ in physical activity, too. [SPEAKER_01]: Obviously, one group farms and the others in the modern, sort of Obesigenic environment, which is not just related to the food supply, but also we have literally due activity-wise day-to-day.

42:39 [SPEAKER_01]: And their genes aren't perfectly identical. [SPEAKER_01]: It's not just a bunch of twins that we're studying. [SPEAKER_01]: None of that really saves this willpower narrative though. [SPEAKER_01]: It just kind of fills in some of the gaps around this environmental argument that we're making.

42:52 [SPEAKER_01]: So this is the answer to the number that we opened with. [SPEAKER_01]: Jeans set your guardrails. [SPEAKER_01]: And over 40 years, the environment kind of moved the whole population up against the top one, right? [SPEAKER_01]: And we don't have any predators. [SPEAKER_01]: So that top number may have shifted even higher in some of the population as well.

43:09 [SPEAKER_01]: Obesity didn't triple because 100 million people lost their willpower or got dumber all at once. [SPEAKER_01]: It's because the environment, particularly the food environment around them changed. [SPEAKER_01]: So, Austin, why, in your opinion, is ultra-process food so easy to overeat? [SPEAKER_01]: Is there like a mechanism behind this?

43:31 [SPEAKER_01]: What sort of stories do you hear from your patients that sort of corroborates that, or makes you kind of think, look, there's something in this food that is unique? [SPEAKER_00]: There's a couple layers to this question. [SPEAKER_00]: It is an interesting one on multiple of these levels.

43:43 [SPEAKER_00]: One is just what is an ultra-processed food and there's certainly been a lot of discussion and debate and controversy around this including topics like the Nova classification system that has some pros, but also some cons and some limitations. [SPEAKER_00]: Because as we have discussed before, are you alluded to a little while ago on this episode that just simply the degree of quote unquote processing alone like doing things to a food does not necessarily automatically or inherently making make it less healthy.

44:12 [SPEAKER_00]: There's also the aspect of like food fortification and that is more often beneficial than it is likely to be negative on these kind of things and there are some. [SPEAKER_00]: elements of vagueness and subjectivity to that classification. [SPEAKER_00]: So it's not something that I think you are I regularly rely on, at least practically when we're working with folks.

44:30 [SPEAKER_00]: But it has some general heuristic value. [SPEAKER_00]: I suppose to decide what is classified as, you know, highly processed or quote unquote ultra processed. [SPEAKER_00]: But I think that our best understanding of this is that many of these foods are [SPEAKER_00]: in many ways deliberately designed to just like light up all of the, you know, areas of our brain, that we like to have lead up, there is this, these types of hunger that we've talked about before as well, there's kind of the more physiologic homeostatic kind of hunger type mechanisms, the things that are really.

45:04 [SPEAKER_00]: you know, much more closely oriented to energy intake that you need to fuel those metabolic processes to keep yourself alive or for fertility or for pregnancy or whatever the case is. [SPEAKER_00]: There's some physiologic drive to it. [SPEAKER_00]: But then there's the what's called hedonic hunger aspect of things.

45:20 [SPEAKER_00]: And this is an interesting way to describe it because I've also heard [SPEAKER_00]: you know modern anti-OV city medicines like GLP ones and things like that called by like the CEO of Lily I believe I heard him in an interview described them as anti-hedonic drugs which I found to be a very interesting discrimmer because they're to some extent targeting that mechanism a bit more because when they're applied properly to a clinical population [SPEAKER_00]: We're not aiming to eliminate the homeostatic hunger that's like, oh, we're just making sure we're trying to prevent you from getting the minimum calorie needs that you need for your metabolic rate.

45:51 [SPEAKER_00]: We're trying to better align your overall calorie intake on that dimension while maybe reducing the amount of excess energy consumption that led to the body fat accumulation. [SPEAKER_00]: oftentimes by way of these hedonic mechanisms. [SPEAKER_00]: Not exclusively, but a big part of it relies on that.

46:08 [SPEAKER_00]: So many of these foods that are so easy to overeat, they really light up those kind of hedonic mechanisms, making them very enjoyable to eat. [SPEAKER_00]: They're often either flavor profiles, textural profiles, various other unique elements of them, while also offering very little in terms of satiation value.

46:25 [SPEAKER_00]: They do not tend to be [SPEAKER_00]: Very filling and this is on purpose and also on accident as a result of the same types of things that light up our brains don't tend to be Oh my gosh, I can't take another bite of this like incredibly delicious thing [SPEAKER_01]: Yeah, that's a really interesting that the, you know, being describing these drugs, uh, these medications is anti-hedonic medications.

46:46 [SPEAKER_01]: I've been calling like behavior change agents for a while because they change the behavior, but that's interesting. [SPEAKER_01]: So, so one of the pushbacks people often have against GLP ones, for example, is are like, well, look, some people get on these, they don't change their dietary habits because they're still eating junk food, right?

47:00 [SPEAKER_01]: And actually, I almost think that's a proof of concept. [SPEAKER_01]: So, so thing one. [SPEAKER_01]: proof of concept of how durable the sort of desirable of these foods are. [SPEAKER_01]: So it's not just that they taste awesome, right, and have all these unique engineered characteristics, again, by design.

47:15 [SPEAKER_01]: They are heavily marketed to us. [SPEAKER_01]: They are ubiquitous. [SPEAKER_01]: They're cheap. [SPEAKER_01]: You can't outrun them. [SPEAKER_01]: They're everywhere, right? [SPEAKER_01]: So did the idea that people are just going to stop eating them, you know, cold turkey, highly unlikely.

47:28 [SPEAKER_01]: However, [SPEAKER_01]: with the modern advances in pharmacology, people are eating less of them, which is the goal, really, that's where, and so even these drugs can stop people from eating as much, which is ultimately what you would want. [SPEAKER_01]: It may be sure in a perfect world, everybody who started GOP one would overnight become a well-trained chef.

47:48 [SPEAKER_01]: They would have the resources to procure, and prepare all of the food, all the meals are gonna eat in their home, in their domicile. [SPEAKER_01]: Superb. [SPEAKER_01]: Oh, sorry, go ahead. [SPEAKER_01]: In the less perfect, maybe more realistic world, you're still exposed to the modern food environment, and like, look, you might have some food that falls in the ultra-processed range, or whatever, and some people would frown upon morally.

48:11 [SPEAKER_01]: But, yes, what? [SPEAKER_01]: They're going to eat less of them. [SPEAKER_01]: Which again, is how the medication's supposed to work if it were to truly target this stuff at the level of the brain and ultimately, again, the outcome outcomes are undeniable. [SPEAKER_00]: So I find that really interesting.

48:26 [SPEAKER_00]: Yeah, I agree. [SPEAKER_00]: It is admittedly super frustrating to have conversations with some of these folks that you're that you're talking about and also why I tend to not have very many of these conversations most often arguments on social media because many of them at the outset will be like, look.

48:38 [SPEAKER_00]: It's just all about calories, you just need a calorie deficit, and it's like, okay, well, if we have a medicine that facilitates people getting a calorie deficit, you'd be on board with that, right? [SPEAKER_00]: And then something that's like, well, no, because they just end up eating less, and they don't end up changing their eating habits, it's like, okay.

48:51 [SPEAKER_00]: So if I showed you evidence that overall people tend to actually shift their eating habits, they tend to purchase less of these kind of like ultra-process foods, they're intake of healthier foods, tends to go up, you'd be in favor of that, right? [SPEAKER_00]: It's like, no, also not like that.

49:03 [SPEAKER_00]: it's just like, you know, you're playing chess with a pigeon. [SPEAKER_00]: It's pointless just move on. [SPEAKER_00]: These people, you know, they're too wet to their position. [SPEAKER_00]: It's like if your position was, you know, as it stated at the outset, then, you know, it would seem to logically follow that you'd be in favor of using these tools because they're achieving the outcome that you're most interested in.

49:21 [SPEAKER_00]: But if you add a moral layer on top of it, or you feel like you [SPEAKER_00]: are better, because you can do this, maybe more consistently or more effectively than someone else can, or if it's in your business interest to do so, because you're a coach or something like that, then it's going to be a, we're going to have a hard time changing minds on that front.

