Live Long and Well with Dr. Bobby
Let's explore how you can Live Long and Well with six evidence based pillars: exercise, good sleep, proper nutrition, mind-body activities, exposure to heat/cold, and social relationships. I am a physician scientist, Ironman Triathlete, and have a passion for helping others achieve their best self.
Live Long and Well with Dr. Bobby
#15: What do we know/not know about losing weight?
Have you ever wondered why weight loss seems so elusive despite following strict diets and exercise routines? Obesity rates have skyrocketed, and we are eating more, likely due to 3 key factors:
- portion sizes are larger than ever before, often doubling what we ate 30 years ago
- the foods on our plate are more calorie dense than ever
- Foods we buy often have the perfect combination so that we crave them: fats, carbohydrates/sugar, and salt (chips, pizza, ice cream)
My key thoughts on losing weight include:
- All diets can work, and ultimately no approach wins out over all of the others (e.g., keto, intermittent fasting, vegan, Mediterranean). Ultimately, weight loss is about the number of calories consumed vs. burned.
- The new GLP-1 obesity drugs have taught us that eating too much is not just about will power--folks who struggled all their lives to lose weight, instantly feel more full and less hungry once starting them. These drugs also help folks lose about 15% of their body weight
Evidence based strategies that might help you to lose weight
- Be more aware of portion size and how many calorie dense and "craving" foods you eat (fat/carbs/salt). For me, portion size has been the key.
- Choose a diet that works for you. And switch them up.
- Give your brain time to adjust (20-30') before eating more. That satiety lag is real and if you start with small portions and wait, you may feel full and satisfied.
- Protein (and fat to a lesser extent) helps reduce our hunger.
Perhaps try an N of 1 study on yourself with some of the strategies above.
Hi, I'm Dr Bobby Dub ois and welcome to Live Long and Well a podcast where we will talk about what you can do to live as long as possible and with as much energy and figure that you wish possible, and with as much energy and figure that you wish. Together, we will explore what practical and evidence-supported steps you can take. Come join me on this very important journey and I hope that you feel empowered along the way. I'm a physician, ironman, triathlete and have published several hundred scientific studies. I'm honored to be your guide. Welcome everyone to what may be the most important topic that we will ever discuss what we do and don't know about losing weight. Have you ever wondered why losing weight feels like such an uphill battle, despite all the diets and advice out there? My hope for today is to give you some insights and practical tips, ones that are supported by evidence and that you might try for yourself. This has also been a very challenging area to summarize, as there are so many views, so many studies and so many experts explaining the problem as they see it. Since I am your curator of evidence, I've tried to faithfully follow the studies and provide a balanced and, hopefully, unbiased view. So why now am I doing this episode?
Dr Bobby Dubois:Like many, I used to think weight loss was just a simple math problem Calories in, calories out but as it turns out, it's much more complex. It is about calories, but the complexity is about why are we eating more and why are we potentially burning fewer calories? Like you, I've had so many friends and family members struggle with weight issues. For some it was 10 or 15 pounds, for others it was 100 or 150 pounds. They tried so hard for years, many types of diets, supplements and approaches, and then the new drugs Ozempo, wygovy, mojaro became available and instantly their struggle with losing weight changed. Seeing the immediate impact of these drugs on my friends and family really changed my understanding of weight loss and how I now think about the issue. More personally, I have a half Ironman triathlon race coming up and wondered whether it would be easier for my training and the seven-hour race itself if I lost a few pounds.
Dr Bobby Dubois:I've been personally testing the evidence-based tips that I will share with you and what seems most helpful to me. Just a tidbit or two of what is to come. I had no idea that my view of a normal portion size was way, way more than what I thought. How few cashews or tortilla chips or ice cream is the proper serving size and how many calories I can consume so quickly before my brain realizes that actually I'm full. Well, let's get to the take-home messages.
