Did you know that fatigue is a common side effect of carrying excess body fat? But here’s the big problem: We live in a world that is virtually designed to make us fat, and losing it is incredibly difficult. What makes matters worse is that there is so much misinformation out there about how to lose it — people are often told the reason they can’t lose fat is that they just don’t want it enough, don’t have self-control, or they are too lazy to make an effort. Now the new science of fat loss is showing that there is more to fat loss than what we previously thought.
This week, I am talking with Dr. Spencer Nadolsky, a specialist in obesity medicine, about the the links between overweight and chronic fatigue, and most importantly, the keys to the new science of fat loss. He will uncover the truth about how fat works in your body, fat loss, and why so many people are struggling to lose weight. If you’ve been stuck in endless cycles of yo-yo-ing in weight, this is a must-watch.
In this podcast, you’ll learn:
- The real cause of fat gain (you will be surprised here)
- The link between being overweight and chronic fatigue
- The real reason why it is difficult to lose fat
- The truth about the role of carbs in fat gain
- What science tells us about the best diet for fat loss
- The role the brain plays in fat loss
- The first (and easy) step in changing your habits for a healthier lifestyle
- The two kinds of fat gain and the key differences in fixing them
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How Being Overweight Causes Chronic Fatigue, And The Science Of Fat Loss – Transcipt
Ari Whitten: Hey, everyone. Welcome back to The Energy Blueprint Podcast. I am Ari Whitten, and I’m with Dr. Spencer Nadolsky who is someone that I’ve actually followed for several years now and I’m a big fan of his work. He is board certified in family medicine and he is a specialist in obesity medicine. He is the author of The Fat Loss Prescription. He’s done a whole bunch of work within the realm of fat loss and a lot of myth debunking around nutrition and exercise myths and fat loss myths. He just does awesome work and I wanted to have him on the show. Welcome, Dr. Nadolsky.
Dr. Spencer Nadolsky: Thanks for having me, buddy.
Why body composition and insulin resistance are relevant to fatigue
Ari Whitten: Yeah. I think a good place to get into this discussion because body composition is so relevant and insulin resistance is so relevant to fatigue and it’s such a common thing that overlaps with fatigue, I think it would be nice to kind of just intro with maybe some of that link, some of that kind of how those things overlap, how metabolic syndrome and diabetes tend to overlap and how they impact metabolic function in a way that maybe can result in fatigue.
Dr. Spencer Nadolsky: Yeah, no, that’s a good topic. Most of my patients have some sort of insulin resistance if I had to guess and so it is a big deal because most of my patients feel some sort of fatigue and there is an overlap. Most people thought that in the past, I don’t know, early 1900s, mid-1900s, all the way up until maybe even still now today that fat is just a storage depot. Something that looks unsightly, a condition of laziness per se and that people just don’t have willpower, right? That’s what most people think.
Most physicians when a patient who we say has overweight or has obesity, we don’t give them that title. We don’t label them as that condition. An obese patient most people would say. I say, has obesity.
They come into a door of a normal physician and physician will just say, “You just need to eat less and move more. You’re fatigued because …” They may even call them fat if they’re not being very sensitive, but they don’t understand the underlying pathophysiology of obesity and how complex it is. You and I are both in these kind of overlapping circles, but I’m kind of in this world of fitness professionals and physicians who a lot of people just think you just need to eat less and move more, which is true from a physiological standpoint, but it’s a lot harder to actually make that happen. The complexities that go behind how hard it is to actually do the eating less and moving more is really substantial.
How fat really works in your body
Like I said, most people think it’s a storage depot of fat, but as of late, we’re starting to find it’s probably our biggest endocrine organ, right? Instead of people thinking our pancreas and all these things, our thyroid, our endocrine organs, we actually now know that our fat secretes all sorts of things, cytokines or adipokines as people would say.
Specifically that belly fat, the stuff that’s maybe that you can’t really pinch. Not the what they call subcutaneous, but the visceral fat or even the liver fat, the stuff that surrounds your organs that kind of gives you that bigger waist circumference, that stuff specifically is metabolically pretty bad.
I imagine on your podcast, I haven’t listened to many of them, but you probably talk about some of these cytokines and inflammatory things that are going on. You can imagine someone with excess weight especially around their abdomen this big endocrine organ that’s secreting a lot of these adipokines causing all sorts of inflammation.