49:39 [SPEAKER_00]: Fortunately, we do have plenty of friends and colleagues in this space and coaches and folks like that who are just like, yeah, let's use the best tools we have for the job, because we actually view this as a mission for, you know, the broader, you know, public health [SPEAKER_01]: Yeah, we actually care if the people get better, but in speaking to that question, you know, again, people have been fighting about this for a long time, is it only calories and macros that drive how much we eat or does how the process the food is change intake on its own.

50:11 [SPEAKER_01]: And Dr. Kevin Hall's team actually addressed this. [SPEAKER_01]: It turned the fight into an experiment. [SPEAKER_01]: They admitted 20 adults into a research ward and controlled everything. [SPEAKER_01]: So if just think it's not like you're going to prison, [SPEAKER_01]: Where, where this, you're being punished, but effectively the intake is controlled meticulously.

50:31 [SPEAKER_01]: Two weeks eating mostly ultra-processed food, two weeks mostly unprocessed. [SPEAKER_01]: The order was randomized. [SPEAKER_01]: The key move here. [SPEAKER_01]: The two menus were matched for calories offered, protein, carbohydrates, fat, sugar, salt, and fiber intake. [SPEAKER_01]: Eat as much or as little as you want.

50:48 [SPEAKER_01]: So if you match the macros and the calories on offer and the only thing left different is the processing, any gap in how much people actually consume comes down to the processing itself. [SPEAKER_01]: And since everyone lived on the word in the word, nobody needs a food diary. [SPEAKER_01]: You don't need to rely on that.

51:08 [SPEAKER_01]: the results here. [SPEAKER_01]: On an ultra-processed food diet, people ate about 500 and 8 calories a day more and gained about a kilo in 2 weeks. [SPEAKER_01]: The same people on an unprocessed food diet 8 less and lost about a kilo, roughly a kilo each way in just 14 days. [SPEAKER_01]: not a catch here.

51:27 [SPEAKER_01]: This was only 20 people. [SPEAKER_01]: It was only two weeks and by the way, it's in a research board. [SPEAKER_01]: So this is the ecological validity like in the real world where you know things are more or less ubiquitous, have more or less effort to go ahead and procure them. [SPEAKER_01]: Yeah, it's different.

51:41 [SPEAKER_01]: This is mostly a tight mechanism study. [SPEAKER_01]: And researchers will still argue about why ultra-processed food does this. [SPEAKER_01]: Is it because of the energy density, how many calories you have for a unit volume of food? [SPEAKER_01]: Is it the texture? [SPEAKER_01]: Is it the mouth feel?

51:56 [SPEAKER_01]: Is it the marketing right? [SPEAKER_01]: A lot of children's textbooks, for example, in school have been sponsored by various food organizations and have their stuff advertised to them, you know, from the time they get into the education system? [SPEAKER_01]: So we see the directionality here, but yeah, as far as the why that is still, um, it hasn't been settled yet.

52:14 [SPEAKER_01]: But in any case, the same person, the same amount of willpower, the same so-called choices, if you change the food that's in the room, the intake's going to move by about 500 calories a day. [SPEAKER_01]: That's the food environment doing the eating for you. [SPEAKER_01]: And now a little weird science here.

52:32 [SPEAKER_01]: Dr. Rocky brought this in my attention. [SPEAKER_01]: How much of this lives in the brain verse in the character of the individual? [SPEAKER_01]: We can look at Gorman syndrome. [SPEAKER_01]: So a specific injury to the right front of the brain flips people into food obsession. [SPEAKER_01]: One businessman used to skip dinner for a tennis match until a brain bleed left him unable to stop thinking about Gorman food.

52:57 [SPEAKER_01]: Another quit his job to write the fine dining column after a stroke. [SPEAKER_01]: You damage the sort of hardware in the brain and the eating changes. [SPEAKER_01]: No moral failure required. [SPEAKER_01]: But when you read about this for the first time, did your brain explode and suddenly did you become fruit obsessed like what happens?

53:12 [SPEAKER_00]: No, I mean, I think it fit with the broader understanding. [SPEAKER_00]: So we know [SPEAKER_00]: that there are critical areas of the brain involved in things like appetite and hunger and satiety and things like that, you know, and many of the folks, for example, if there are congenital conditions or acquired conditions as an adult, that can lead to, for example, conditions like hypotherlamic obesity.

53:35 [SPEAKER_00]: And those have direct targeted treatments, there are, you know, drugs that direct specifically target hypotherlamic obesity and have uniquely beneficial effects on that situation. [SPEAKER_00]: And it's the person might have been living otherwise normal life until that acquired some sort of injury to this critical area of the brain.

53:51 [SPEAKER_00]: Kind of like classic stroke stroke syndromes. [SPEAKER_00]: And this is one where suddenly people can develop, you know, insatiable appetite and can, in, in, exerably gain weight afterwards unless it's treated. [SPEAKER_00]: This one was a bit more interesting because it's not in that prototypical area that you think of in terms of the, the hypothalamus, this kind of like right frontal.

54:09 [SPEAKER_00]: area. [SPEAKER_00]: And this is a relatively rare syndrome, but it's just so interesting because it led people not just to food obsession in general, but apparently like to find dining in particular. [SPEAKER_00]: And it's just like such an interesting thing. [SPEAKER_00]: And how much of this is like, you know, really within our conscious control, it's like people who happen to have this very particular type of stroke or brain injury, suddenly they are like seeking out Michelin darn Michelin stars and things like that, really, really fascinating.

54:33 [SPEAKER_00]: So Gorman syndrome was a cool one to learn about. [SPEAKER_01]: Do we think that Pheneas Gage had a Vermont syndrome? [SPEAKER_01]: There was just no access to that to find out. [SPEAKER_00]: Yeah, maybe. [SPEAKER_00]: Or unfortunately, just hit the wrong area of his brain. [SPEAKER_00]: Otherwise, it would have had a very different outcome.

54:47 [SPEAKER_00]: Yeah. [SPEAKER_00]: Yeah. [SPEAKER_00]: He wouldn't be flat all the time. [SPEAKER_01]: Yeah. [SPEAKER_01]: Yeah. [SPEAKER_01]: Yeah. [SPEAKER_01]: All right. [SPEAKER_01]: So, so, look. [SPEAKER_01]: Dr. Barack, a patient tells you that she has no willpower because she graces every night after dinner.

55:01 [SPEAKER_01]: Before you say anything about willpower, what do you suggest changing first or how do you address this issue? [SPEAKER_00]: Yeah, there's a lot of different ways that this could pan out because there's a lot of context that needs to be filled in here. [SPEAKER_00]: For example, what is the rest of the day's dietary intake?

55:15 [SPEAKER_00]: What are her habitual physical activity habits? [SPEAKER_00]: What is her sleep schedule? [SPEAKER_00]: What is her work schedule? [SPEAKER_00]: What's the environment who's with her in that evening timeframe? [SPEAKER_00]: Is there alcohol use involved or other substance use that can also, you know, like cannabis use and things like that that can also increase appetite and contribute to food intake?

55:32 [SPEAKER_00]: You know, but if for example, let's say that she has decided, oh, I'm going to lose weight and go on an intermittent fasting diet and like skip breakfast and then have maybe almost nothing or even skip lunch and then I'll have a normal dinner. [SPEAKER_00]: It's like, yeah, well, probably be kind of normal to still be hungry after that and to want to graze after dinner or if she's having substantial sleep impairment, you know, we know that when people have sleep restriction or impaired sleep quality, their appetite will tend to be higher and they'll spontaneously tend to consume greater calories the the next day.

56:00 [SPEAKER_00]: If there are disinhibiting substances like alcohol or cannabis or something like that, or again, what's the social environment? [SPEAKER_00]: Is it has it been your adult life-long habit with your partner that you bring out some snacks when you're, you know, watching a movie or something in the evening?

56:13 [SPEAKER_00]: Then yep, foods in front of you, it's going to go down the hatch. [SPEAKER_00]: So these are the types of things that I'm trying to illustrate or to get a sense of what's the context that is [SPEAKER_00]: like around this behavior to better understand it before I automatically say, oh, this like pathologize it or to say, oh, like this needs a new medicine to like suppress that, because there might be a lot of other things to consider first.

56:35 [SPEAKER_00]: Now, there are still some people who say, look, I sleep well, I'm physically active. [SPEAKER_00]: I feel like I'm eating, you know, healthy, you know, couple handful of meals throughout the day, and I still am having these cravings, these insatiable cravings at night or something like that.