Dr Bobby Dubois:Number one rates of obesity have tripled during the past few decades and there are pretty understandable reasons why it has occurred. I believe. Number two that there are many nuances, but ultimately, weight gain and loss are about calories eaten versus calories burned throughout the day. Number three all diets work until they don't, meaning there's no magic way to eat. Paleo or carnivore, or plant-based or intermittent fasting helps, but no approach has been shown to be better than the others. Number four we have learned so much from the new weight loss drugs. People who have struggled with overeating all their lives instantly find that they can eat less. All their lives instantly find that they can eat less. I will use this evidence to talk about what the lessons are for the rest of us. And number five, and most importantly, there are evidence-based approaches you can use to create your own approach to losing weight. I am optimistic that we may finally be on the cusp of a breakthrough in the battle against obesity.
Dr Bobby Dubois:Let's dive in and find out Well our plan for today. Part one we'll talk about the rise in rates of obesity, why it matters and, most importantly, why it may have come about. This may be the most important segment, as these causes may help us with solutions you can try for yourself. Part two what do we know about what does and does not work to lose weight? I believe that the success of Ozempic and the other GLP-1s has fundamentally changed our understanding of the problem and the solutions. Part 3. Practical Ideas that you Might Try To Help you Lose Weight.
Dr Bobby Dubois:As I've shared before, I am not an endocrinologist or a nutritionist, but I have the skill to read the scientific studies and since I don't have a pony in the race, I hope that I can be fair in what I say. Before we dive in, I want to share a perspective with you. It will help you understand me and how I approach each topic for you. Me and how I approach each topic for you. So much of the discussion around weight loss and other topics are based upon science, but what I call mechanism or pathway-based medicine, meaning they build a theory based upon pieces of a puzzle. For example, a particular food has a certain compound in it, say sugar or something else. Sugar raises insulin levels. Insulin levels cause fat to form. Therefore, we should not eat foods with sugar, but often in medicine. Although each step has some science to support it, when actually tried in people in a randomized controlled trial, it does not hold up. My approach doesn't focus on the chain of biochemical steps, as intriguing as they might be. Rather, my view of evidence-based medicine is to look at well-designed studies in people that test one food versus another or one dietary approach versus another. It may be compelling in the laboratory, but if it doesn't work for people, then I'm not excited and I won't suggest it for you. Okay, here we go.
Dr Bobby Dubois:Part one the number of folks who are overweight or obese has been rising for decades Now. It didn't happen overnight. In about 1980, about 13% of us were obese. Today that number has risen to 42%, or more than a tripling, and obesity is defined as a BMI 30 or above. Today the average man weighs about 200 pounds, having risen from about 166 pounds a few decades ago, and women today average about 170 pounds, and again a few decades ago it was 142 pounds. Being overweight or obese makes it difficult to live long and well. It raises your risk of heart disease or cancer, diabetes, cognitive decline and it makes it more difficult to do the activities that you may love to do. Carrying around more weight is challenging, discouraging and can lead to problems in your back or hip or knees.
Dr Bobby Dubois:I don't want to dwell on this aspect of the topic, as most of you are aware of the problem and there's plenty of information out there about it. What I truly wish to explore with you is what has potentially caused this obesity epidemic. If you understand the causes and I hope I can help you do that it can help you to create real solutions. I do believe it comes down to the mathematical equation of eating more calories and burning fewer. But why are we eating more? In my opinion, there are three critical and compelling reasons that we'll walk through. First, our portion sizes have gotten bigger and bigger over the years. Second, calorie-dense foods are all around us more than ever before. And third, many of the packaged foods we buy have a unique mixture of carbohydrates, fat and salt that makes us crave them and want more and more and more. So let's go through each of these in turn.
Dr Bobby Dubois:Portion size Portion sizes have really grown over the decades what has been called portion distortion. Well, in the mid-1980s, a typical bagel was about three inches in diameter. Today's standard bagels are twice as wide, about six inches each. Back in the 80s a bagel was about 140 calories, but today it's about 350 calories per bagel. 20 years ago, a cheeseburger had about 330 calories. Today it's about 590. A bottle of soda in the 1980s, for example, contained a single serving of six and a half ounces and about 85 calories. Today, a bottle of soda packs almost three of those servings, or 20 ounces and 250 calories. A major scientific review of 72 studies found that people A major scientific review of 72 studies found that people, regardless of their eating behavior, body weight, whether you're a man or a woman, or susceptibility to hunger, ate more if they were given larger portion sizes. And again, all of the key studies I'll talk about will be linked in the show notes. The key studies I'll talk about will be linked in the show notes.
Dr Bobby Dubois:If most of our portions have grown, we will inevitably eat more calories and, importantly, our expectation of what our plate of food should look like perpetuates the problem. Number two the foods on our plate are more calorie dense than ever before. A plate of broccoli, fish or a sweet potato have a modest amount of calories per bite. But french fries or tortilla chips or sugar-containing soda or even salad dressing are way more calorie dense. Containing soda or even salad dressing are way more calorie dense.
Dr Bobby Dubois:As I'm trying to get lighter for my race, I've been looking at portion sizes and calorie denseness. It's amazing how many calories a healthy looking salad might be if you consider the amount of salad dressing I like to add. Or the yummy cheddar cheese, perhaps some nuts sprinkled on it as well. What I might have thought was a 400 calorie lunch could easily be double that or more. I love dessert, and especially chocolate. Well, it turns out a single piece of Godiva chocolate cheesecake factory cheesecake is about 1,400 calories. Well, back 30 or 40 years ago we might have had that for an entire family of four, or 350 calories per person. But now I might look at that piece of cheesecake and easily eat the whole thing.
Dr Bobby Dubois:The other night I had a filling dinner with pretty healthy foods a simple salad, some broccoli and a piece of meat. At the end of the meal I was full, but I wasn't satisfied. I wanted something more, perhaps dessert or a spoonful of peanut butter. My brain was telling me something. Was it that I wanted some calorie-dense foods, or was it the last of the three key reasons why we want to eat more? Here's number three. Why we want to eat more? Here's number three.
Dr Bobby Dubois:Some foods have the perfect storm of combining the right amount of fat, carbohydrates and salt. Think of chips or pizza or lasagna. We crave that combination. It's hard to stop once we start. In fact, there were commercials for Lay's potato chips years ago that said nobody can eat just one.
Dr Bobby Dubois:Manufacturers have prepared foods for us that have this trifecta of carbs and fat and salt. Now I enjoy eating nuts, but all unsalted ones don't really do it for me. Salted ones, they are trouble. Similarly, a skinless chicken breast by itself is tasty, but leave the skin on it, which is the fat, and add salt. Now we've got fried chicken and boy, that's hard to stop eating. I have lots of salad dressing on my salads and wouldn't you know it? It has the three critical ingredients and studies have shown that even if you just have two of those in combination, that can be really powerful as well. In a study that compared how satisfying foods were, the fat-carbohydrate combination was more desirable than just calorie denseness or highly processed nature. Back to my story about feeling full from dinner but not satisfied, feeling full from dinner, but not satisfied. My body was telling me something it was craving, I think, that yummy combination of fat, carbs and salt, and even better if it was also calorie dense. So to summarize, it's pretty easy to see why we eat more calories than we did decades ago. Our portion sizes are much bigger and we expect those portion sizes. Each bite we take is likely more calorie-dense and the combination of carbs, fat and salt in so many foods are almost irresistible.
Dr Bobby Dubois:Well, if weight gain and loss ultimately relates to calories in versus out, the increase in obesity also likely reflects reduced amount of activity or exercise. As I talked about in episode 11, sit less and move more. The number of steps we take each day has fallen to about 4,000, from a lot more in other places in the world and over time. If we used to walk 8,000 steps a few decades ago and now it's about half. That, the lower number of steps means about 160 calories not burned, or about 40 calories per thousand steps Each month, that would amount to one and a half pounds. Part of the weight problem likely relates to less movement, but I do believe that calorie intake is likely the larger part, and that is what I want to focus on here. The exercise element to weight loss can be a topic for another day and is indeed also very important.