56:47 [SPEAKER_00]: And then maybe there's a role for certain types of treatments or interventions to try to mitigate that and I've certainly used that, you know, whether, you know, as part of the, the GLP one therapy conversation that I often have with folk or sometimes combination therapies using other things like to appear made or not tracks on that can also kind of more specifically target.

57:05 [SPEAKER_00]: Some of those types of behaviors also have some utility as well. [SPEAKER_00]: But I don't automatically assume that that's the case and that it is going to necessitate that until I fill in the rest of the details. [SPEAKER_00]: I've certainly had some patients who, you know, they maybe start using one of these GLP1 medicines and they're like, I feel hungrier than ever, you know, in the evenings.

57:23 [SPEAKER_00]: This met this medicine is not doing what I thought it was and then I find out that they're like legitimately not eating anything all day and it's like, [SPEAKER_00]: Yeah, you're going to be hungry in the evening, so we need to actually find a way to maintain some like consistent quality nutrition throughout the day to try to balance that out, so you don't have less of these kind of swings back and forth.

57:42 [SPEAKER_01]: Yeah, yeah, well said, and I think ultimately just speaks to, you know, the idea that hunger and subsequently the food seeking practices, food consuming practices are not just related to biology, not just related to psychology and not just related to the environment. [SPEAKER_01]: It's all of them together all at once, all the time.

58:03 [SPEAKER_01]: And so if you really want to blow your mind, [SPEAKER_01]: you can go and look at research on different sort of environmental setups where they see how much people eat. [SPEAKER_01]: Do you eat more when you have a TV screen in front of you generally yes? [SPEAKER_01]: Do you eat more if you're in a social setting depends who are you with and because you tend to mimic their eating behaviors right and so all of these things it's not that they're conspiring although I suspect if somebody had been living with obesity most their adult life they could say it's they are [SPEAKER_01]: the point is it's just more complex than choosing.

58:39 [SPEAKER_01]: It's more complex than the hormones going on biologically, and it's more complex than the environment alone. [SPEAKER_01]: It's all of it together all at once. [SPEAKER_00]: And it may be, it may be possible to say, well, I can choose, yeah, you can choose like once. [SPEAKER_01]: or twice.

58:55 [SPEAKER_00]: What about every decision every day forever? [SPEAKER_00]: That's where things get exponentially harder just for like real people living in the real world with like things to do in their life who don't need to make it their constant mission to maintain a particular body shape body size body composition and that's where this struggle comes in.

59:16 [SPEAKER_01]: Yeah, yeah, I think, you know, the idea of agency and choice and what do I think, again, we're not saying there's nothing you can do. [SPEAKER_01]: We're just trying to shift where you put your attention as far as, you know, focusing on making food decisions, you know, when you're at the table.

59:34 [SPEAKER_01]: that you're probably a few steps removed from where we would want those choices to be made. [SPEAKER_01]: That would probably be made at the grocery store if possible, adjusting your micro environments, for example. [SPEAKER_01]: And other things that sort of allow your default food-related practices to get you to arrive at not only in the right stuff, but also the right amount, and that to happen over and over and over again, and you know, over a long term.

1:00:00 [SPEAKER_01]: If the eating, though, is mostly automatic, and the environment is mostly running it, why are we also sure that it's a character flaw? [SPEAKER_01]: For that, you've got to go back a few thousand years. [SPEAKER_01]: This one is about why the will power story is stuck even after most of the science has stopped backing it.

1:00:17 [SPEAKER_01]: The idea that a body with excess adiposity, excess body fat is a moral failure that the story's old. [SPEAKER_01]: And a lot of people, it's been doing a lot of work for a long time. [SPEAKER_01]: Two of the seven deadly sins are gluttony and slot over eating and laziness. [SPEAKER_01]: Now, for most of Western history, a person with excess body fat wasn't read as sort of a medical problem, right?

1:00:41 [SPEAKER_01]: It was read as a moral problem, and maybe something that's socially unacceptable. [SPEAKER_01]: Visible proof that the person couldn't control themselves. [SPEAKER_01]: That framing hasn't left. [SPEAKER_01]: It's just changed clothing over the over the years. [SPEAKER_01]: The Greeks blamed the humors, the victorians blamed weakwill, and now we say you just need more discipline.

1:00:59 [SPEAKER_01]: It's the same verdict, just different vocabulary. [SPEAKER_01]: So let's put this moral story to the test. [SPEAKER_01]: If obesity were a failure of discipline or intelligence, it would track with discipline and intelligence, you can take two of the most demanding jobs in American public life.

1:01:16 [SPEAKER_01]: William Howard Taft held both of them. [SPEAKER_01]: President of the United States and then chief justice of the Supreme Court and by the careful reconstruction in the medical literature, his BMI while while being president was around 42, that is severe obesity in a man running the country and then [SPEAKER_01]: Or the Nobel Prize, Winston Churchill won the Nobel Prize in literature in 1953, uh, ran a country through a World War, wrote his way to one of the highest honors we hand out, and was visibly overweight for most of his adult life.

1:01:47 [SPEAKER_01]: Nobody has ever looked at taffed for Churchill and concluded they lacked willpower or brains. [SPEAKER_01]: Uh, the mistake is obvious. [SPEAKER_01]: The second you put a name and a resume next to the body. [SPEAKER_01]: Uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, uh, [SPEAKER_01]: I come back to this all the time.

1:01:58 [SPEAKER_01]: If you look at people, high achievers, right, whether it's business, Nobel Prize Lawyers, whatever, a clinical research, you can just go to any profession and you're going to find highly intelligent, hardworking people who have struggled with their weight. [SPEAKER_01]: You don't need a president to see this.

1:02:14 [SPEAKER_01]: You think about the most discipline person that you know right now. [SPEAKER_01]: They're up at five. [SPEAKER_01]: They never missed a deadline. [SPEAKER_01]: They hold the whole household together and they [SPEAKER_01]: It's not, again, a willpower or a work ethic issue. [SPEAKER_01]: It's something else.

1:02:31 [SPEAKER_01]: And we've been talking about this this whole episode. [SPEAKER_01]: And it even holds up when you leave anecdotes and go to the data. [SPEAKER_01]: There's a real population level correlation where higher cognitive test scores line up with slightly lower body weight. [SPEAKER_01]: And people wave it around as if smart equals thin, right?

1:02:46 [SPEAKER_01]: A few problems with this problem number one. [SPEAKER_01]: that becomes the idea that you have to teach people, Disney more education, if people only knew something about their metabolism, their hormones, or what's healthy, if you ask people, even those who do not have a lot of formal education, hey, what's healthier, broccoli or a Twinkie, right?

1:03:06 [SPEAKER_01]: And they're like, well, obviously, the broccoli. [SPEAKER_01]: It's the same thing about exercise. [SPEAKER_01]: Is exercise likely to be held, yes, of course. [SPEAKER_01]: That doesn't tell you why they're not doing it. [SPEAKER_01]: In a 2023 study, they compared over 12,000 siblings raised in the same family, between unrelated strangers, the smarter, leaner link was there.

1:03:27 [SPEAKER_01]: But between siblings, once you hold the family and the upbringing constant, it basically vanished, down to a difference you couldn't tell apart from zero. [SPEAKER_01]: Uh, so that near zero difference within families tells you the original correlation was mostly shared background money socioeconomic status neighborhood the food environment they grew are up grew up around not intelligence causing their thinness and to whatever tiny extent a real sort of direction exists there the better evidence actually runs the other way from metabolic and vascular factors to the brain.

1:03:59 [SPEAKER_01]: not from dumb to fat right so either way this thing the thing that will power crowd needs intelligence and character driving the weight it's the one thing we really can't find in in the evidence it would be very interesting to see that right because then you'd be like well shoot we just need we just need this PSA this brilliant country wide education on here's what healthy foods are maybe you would publish a set of like dietary guidelines every so often that would tell [SPEAKER_01]: The problem is people don't really read them.