Dr Bobby Dubois:Well, let's switch to part two. What do we know about losing weight? Number one all diets can work. Let me repeat that All diets can work. There's so many of them out there that experts tout Paleo, carnivore, mediterranean how about intermittent fasting? Vegetarian, vegan and more. As I shared in episode four on nutrition, all diets work until they don't. Looking at studies, all of the diets I mentioned help people on average to lose weight for a while, but then those diets stop working and most people regain the weight. A meta-analysis or, as we've talked about, a summary of studies looking at various diets showed that they all produced roughly similar weight losses.
Dr Bobby Dubois:Now there's recently been a lot of excitement about intermittent fasting or time-restricted eating, where you'll only eat during a smaller portion of the day. Perhaps you skip breakfast and you just eat from the hours of noon until 6 pm or something like that. Studies show that it works. It helps people lose weight, but in a key study that compared intermittent fasting or time-restricted eating to a usual diet, when they kept the number of calories the same, the intermittent fasting was no better. At the end of about a 12-week long study.
Dr Bobby Dubois:My take on this study and so many others, is that diets, whatever they are, help us to be more mindful on how much we're eating. They help us, in essence, to reduce calorie intake by maybe reducing the portion size and not having as much of the calorie-dense foods or as much of the ones that have the trifecta of yummy ingredients. By all means, try various diets out and see if one works better for you. I like intermittent fasting as it helps me to keep calories under control, but there's no magic here. Under control, but there's no magic here.
Dr Bobby Dubois:Number two and now we get to the new and very important weight loss drugs semaglutide and the other GLP-1s like Ozempic, wygovy and Monjaro. In one of the first studies in this area, on Ozempic, they did a randomized control trial of 1,900 people, and those individuals on average lost about 15% of their body weight and 85% lost 5% or more. And for some of the other drugs they may have even higher amounts of weight loss, maybe 18 or 20% of their body weight. What these drug studies showed us is that people who struggled to eat less over their entire lives immediately found they could eat less. How does this happen? Well, these new drugs reduce our cravings for food and our appetite Of interest. It's now turning out that these same drugs may reduce cravings for other things like smoking and alcohol. So the craving centers in our brain that tell us we want to eat more and more and we're not full seem to be helped with these drugs. Secondly, these drugs also slow down our stomach emptying, which then helps signal our brain that we are actually full. Really importantly, the GLP-1s. These drugs have taught us that our desire to eat more isn't just willpower. Folks who struggled for years instantly felt less urges to eat and felt fuller more quickly when they started the drugs. The brain chatter of wanting to eat more or thinking about your next meal just seems to lessen or go away.
Dr Bobby Dubois:Now my listeners know I love end-of-one studies, where you try things in yourself and see what works or doesn't work. Well, a friend of mine inadvertently did an end-of-one study. A friend of mine inadvertently did an N of 1 study. He was on one of the new drugs for weight loss and he wanted to save money because they are pretty darn expensive and he extended the two-week interval. So you're supposed to take the injection every two weeks Well, he would push it beyond two weeks, maybe getting closer to three weeks. Two weeks Well, he would push it beyond two weeks, maybe getting closer to three weeks. What he found over and over what? As the time went beyond the two weeks, slowly, the food craving and the constant focus on the next meal gradually came back, only to leave once again after the next injection.
Dr Bobby Dubois:What I've learned from these drugs has been that so much of the problem resides in our brain, and when we perceive that we are hungry or full, it isn't just about willpower Our brains are driving how much we eat. Before this episode ends, I will share my theory and look to be clear. It's just a theory on what has perhaps changed in our brains. As much as I see tremendous value in these drugs and how they have really taught us about what might be going on, there are a few downsides. The first is, with these drugs, you're likely going to need to take them for your entire life, most everyone who regains weight as soon as they stop the drugs. Now, there may be a rare person who is able to keep the weight off, but 85 or 90% do regain most or all of their weight, and we don't know, but there could be some long-term problems that we're not real clear about yet.
Dr Bobby Dubois:We've observed that some of these drugs increase our baseline heart rate by a few beats or five beats. Now what does that mean for long-term impact? We just don't know. So we need to be cautious and be aware and keep following what's going on. Hopefully, the long-term consequences are good and not problematic, but we don't know quite now. Okay, the all-important part three what can we do to help us lose weight? Well, now that we know that it isn't just a story of willpower, this may give you reassurance and confidence to try one or all of the following five approaches, and each of these approaches come from what I've just been talking about and the studies that I've shared with you and a few more that I will about to share, and the studies that I've shared with you and a few more that I will about to share.
Dr Bobby Dubois:Number one be aware of the number of calories that you're eating each day. Now, this is not a new recommendation. Perhaps log that information for a week or so, but not just logging calories. Be aware of what are our portion sizes. Are they they like me way larger than they should be, in which case, you might have a solution right away of putting a smaller portion on your plate. Second, do you crave calorie-dense foods, and is a meal like I described not satisfying until you've had some? And how much of your daily diet are these calorie-dense foods? Third, do you have foods on your plate that do have that perfect storm of carbs and fat and salt? Now, once you've done this, armed with this self-awareness, maybe you can create an approach that helps you to lose the number of calories eaten by focusing on where you find the problem.
Dr Bobby Dubois:To me, in my case, it's portion size, or not realizing that some foods have a huge amount of calories in them, like my salad dressing, where the serving size is supposed to be two tablespoons, but I could put two, three or four times that amount on a large salad that I love to eat. And maybe one of the ways to go about it is to limit those high-calorie foods Not take them away, but just limit the amount. Or perhaps it's those yummy but addicting foods with fat, carbs and salt. You might need to cut them out. Or at least, if you're going to have them, be aware that they're going to make you want to eat more of them and just sort of decide how much you're going to eat of that. So, for me, the critical piece of the puzzle has been portion size, and I've been very focused on that with great success.
Dr Bobby Dubois:Two choose a diet that works for you. Now, my definition of working is that it helps you lower the number of calories you might otherwise eat. It might be intermittent fasting, it might be plant-based, it might be keto or paleo. Whatever works for you to reduce calories is the way to go and switch it up. Do one approach for a while and then switch to another. That's number two. Number three this is one you may not be as aware of, and boy is it powerful. Give your brain time to adjust, what's called the satiety lag.
Dr Bobby Dubois:It's often said that it takes 20 minutes or 30 minutes for you to feel full. Now, it's hard to find the perfect studies that focused on it, but they did have one study I'd like to talk about where they had two groups of people. One ate their meal pretty quickly, like in six minutes, and the other ate their meal very slowly, about 24 minutes. Well, it turned out, the slow eating group felt more full over the subsequent time period. This is very, very powerful, because we often eat quickly and we think we're still hungry, we're not full, we're not satisfied. If we had only waited, maybe that amount of food might have been perfectly fulfilling.
Dr Bobby Dubois:Here's my unscientific personal experience, but it relates exactly to this study. I can't tell you the number of times that I'm sitting down to dinner, I have a nice big plate full of food Again, my portion sizes are not the way they're supposed to be and I get interrupted. Might be a phone call, might be somebody at the front door and maybe something that just has to get taken care of on the ranch or with our bed and breakfast guests. So when I get interrupted in that meal, say for 15 or 20 minutes, I have to go deal with something and then I come back to the table. I can't tell you how remarkable it is. I don't feel a need to eat anymore. Don't feel a need to eat anymore. It was just the 20 minutes or so of waiting that allowed the food that I had already eaten to reach my brain. So here's a life hack Perhaps take a small portion, a ridiculously small amount of food on your plate, wait, eat it, wait 20 minutes and see if you wish to eat more.
Dr Bobby Dubois:And if you do well then, go back and fill up more on your plate. That might reflect what you were hoping to eat overall, but you might find that that waiting has reduced your appetite and you really don't want to eat more. This is particularly particular problem if you eat your dessert right after dinner. And if you ate a quick dinner, you might say, oh, I think I definitely need dessert, whereas if you took a pause, took a walk after your meal and then came back, you know the amount of dessert you might want could be a lot less Okay.