1:04:32 [SPEAKER_01]: That's thing one. [SPEAKER_01]: And then thing two, even if you do read them, that doesn't change food behaviors because again, when you look at the different dietary guidelines and what's subsequently happened, the things in the dietary guidelines don't shape up. [SPEAKER_01]: So, [SPEAKER_01]: It's the same argument as the genes to me, the country's intelligence and character didn't collapse over the last 40 to 50 years, any more than the genes changed, the thing that actually tracks with obesity across history, across borders, across Nobel Prizes is the food environment.

1:05:01 [SPEAKER_01]: So Austin, imagine this. [SPEAKER_01]: A patient who's kind of been carrying this shame version of obesity their whole life told since childhood that his weight is a character flaw. [SPEAKER_01]: How do you take that off him or address that in the visits assuming it came up? [SPEAKER_00]: Yeah, this, you know, I was having flashbacks to multiple patient conversations that I've had as you were describing some of those very high achievers, there are many that I have interacted with over time in this weight management space, some who we know from [SPEAKER_00]: You know, our training world, Barbell medicine history from prior seminars.

1:05:37 [SPEAKER_00]: We've done things like that as well as other patients who've kind of found me in other ways. [SPEAKER_00]: And really, as I was describing earlier, gone on to achieve really remarkable things, leaders in healthcare, leaders in government leaders in their, their, you know, sports fields, ultra, you know, endurance athletes in all different kinds of modalities and things like that.

1:05:55 [SPEAKER_00]: And so, you know, seeing the amount of skill and. [SPEAKER_00]: discipline that they have over those areas of their lives, it illustrates the very point that you're making that this is not necessarily a very generalized character flaw that this person suffers from. [SPEAKER_00]: And so that's really oftentimes my entry point into the conversation of.

1:06:17 [SPEAKER_00]: getting a sense of what led them to this belief and almost trying to do what we've talked about before of like an expectancy violation kind of thing or just like, you know, trying to find a little weakness in their argument. [SPEAKER_00]: Oh, if it were true that this were such a flaw, such a weakness, such a deficiency that you have, how do you explain some of these other things?

1:06:38 [SPEAKER_00]: That's one potential route into the conversation. [SPEAKER_00]: the other is that I don't always automatically try to change this person's mind on this because I don't think that that's always a smart thing to do. [SPEAKER_00]: A lot of people don't want to feel like, you know, they're there, somebody's playing mind games with them or that they might feel gas lit or something like that.

1:06:56 [SPEAKER_00]: So there have been some folks where I've just kind of bided my time because many of these folks who are very hard charging successful motivated people [SPEAKER_00]: do it like you know and I and that's my mentality is like show me but not in a doubting way because there are certainly some people who are going to accomplish these things a smaller portion of people who are going to accomplish these things and sustain it again because what you're faced with is you have struggled with this with for your whole life so far.

1:07:28 [SPEAKER_00]: I've no doubt that you can do some things that will facilitate some weight loss in the short term. [SPEAKER_00]: What you are faced with is doing that forever for the rest of your life through this constant daily, you know, waking up, going to war against the dinner plate, going to war against the pantry, or whatever other, you know, you perceive to be kind of, you know, your quote unquote source of weakness or something like that.

1:07:49 [SPEAKER_00]: And so more often, you know, than I can count, there have been folks who I've had these kind of conversations, and they feel so strongly that, like, look, I have been crushing it in so many areas of my life. [SPEAKER_00]: I ought to be able to do this. [SPEAKER_00]: I'm like, okay, I am full support.

1:08:02 [SPEAKER_00]: How can I, how can I help? [SPEAKER_00]: But over time, if they either succeed or relapse or tend to not have as much success, I start to gently sprinkle in the idea of, is it more important kind of how we get there or is it more important that we get there? [SPEAKER_00]: And would you be open to some tools, some strategies, some other things that I have up my sleeve, that can improve your odds of success?

1:08:26 [SPEAKER_00]: and really all it takes once we get over that hump is somebody saying I'm willing to you know give this a try I'm at my witsend or I've been trying as hard as I can and what I have success but it feels again that I have to be perfect all day every day otherwise it all falls apart and well I have a tool that can help with that and you know it for for one patient in particular that I can think of all it took was literally [SPEAKER_00]: the first 2.5 milligram dose of trisepatite.

1:08:53 [SPEAKER_00]: When it was like, oh, I get it now. [SPEAKER_00]: I get it now and all of these prior beliefs that I had about myself, that was not actually an accurate understanding of what was going on under the hood. [SPEAKER_00]: Now I actually understand. [SPEAKER_00]: You know, making fantastic progress and they're like, yeah, I would, I'm, I'm going to be on this the rest of my life.

1:09:13 [SPEAKER_00]: You can pry it from my cold dead hands and I'm like, yeah, I get it. [SPEAKER_00]: But it took quite a journey to get there because, again, I didn't jump from the outset of like, I need to change your mind. [SPEAKER_00]: It was rather I have to like kind of guide you, guide you there while observing.

1:09:24 [SPEAKER_00]: Like, if you have success along the way, quote unquote on your own, great, like cool. [SPEAKER_00]: But I also recognize that that's a relative minority of folks and those who, you know, use these tools. [SPEAKER_00]: They have a higher chance of success, but I don't, you know, force it in the conversation right off the bat.

1:09:39 [SPEAKER_01]: Yeah, I do think that that's where this maybe will power argument or or or narrative is kind of responding from, but I do think it has been present throughout human history, particularly as like leanness and thinness has been you know incentivized we'll say rewarded, but now because [SPEAKER_01]: because of the availability of tools that can sort of actually change how people go about weight management is GLP1s, for example, in the future multi-agonist agents.

1:10:16 [SPEAKER_01]: again, will power now has been shoved to the forefront. [SPEAKER_01]: You're like, well, look, you do in a that way. [SPEAKER_01]: It's because you're a weak moral character and you needed some additional help. [SPEAKER_01]: And there's so many holes in that argument to me, argument number one is like, well, what if you had hired a coach to write some training for you?

1:10:33 [SPEAKER_01]: Do your quote, macros, whatever is using that sort of support? [SPEAKER_01]: You know, a failure of willpower, right? [SPEAKER_01]: It was just you leveraging the resources [SPEAKER_01]: Okay, where do you draw the line? [SPEAKER_01]: Well, just because it's not natural, it's outside of your body when your body does make it naturally right and like [SPEAKER_01]: Okay, is it okay for use gym equipment?

1:10:54 [SPEAKER_01]: That's a, you know, something of modernity. [SPEAKER_01]: So I want to talk about these medications specifically how this kind of alters how our genes interact with our environment and subsequently our food-related practices. [SPEAKER_01]: You've heard that these drugs call cheating certainly if you've been on the internet at all in the last few years, that the easy way out, you didn't require any willpower, but let's look at what these things actually do.

1:11:22 [SPEAKER_01]: So GLP1 is a hormone that your own gut makes after you eat. [SPEAKER_01]: It's usually gone within seconds to minutes and it's in it. [SPEAKER_01]: It's made in a relatively low amount. [SPEAKER_01]: It is not a major player in appetite, satiety, in humans. [SPEAKER_01]: It's involved to some degree, but not a lot because again, low amounts that you make and again, it's gone in minutes.

1:11:44 [SPEAKER_01]: So it can't possibly have these huge effects. [SPEAKER_01]: the medications are engineered copies of it pretty ingenious actually they reach the brain's appetite centers uh the argument nucleus in the hypothalamus and the area postyema down in the brainstem [SPEAKER_01]: They're going to be other targets that we identify, but that's what we think right now.

1:12:02 [SPEAKER_01]: And then they turn the dive. [SPEAKER_01]: They switch on the neurons, the nerves that say stop eating, and they quiet the ones that are yelling, keep going. [SPEAKER_01]: Cherseptatide the newer one does it with two different targets. [SPEAKER_01]: One's GLP one, the other one is GIP. [SPEAKER_01]: Either way, they reach the exact same machinery in the brain.

1:12:19 [SPEAKER_01]: We spent multiple episodes talking about this in detail. [SPEAKER_01]: Now, the effect of these medications, they're not small. [SPEAKER_01]: And that's the whole point here, okay. [SPEAKER_01]: If this was like an incremental change where people lost just a little bit of weight and then it was really hard to keep off.