Dr Bobby Dubois:Number four and I found this to be an eye-opener Some foods help us to feel fuller than others. Now, I used to think that was fat, and my life hack would be to have a small amount of peanut butter 20 minutes before dinner. Or if I were going out to dinner and I didn't want to eat too much, I kind of dulled my appetite by having a small bit of peanut butter, thinking that the fat in the peanut butter would help me not to feel quite so hungry. And it did work to some extent. But in looking at the literature for you, my listeners, it turns out that even more powerful is protein, that it helps us to feel fuller, more so even than fat, and there's studies to show this and I'll link to them. That protein is probably the best way to help your sense of fullness and reduce our appetite if you eat that a bit before your meal or a heavy part of it in your meal. So, instead of your peanut butter 15-20 minutes before a meal, I might have a piece of beef jerky or something to get some protein in my system ahead of the time when I eat. And for many people, fiber is also helpful. I happen to like lentils, or my new recent favorite combination half lentils and half brown rice.
Dr Bobby Dubois:Number five perhaps and again the evidence is not great, but perhaps drink more water as part of your meal. In the episode on eight glasses of water, I mentioned some studies that suggested that drinking extra water before a meal may help to reduce calories. Try an N of 1 study and see if it helps for you. Well, where are we? We now have a perfect N-one opportunity. Take a baseline assessment of your weight and how many calories you're eating a day. Try one of these five approaches and see what happens. Maybe you'll try focusing on the number of calories you're eating each day by portion sizes or the craving foods. Maybe you'll try a particular diet that might work for you for a while. Or you may try the 20-minute lag to let your brain catch up. Or you'll try some protein and see if that helps you with how your appetite might be. Or you'll try drinking some more water and, in an N of 1 approach, try one, try all and see if it makes a difference, and then you've built an approach for you that might be a game changer. Well, as I mentioned earlier, let me finish up with some musings.
Dr Bobby Dubois:I do believe that the obesity epidemic has come about because we eat more calories than ever before and we do exercise and move less. Now this isn't true for everybody, but on balance in the population. But I believe and this is just my opinion and I hope I make clear when I'm sharing opinion versus information based on studies I do believe there's something more going on than just the calorie in and out and our desire to eat more. Our genetics haven't changed over 40 or 50 years, but surely the amount of folks who are overweight or obese has Now.
Dr Bobby Dubois:I have a theory that decades of eating more and more calorie-dense food so we've been doing this for decades may have changed our brains that are really tough to undo. Because of the diets we've had the larger portions on on our plate, our brains have come accustomed to that. The calorie dense foods that we love we've become accustomed to that and that trifecta perfect storm of carbs and fats and salt. I believe perhaps and this is again all opinion that our brains may have come to expect certain foods in certain quantities and the wiring in our brain has subtly or not so subtly changed over the decades of our eating patterns. Do I have data to support this? No, but it kind of makes sense to me and I wanted to share it with you. If what I'm suggesting that our brain in some sense has been changed over the decades by eating like this, it may take time, and maybe a fair bit of time, to rewire our brains. So once we try the new approaches I've talked about, it may take a bit of time not just to see that they work. I think you'll find quickly that they work, but we may kind of sink back into our old habits because our brains are taking us there. But maybe over time, if we're rigorous about it, maybe our brains will return to where it was that they used to be and our cravings weren't quite the same. Just a theory. I'll keep you posted if I find some evidence that supports it.
Dr Bobby Dubois:Well, the weight loss journey is important. Let me know what works for you and I'll be happy to share it with the rest of us. You can share your thoughts on my website, drbobbylivelongandwellcom, or through Instagram. Until next time, I hope that you can live long and well. Thanks so much for listening to Live Long and Well with Dr Bobby. If you liked this episode, please provide a review on Apple or Spotify or wherever you listen. If you want to continue this journey or want to receive my newsletter on practical and scientific ways to improve your health and longevity, please visit me at drbobbilivelongandwellcom. That's, doctor, as in D-R Bobby. Live long and well dot com.