1:12:34 [SPEAKER_01]: These drugs wouldn't be blockbusters, right? [SPEAKER_01]: And we wouldn't have spent multiple episodes talking about them. [SPEAKER_01]: But to give you guys just a little refresher, probably the whole study that kicked this thing off was the step one trial published in the New England Journal of Medicine in 2021 about 2,000 adults on weekly, some aglytide, that's those epic, where we go, we lost roughly 15% of their body weight over 68 weeks.

1:12:55 [SPEAKER_01]: They lost about 2% on placebo. [SPEAKER_01]: To put that in perspective, lifestyle alone, so diet, exercise, behavior change, [SPEAKER_01]: people are fortunate if they achieve 5% of weight loss, right? [SPEAKER_01]: Depending on the time frame you look at, maybe half of folks and in the best studies we have maybe 2-3rds of folks will lose that amount within, let's call it 6 months.

1:13:21 [SPEAKER_01]: Okay, very few people will reach 10% in the most charitable studies we have, maybe a third, a folks with lifestyle alone would reach 10% when you talk about 15% though, that number drops to near zero, not nobody, but very few people achieve 15% weight loss with lifestyle alone, mainly because it is very challenging to push back against biology and again, by the way, the environment hasn't changed.

1:13:47 [SPEAKER_01]: The follow-up drug, if some agulotide, on average, 15% of weight loss. [SPEAKER_01]: The follow-up drug is epitide, so Zepound, Manjaro. [SPEAKER_01]: In the Sermount 1 trial, that put the amount of weight loss around 21% now we're getting decidedly into metabolic bariatric surgery, territory, retatratide, or retratutide, would a however you pronounce what we know and knows.

1:14:09 [SPEAKER_01]: I'm going to keep saying we're attached or tied just because it's different than what everybody else you're saying is going to be a little higher than that and we're going to have multiple agents coming out that are probably going to be these numbers. [SPEAKER_01]: One weekly injection and maybe in the future one weekly pill, we'll see nudges these appetite and satiety signals at scale in a way that produces not only significant weight loss, but in a manner where it can be sustained for as long as people are taking the medication.

1:14:40 [SPEAKER_01]: it suggests it enhances people's ability to do the things they were already trying to do. [SPEAKER_01]: So if anything, maybe anti-hedonic medication, maybe that's the wrong term, maybe behavior change agent, is not the right term. [SPEAKER_01]: Maybe you just call it a willpower drug. [SPEAKER_01]: Like if if your dead set on this willpower thing right and we can't talk you off it, or whatever, look, this is your willpower support system.

1:14:59 [SPEAKER_01]: It's helpful. [SPEAKER_01]: I don't love that because again, it doesn't sure. [SPEAKER_01]: It doesn't seem to be the moral aspect and I don't love that. [SPEAKER_01]: Austin, look in plain terms, what is a GLP1 and what should we care about beyond the scale, like muscle and like actual dietary practices?

1:15:14 [SPEAKER_00]: Yeah, these medicines essentially augment the effect of what you described as our kind of natural, naturally produced peptides. [SPEAKER_00]: These are called Incretin hormones and we're giving them in higher doses from our collogic doses and they can have [SPEAKER_00]: on appetite, on satiation, feelings of fullness, spontaneously reduce a kind of calorie intake and facilitate improvements and rapid and substantial losses in body fat, as well as visceral fat, which as we've talked about before is the type of fat that tends to have the most harmful consequences on long-term health.

1:15:49 [SPEAKER_00]: And so it's not surprising that in addition to looking at outcomes from obesity, we are also seeing benefits on numerous other of the wide range of obesity associated diseases. [SPEAKER_00]: We see improvements in sleep apnea. [SPEAKER_00]: We see putting fatty liver disease into remission.

1:16:04 [SPEAKER_00]: We see decreases in heart failure in chronic kidney disease. [SPEAKER_00]: We see improvements in many, many, many other areas of health, osteoarthritis, chronic pain. [SPEAKER_00]: PCOS, formerly known as as another condition where we're seeing some early emerging evidence of benefit as well as anecdotal in the women that I've treated with that condition using these medicines.

1:16:27 [SPEAKER_00]: Beyond the scale, which is firmly where I plant my flag, the scale is one crude metric of the effects of these medicines, looking at outcomes of body composition fat loss is certainly an [SPEAKER_00]: Other metabolic parameters, things like blood pressure, blood cholesterol levels, blood sugar levels as other important areas and then when it comes to concerns around what is often conflated things like what will put lean body mass or muscle mass bone mass things like that.

1:16:56 [SPEAKER_00]: Any time, as we've talked about, when people lose weight, there's going to be some fraction of fat mass loss and then some fraction of non-fat mass or lean mass or muscle or bone that also tends to be lost, although this can be substantially mitigated and in some cases prevented and I've had several patients send me their body composition data or that we've gotten body composition data on them and they've been able to actually improve their gain muscle mass while they have lost body fat, particularly if they were previously [SPEAKER_00]: under-trained or untrained and using these medicines to lose body fat.

1:17:26 [SPEAKER_00]: So, lastly, the nutrition piece itself, quality nutrition can take things even further to improve the health outcomes. [SPEAKER_00]: As we mentioned a little while ago, yes, the overall calorie intake tends to decrease. [SPEAKER_00]: That tends to deliver the bulk of the benefits. [SPEAKER_00]: So even if you did have folks who were, quote, unquote, eating the same, you know, maybe poor diet, but just less of it, they probably, if they're being appropriately treated with these medicines, you know, meaning that they started out with clinical obesity, they would probably still have net benefit.

1:17:57 [SPEAKER_00]: They would probably be less likely to develop. [SPEAKER_00]: Diseases, they would probably be more likely to put diseases into remission, they'd probably be longer likely to live longer with less disability and disease. [SPEAKER_00]: But when it is further supported by improvements in nutrition equality, then it can really put the health impacts kind of over the top.

1:18:14 [SPEAKER_00]: So those are the big picture things. [SPEAKER_00]: These medicines improve appetite regulation, lead to improvements in body composition, [SPEAKER_01]: Yeah, and I think ultimately the mechanisms regarding appetite regulation, satiety regulation, I think if people would agree that the majority of the obesity issue is related to some sort of problem when it comes to appetite and satiety, right?

1:18:54 [SPEAKER_01]: and that when they try to lose weight, that that becomes even more problematic. [SPEAKER_01]: If people are agree with that, and that GOP ones treat that directly right in many ways, then the willpower argument kind of dissolves on its own. [SPEAKER_01]: You're like, wait, this stuff is of output of your subconscious.

1:19:13 [SPEAKER_01]: It is in your brain. [SPEAKER_01]: You can't [SPEAKER_01]: feel, uh, will yourself to feel less hungry or feel more, more full, just like you couldn't do, feel less thirsty, right, that doesn't work, or when you can't sleep, just feel more tired, go for it, these are more complex. [SPEAKER_01]: But if people are in agreement with all of that, then I think the willpower argument tends to dissolve.

1:19:31 [SPEAKER_01]: Now, I do think it's worth saying because if people say, look, I agree, I agree with you guys. [SPEAKER_01]: Look, it's just, if at the level of the brain, it's subconscious, you can't control its appetites to tidy regulation, some issue there. [SPEAKER_01]: So your saying just got no agency, I can't do anything, don't do anything at all.

1:19:46 [SPEAKER_01]: We're not saying that. [SPEAKER_01]: We're saying we have to move your effort, shift your efforts, your priorities, your sort of resources to a different spot. [SPEAKER_01]: In this case, it would be either accessing health care, it would be changing food environment, doing all of these sort of things together rather than just sort of just try harder.

1:20:06 [SPEAKER_01]: Which to me is like, try harder with what? [SPEAKER_01]: try harder to feel less hungry, try harder to, yeah, I don't know exactly where you're targeting the tri-harder thing, I guess. [SPEAKER_01]: Now, I do think that it would be interesting to come at this from the other way. [SPEAKER_01]: What if you had a patient, Dr. Barackie, a patient comes in, they want a GLP one, right?

1:20:30 [SPEAKER_01]: And his wife thinks, look, if you do this, you're taking the easy way out, you should just, again, try [SPEAKER_00]: Uh, it's like you are, I don't know, sitting on my shoulder, watching many of these patient visits. [SPEAKER_00]: I've had this go both directions where the husband is interested in the wife wants it to go the other way.

1:20:48 [SPEAKER_00]: I would say a little bit more often, the wife is interested, and then the husband is the one who wants it to go kind of the other way, and really this is just a conversation of getting to know where the person and their ideas and their beliefs come from. [SPEAKER_00]: So just like they should wipe, not call it, why?

1:21:03 [SPEAKER_00]: Just tell me, you know, what makes that better, because my, what I suspect and I don't explicitly say this right away is that they've tried to what knuckle it before repeatedly and you know, most likely you're and so I'm here to be somebody who guides them walks with them through this process and gives them the support that they are looking for kind of meeting them where they're at in this journey.

1:21:24 [SPEAKER_00]: And so if they're preference based on there. [SPEAKER_00]: world view, their beliefs, their background is that they should, in fact, white knuckle it, more power to you. [SPEAKER_00]: Like, okay, how should I help? [SPEAKER_01]: Yeah. [SPEAKER_00]: But on the other hand, if we can get to an understanding of like, there's nothing actually necessarily better about doing it that way.

1:21:45 [SPEAKER_00]: And in fact, that is a path that has a substantially lower likelihood of success, particularly long-term durable success. [SPEAKER_00]: Then if we are trying to be kind of neutral observers of the evidence of what this process can look like, the math is pretty clear of which one is more likely to give us the outcome that we are looking for and at what cost and if that cost, whether financially or in terms of risk of side effects or inconvenience or whatever is worth it to you, then let's do it.

1:22:20 [SPEAKER_00]: You know, what is often perceived as one of the downsides of these medicines that you need to keep using it to sustain the benefit. [SPEAKER_00]: In a case like this, it could also be an advantage. [SPEAKER_00]: And it's similar to the advantage that I described in the last case where somebody might have pretty rigid beliefs around they should be able to do it on their own.

1:22:38 [SPEAKER_00]: And they've been trying and trying and not having success. [SPEAKER_00]: And sometimes I frame it of like it look it's not it doesn't have to be a permanent commitment kind of like when we've talked about testosterone therapy before you can do a trial and see how it go see if it helps you because there is nothing that I am going to be able to say that will come anywhere close.

1:22:57 [SPEAKER_00]: to what it feels like for you to take a therapeutic dose of this medicine. [SPEAKER_00]: It might not be the first dose because you might be somebody who needs more than 2.5 milligrams, you might need a higher dose. [SPEAKER_00]: But once you hit that therapeutic dose and you actually feel what that feels like, or you notice that you aren't hanging out by the fridge and realizing like, I'm not even hungry.

1:23:15 [SPEAKER_00]: What am I doing here? [SPEAKER_00]: Or you notice that you're actually losing weight without a white knuckling it for the first time in your life. [SPEAKER_00]: Nothing that I can say is gonna actually compare to that experience. [SPEAKER_00]: And so if it is within reach within your means, be it again, coverage wise, financially, whatever, and you're willing to just like do a trial of this, I would say that's a better, more powerful argument than anything that I can say.

1:23:36 [SPEAKER_00]: Because again, I don't feel like, look, it's your life and it's your health. [SPEAKER_00]: I'm not there to like, coerce health out of you. [SPEAKER_00]: I'm here to be a consultant, be an advisor. [SPEAKER_00]: I can give recommendations, you can take them, you cannot, that is entirely up to you.

1:23:51 [SPEAKER_00]: I would have my recommendations, and if you'd like to take them, that's great. [SPEAKER_00]: If not, I'm here to support you in any other way you'd like, but again, there's nothing necessarily beneficial or advantageous about what I'm doing it harder than using these tools that improve your odds of a successful outcome.

1:24:09 [SPEAKER_01]: Yeah. [SPEAKER_01]: Yeah. [SPEAKER_01]: I think we've established that it's not will power. [SPEAKER_01]: It's not cheating. [SPEAKER_01]: Not necessarily benefits to living life on hard mode before we get to what actually works. [SPEAKER_01]: I want to do some myth busting. [SPEAKER_01]: You know, we love this.

1:24:21 [SPEAKER_01]: We we you and I regularly engage with people on the intro webs for some myth busting. [SPEAKER_01]: So this is a bit of a lightning round. [SPEAKER_01]: These are four takes you've certainly heard before or seen before on the on the intro webs. [SPEAKER_01]: We're going to give you [SPEAKER_01]: first take.

1:24:38 [SPEAKER_01]: It's simple, just eat less and move more. [SPEAKER_01]: This isn't wrong, like, math-wise, energy balance is real. [SPEAKER_01]: I kind of describe it as the final common pathway, right? [SPEAKER_01]: Whatever intervention, or tool resource, whatever you're going to use, it has to affect energy balance, right?

1:24:56 [SPEAKER_01]: And in order to lose weight, you have to be in a calorie deficit. [SPEAKER_01]: None of that is on true. [SPEAKER_01]: That's [SPEAKER_01]: energy intake and energy expenditure, and so if you accept that energy balance is what drives changes in body weight. [SPEAKER_01]: Great. [SPEAKER_01]: You have to go one step up from there, what influences those things?

1:25:21 [SPEAKER_01]: And when you realize that a lot of the food related practices are not conscious decisions, right? [SPEAKER_01]: They are primarily influenced by your genetic makeup and how that is mismatched to our current environment. [SPEAKER_01]: And then you're like, well, how important is it really to focus on eating less and moving more via conscious decision?

1:25:43 [SPEAKER_01]: If you accept all of that, then it's like, while true, while the math is mathing, it's not very useful to focus on this. [SPEAKER_01]: The inputs are highly dynamic, how hungry you are, how full you feel, how much energy you expend, and you're not controlling any of these with your mind.

1:26:00 [SPEAKER_01]: It's not a Jedi mind trick. [SPEAKER_01]: I think what happens here is that people who have either never struggled with obesity or are one of the relatively few people who are able to achieve weight loss and their ideal body composition through lifestyle alone. [SPEAKER_01]: They are like these living counterfactuals and they're like, no, look, I did it, so everyone can do it.

1:26:23 [SPEAKER_01]: To which you would say, well, look, I've done lifted 765 pounds. [SPEAKER_01]: Why can't you? [SPEAKER_01]: 10%. [SPEAKER_01]: I mean, I assume that nobody is arguing with you when they're in front of you, you know, in the clinic or in the, you know, remote visit where they're like, look doc.

1:26:38 [SPEAKER_01]: I know it's just energy balance. [SPEAKER_01]: So like, I just need to eat less and move more. [SPEAKER_01]: You know, if they've made it to you, that's not something that's actually not. [SPEAKER_01]: Yeah. [SPEAKER_00]: Yeah, I mean, you're right that it is simple, only in the form of a final common pathway.

1:26:50 [SPEAKER_00]: And maybe it would be that simple in real life if, um, let's say, if you were, if you were the pet of another organism in the same way that like, if, you know, a lot of people there, maybe their pet dog or their pet get has like gained weight and they want to. [SPEAKER_00]: restore a healthy weight, they will start feeding them less and start taking them on more walks.

1:27:07 [SPEAKER_00]: Maybe if you as a human, you had an owner and they started controlling your portions and feeding you less and taking you on more walks, maybe that would work. [SPEAKER_00]: But that means you truly have no agency. [SPEAKER_00]: Somebody else is entirely in charge of your existence and you would also still be miserable during that because you would be desperately hungry and you would probably have other spontaneous behavioral changes and things like that as a result.

1:27:29 [SPEAKER_00]: The sustained calorie deficit beyond what your physiology or your biology is, you know, happy with, so to speak, right? [SPEAKER_00]: But it's just, that's not the environment, that's not the world that we live in. [SPEAKER_00]: You are the person who is, you know, standing in front of the options at the grocery store or in front of the pantry or in front of the fridge or dining out at the restaurant.

1:27:47 [SPEAKER_00]: And again, much so much of this is not as much within our conscious control as we would like. [SPEAKER_00]: So while it may be simple in that final common pathway, [SPEAKER_00]: that makes it neither easy nor does it make it practical for a lot of people living in this world as it is today.

1:28:05 [SPEAKER_01]: Yeah, yeah, I think that the first, you know, myth here's the oh, it's just less move more. [SPEAKER_01]: It's just energy balance, right? [SPEAKER_01]: Which on the one has not really a myth, but the idea that you can just do that, choose to do that, folds into the second, you know, myth will look, [SPEAKER_01]: Again, we kind of deconstructed that, but also, like, just heads up, that's the survivorship bias playing out in real life.

1:28:30 [SPEAKER_01]: Can you imagine if somebody posted a hot take would look if I lost weight anyone can, it's just willpower, and then every single person, just in their immediate community. [SPEAKER_01]: said, they look, I tried, again, on average individuals with obesity will try and have it about eight times per year in their lifetime to lose weight.

1:28:48 [SPEAKER_01]: And they said, look, I've tried this many times, didn't work, just that they all posted. [SPEAKER_01]: And so the comments, there's tens of thousands, if not hundreds of thousands of people saying they actually didn't. [SPEAKER_01]: Do you think that would change their mind where they'd be like, oh, maybe I'm not seeing this?

1:29:01 [SPEAKER_01]: I imagine it's very challenging for you to have a lived experience, right, your end of one experiment. [SPEAKER_01]: and then almost reject it and say, well, look, while this was my experience, this cannot be the experience for everyone, or is not the experience for everyone else. [SPEAKER_01]: I feel like you and I do that on a regular basis.

1:29:18 [SPEAKER_01]: People are like, look, hey, do you think anyone, everyone? [SPEAKER_01]: Every man who starts lifting weights can deadlift. [SPEAKER_01]: in certain number, 500 pounds. [SPEAKER_01]: No, like, no, and you're like, what do you guys in? [SPEAKER_01]: And we're like, yeah, look, our genetics, our environment, happened to work out in a very opportunistic opportune time when our lives.

1:29:36 [SPEAKER_01]: And we were able to take advantage of that, but that's certainly not everyone's experience. [SPEAKER_00]: And so, yeah, I think it's a combination of knowing that the stars aligned in our favor on that particular thing. [SPEAKER_00]: But also, having, like, being socialized in the world.

1:29:49 [SPEAKER_00]: And [SPEAKER_00]: interacting with other people. [SPEAKER_00]: Now, obviously, I have the advantage of, yes, I've seen thousands and thousands of patients over the years, and that is my way socializing and listening to what these folks experiences are like. [SPEAKER_00]: And I have just innumerable stories and examples of scenarios where it's like, oh my gosh, if I was living in that particular situation that you are living in, where you are an adult parent struggling with obesity since you were a child and you're trying [SPEAKER_00]: your child who has some sort of disability, or themselves has an eating disorder, how do you even navigate that sort of, that's an example of something that I'm, it's like, that is exceptionally challenging, sort of thing to navigate.

1:30:31 [SPEAKER_00]: And it's like, yeah, the stars are certainly not aligned in your favor on this, and it is perfectly okay to have some additional help to use other tools when it is needed to achieve this outcome. [SPEAKER_00]: Again, especially when it comes to your health, it's not like your, [SPEAKER_00]: You know, trying to do this so that you can get a leg up on competitors in a sport where it's drug tested and the rules say you can't use the drug.

1:30:52 [SPEAKER_00]: This is just like life. [SPEAKER_00]: There's not, you know, you saw to for life health outcomes or something like that. [SPEAKER_00]: It's okay to use the tools that are there. [SPEAKER_00]: And so similarly for us with like training outcomes, you know, powerlifting, whatever conditioning, it's like, yeah, we've coached.

1:31:07 [SPEAKER_00]: hundreds to thousands of people, you know, over the years, and recognized, it's like, yeah, there have been plenty of trainees who it's like, yeah, I don't think that a 500 pound deadlift is in the cards for this person. [SPEAKER_00]: They could train all day, every day, they could train, you know, one day a week to seven days a week, high volume, low volume, variations, intensity, you know, all sorts of other things, and it's like, [SPEAKER_00]: I don't necessarily see that that's likely to be in their future or at least in a way that is compatible with other outcomes that they care about, meaning without gaining substantial amounts of weight that they don't want to gain without using anabolic steroids that they don't want to use things like that because again, tools can help them get to that outcome if they want to use them in the same way that we're talking about it here.

1:31:47 [SPEAKER_01]: Yep, yeah, yeah, I appreciate it. [SPEAKER_01]: I do, I do enjoy dropping the, well, look, I, I [SPEAKER_01]: are you sure is we in the right. [SPEAKER_01]: Yeah. [SPEAKER_01]: Yeah. [SPEAKER_01]: All right. [SPEAKER_01]: So that that's two of the sort of hot takes myth-busting things. [SPEAKER_01]: Third one here is look discipline is a muscle.

1:32:11 [SPEAKER_01]: You just don't want it badly enough. [SPEAKER_01]: And it's kind of like this idea that look, you can change your habits in the short term and then that compounds over time and to keep it going is just disciplined and to some extent there is a kernel of truth in there, I feel like particularly if you apply those efforts.

1:32:32 [SPEAKER_01]: upstream from the just eat less move more to get to the net the result of eating less and moving more. [SPEAKER_01]: So I think there's some truth there. [SPEAKER_01]: For example, changing the food environment, changing the eating environment, you know, ultimately leveraging your community if possible, like work out with the print, something to get you doing some of these behaviors are making a more accessible.

1:32:51 [SPEAKER_01]: for you. [SPEAKER_01]: But the idea that look, you just got to train this muscle and become even better at resisting the temptation. [SPEAKER_01]: I'm like, look, the diaphragm is a muscle. [SPEAKER_01]: You still can't hold your breath for an hour, even though you can improve your ability to hold your breath a little bit.

1:33:05 [SPEAKER_01]: I don't know. [SPEAKER_01]: What do you think about this sort of take? [SPEAKER_01]: Yeah. [SPEAKER_00]: habits can certainly improve. [SPEAKER_00]: But I think you summarize it succinctly earlier is like on its own, biology is undefeated, right? [SPEAKER_00]: And so you can have a lot of these healthy habits.

1:33:18 [SPEAKER_00]: And so many of the patients that I work with have actually very good, very healthy habits. [SPEAKER_00]: They're actually exercising regularly. [SPEAKER_00]: Again, ultra endurance athletes. [SPEAKER_00]: And they're sleeping well. [SPEAKER_00]: And they're trying to do these things yet.

1:33:28 [SPEAKER_00]: They still continue to struggle. [SPEAKER_00]: And there is that element of biology that is [SPEAKER_00]: over enough time it grinds you down like they might be able to you know skip a meal or restrict a meal for a day for two days for a week for a month but over a long enough time horizon that idea of white knuckling it forever is something that you know pretty much everybody is likely to to break at some point if they're having to consciously restrict again it's like imagine how long could you go just living being like moderately thirsty [SPEAKER_00]: just like all day, every day, just like living with that nonstop.

1:34:06 [SPEAKER_00]: And then being faced with, oh, right in front of you, in the fridge, there is an ice cold, most refreshing beverage that you like, and it's there all the time, but you're just like constantly thirsty. [SPEAKER_00]: And for some reason, you have to be able to consciously restrict yourself from, you know, just go into the fridge and drinking it.

1:34:25 [SPEAKER_00]: You will break. [SPEAKER_00]: you will break over that period of time, right? [SPEAKER_00]: And so that's kind of where this tends to fall apart for most people. [SPEAKER_01]: Yeah, yeah, I agree. [SPEAKER_01]: Our last myth we're going to bust here is I guess one that we're kind of creating on our own, but only if you didn't listen carefully, diets never work.

1:34:45 [SPEAKER_01]: It's all genetics. [SPEAKER_01]: Why even bother? [SPEAKER_01]: And I think this has come from people who have been burned before look at the average person with excess body fat with obesity has tried eight times on average in their life to lose weight in the didn't work. [SPEAKER_01]: There's a look why, why even try?

1:35:01 [SPEAKER_01]: And there's some real data here where people who have had multiple negative experiences, they tend to become a little bit more resistant, not in a biological way, but they're just like, look, why am I trying this? [SPEAKER_01]: And I think most of this, I'll get your take on this, is due to just our lack of tools that we had before.

1:35:20 [SPEAKER_01]: The environment, if anything, continues to get worse. [SPEAKER_01]: Okay, so like more and more pressures, outside of our control, and if we did not have any medications and any surgery and any sort of lifestyle change programs that were maybe a little more intensive. [SPEAKER_01]: Yeah, I kind of get that line of thinking, right?

1:35:39 [SPEAKER_01]: at some point the Herkulean effort you run out of you can't go to that well anymore, but we have new tools. [SPEAKER_01]: So I don't know. [SPEAKER_01]: Yeah, what's your take on that? [SPEAKER_00]: Yeah, the idea of why even bother is not really taking a full view of the issue because, again, it's more, we're not just looking at scale weight here.

1:35:58 [SPEAKER_00]: The why even bother is because it has implications for your health, for your longevity, for your risk of preventable diseases, for your risk of death, or being around for, you know, things you care about, things you want to be able to do for your family, for other things like that. [SPEAKER_00]: So there is valid reason to improve, for example, the quality of your nutrition.

1:36:15 [SPEAKER_00]: to remain sufficiently physically active to the extent that you struggle day in and day out with maintaining the ideal amount of calorie intake for your physiology to maintain a healthy body weight. [SPEAKER_00]: Yeah, we got tools that can help with that if that is a challenge that afflicts you potentially more than someone else there are certainly other plenty of people out there who we all know and who tend to remain naturally very lean [SPEAKER_00]: who couldn't finish a plate of food in front of them, if you, if you had a gun to their head, they would say, no, I'm just too full.

1:36:44 [SPEAKER_00]: I can't do it. [SPEAKER_00]: And there are also people at the other end of that spectrum, right? [SPEAKER_00]: And so that's why I think the idea of why bother is because there are other implications to this that people care about more than just, you know, if it was all about like just, [SPEAKER_00]: achieving a particular scale weight for the sake of it.

1:36:59 [SPEAKER_00]: Then yeah, I think you have a harder case to make of like, why bother? [SPEAKER_00]: Because it's like, yeah, it's just a number on the scale. [SPEAKER_00]: But there's a lot more, you know, baked into this in implications for your health, for your life, for your function, for things like that.

1:37:09 [SPEAKER_00]: And we have, you know, more effective tools than ever to help you get there. [SPEAKER_01]: Yeah. [SPEAKER_01]: Yeah. [SPEAKER_01]: There are a number of weight independent benefits that come from the lifestyle stuff, even if they're ineffective for many for weight management, for health management, they like biology are undefeated.

1:37:27 [SPEAKER_01]: So 10 out of 10 would recommend. [SPEAKER_01]: All right, Austin, last question to you. [SPEAKER_01]: You got a new patient. [SPEAKER_01]: They want to lose weight, but they've had that experience as before, which they find demoralizing because they think it says something about their character.

1:37:41 [SPEAKER_01]: How does that conversation go? [SPEAKER_00]: Tell me more. [SPEAKER_00]: Describe those experiences. [SPEAKER_00]: Tell me what it was like. [SPEAKER_00]: And [SPEAKER_00]: really just by listening sufficiently to those experiences. [SPEAKER_00]: I can try to get a sense of like what exactly about it was the thing that led to them feeling this sense of being demoralized as a result.

1:37:59 [SPEAKER_00]: What was the the linchpin of that experience that was most emotionally salient to them? [SPEAKER_00]: And then trying to see, you know, is this something that they are talking to me about because they are motivated to give it another shot to try and novel strategy, because they want another opinion or are they just like fed up with it all and they're seeing me because they feel like they have to because they ought to see a doctor because I'm not there to impose a treatment on somebody who is not interested.

1:38:23 [SPEAKER_00]: or motivated to pursue it. [SPEAKER_00]: But if they are, then again, we have tools. [SPEAKER_00]: And I think framing it in a way of, hey, we have tools that are very safe, that are super effective, that I have a boatload of experience with that can be dosed very carefully, that are not permanent commitments, if you don't want it to be.

1:38:41 [SPEAKER_00]: you could try it for a bit of time and see if it fits your, you know, what you're looking for. [SPEAKER_00]: And then we can give you all the support you need along the way. [SPEAKER_00]: That's basically how I would go about it. [SPEAKER_00]: And then if there are any other kind of individual unique elements that need to be addressed or supported, or if they need other, you know, psychological psychiatric support, things like that, then we can certainly, you know, arrange for that as well.

1:39:00 [SPEAKER_01]: We spent the whole episode on why this is hard and why it's not a character flaw. [SPEAKER_01]: But let me bring it home with what you should actually do about it. [SPEAKER_01]: Think of each of these as a takeaway and the strategy that goes with it. [SPEAKER_01]: 1. [SPEAKER_01]: Aim at the environment because that's the thing that's actually changed.

1:39:15 [SPEAKER_01]: Obesity has roughly tripled in the last 40 to 50 years, on a set of genes that haven't changed at all, so the environment is where the leverage is. [SPEAKER_01]: One of the highest field things you can do is decide once, whenever you do your grocery shopping, what comes into the house? [SPEAKER_01]: Because if it's not there, it can't get you at 9 o'clock on a Tuesday when you're fried.

1:39:33 [SPEAKER_01]: We go deep on how that environment got built over on the big food episode that's linked in the show notes below. [SPEAKER_01]: Number two, when you lose weight, your body is going to fight back to some degree. [SPEAKER_01]: The hunger is going to go up, the calorie burns going to go down, and that varies a lot between individuals.

1:39:48 [SPEAKER_01]: It's going to stay that way for years. [SPEAKER_01]: So while you're losing, makes sense to protect the engine as much as possible. [SPEAKER_01]: Now one of the biggest drivers of your basal metabolic rate or your resting metabolic rate is how much muscle mass that you have. [SPEAKER_01]: And so to the extent, we can prevent its loss.

1:40:03 [SPEAKER_01]: We should do so, through enough protein and enough resistance training. [SPEAKER_01]: Generally, we can cut the losses down to at least half, maybe more, compared to not doing that at all. [SPEAKER_01]: Now, [SPEAKER_01]: It doesn't take a lot. [SPEAKER_01]: We're not telling you to protein max or to lift 5 days a week, a little will go a long way.

1:40:19 [SPEAKER_01]: That's honestly what we do with most of the people here at Barbomedicine. [SPEAKER_01]: Number 3. [SPEAKER_01]: The drugs, GOP ones in this case, aren't cheating. [SPEAKER_01]: They work on the exact appetite and satiety machinery. [SPEAKER_01]: This whole problem runs on, which is about the best evidence you could ask for, that it was never a matter of wanting it more.

1:40:35 [SPEAKER_01]: If your biology was fighting you hard, that's a real medical tool worth a conversation with your doctor, same as coaching or a good structure in general. [SPEAKER_01]: Put it all together and it's pretty simple. [SPEAKER_01]: Jeans in the environment set the table, what you can do is go after the inputs that are actually in your reach and that's where the effort pays off.

1:40:52 [SPEAKER_01]: So think back to Danny K. Hill on that stage. [SPEAKER_01]: 239 pounds down, having done the hardest thing that shows as asked of anyone. [SPEAKER_01]: The cameras left and his body spent the next six years putting that weight back on. [SPEAKER_01]: And the whole time, the only word anybody had for him was discipline.

1:41:07 [SPEAKER_01]: That was the wrong word. [SPEAKER_01]: What he was up against was his own biology, and an environment built to feed it, and discipline was never going to be enough on its own. [SPEAKER_01]: That's the whole point of today. [SPEAKER_01]: Your weight is the output of a system. [SPEAKER_01]: Your genes, the hunger, your body defends, and the environment that you're making your decisions within.

1:41:24 [SPEAKER_01]: How badly you want it is a small piece of that, and shame has never moved any of it. [SPEAKER_01]: What helps is understanding the system and then changing the parts of it you can actually reach. [SPEAKER_01]: So if you spent the years losing and gaining the same weight over and over again and beating yourself up about it, you can let that go.

1:41:39 [SPEAKER_01]: It was never a character problem and there is real effective help now that we just didn't have a few years ago. [SPEAKER_01]: If you want a hand building that system, that's what we do here at Barbell Medicine and it's linked in the show notes. [SPEAKER_01]: And before you guys go anywhere, please leave us a 5 star rating and a review.

1:41:52 [SPEAKER_01]: It generally drives traffic to our podcast so we can keep bringing you all the latest new ones and health and fitness. [SPEAKER_01]: For Dr. Austin Baraki, I'm Dr. Jordan Fagamam. [SPEAKER_01]: We'll catch you next time right here on the Barbell Medicine podcast.