It’s also actually interacting with your cells and possibly causing some cellular respiration issues and all sorts of things. From a macro lens though, when a patient comes in with some excess weight, there’s all sorts of things that could be causing the fatigue and overlaps though and that’s kind of me as a physician trying to look at it from that lens. We can get into that if you want.
Ari Whitten: Yeah. One of the biggest factors that I definitely talk about is the link between inflammation and chronic fatigue and there’s a whole bunch of mechanisms by which inflammation can cause chronic fatigue.
Just for people who didn’t quite catch it or unfamiliar with the terminology, these cytokines or adipokines that Dr. Nadolsky is referring to and kind of this endocrine organ, what this means is that your fat is actually like a hormone producing organ in the same way that your thyroid and your pancreas are. In addition to that, produces inflammatory cytokines, things that cause chronic inflammation in the body. There’s well known mechanisms that we know that that inflammation can impact certain brain areas that regulate energy levels and so on.
With that in mind, with kind of this context of how body composition or being overweight can … Having overweight.
Dr. Spencer Nadolsky: That actually sounds the most … Having obesity makes sense. Having overweight is actually tough for me to say, although I’m supposed to say it, but yeah.
Ari Whitten: Yeah, I agree. It sounds odd to say.
Dr. Spencer Nadolsky: It’s a little bit odd.
The science of fat gain
Ari Whitten: I agree. It’s a better way of saying it. Having said that we understand this context of how that relates to potentially causing fatigue, let’s get into some of the kind of the meat around fat loss. Why are people gaining fat? I guess let’s start there because I know there’s a ton of misconceptions that people have in the lay public around the causes of fat gain in the first place. Let’s get into that. Do some myth debunking around that. First of all, I guess I should say is obesity caused by simply gluttony and sloth? Is it just a choice? Is it somebody who’s just being lazy and eating too much?
Dr. Spencer Nadolsky: Right. Even if I look at my elementary school pictures from late ’80s, early ’90s and you compare them to the elementary school kids now in the 2010s, there has been a shift. What’s changed? Our genetics haven’t really changed, but our environment has. I’m not just going to blame it all on our environment, but there’s a mismatch going on. There’s a good quote that basically genetics and even epigenetics load the gun and the environment pulls the trigger. Clearly some sort of mismatch has come on in the past 20, 30 years that’s really accelerated the obesity. Everybody wants to point the finger at one little thing. When it comes down to it from a physiological level, there is a mismatch of excess energy being taken in versus going out.
From that macro lens or whatever you want to say is yes, we are eating more and so we need to eat less somehow, but it’s much more complicated than that. This whole is obesity a choice? Well, I think we have less choice in it than we really think because of how our bodies are driven to wanting to eat more and our appetite.
First, if you’re lean and you’re lucky enough to have a lean family, despite your environment, you may never become or get overweight or obesity. If you’re one of the unlucky ones who has a genetic predisposition to gaining a little bit of excess weight, you’re going to have to try a little bit harder to not do that and it’s going to be a lot easier in the environment.
Then once you actually gain the weight because of all these adipokines, these hormonal changes and the free fatty acids causing all sorts of inflammation, that actually has an effect on your brain to make it even harder to then lose the weight and keep it off.
We can get into the nuances of that. I have a little blog and I think you’re reading it, about is obesity a choice? This isn’t supposed to be a question that’s supposed to be answered. No, it’s not a choice. You have no choice. Of course, we have choices. Of course, we can change things and specifically choose certain foods in the moment.
When you start taking a step back and you start looking at all the driving factors making us gain weight, it’s kind of like, “Holy cow. How do some of these people even stand a chance?” I always talk about Steve and Joe’s mom. Steve’s mom, she exercised during pregnancy and stayed a normal weight. Gained appropriate amount of weight for her pregnancy and ate mostly vegetables, some lean proteins, some lean dairies, maybe some legumes. She was very active, right? Then there’s Joe’s mom who was very sedentary. Ate a ton of fast food. Gained way more weight than she was supposed to during her pregnancy. Both of them had babies. Steve was of normal weight and then Joe was large for gestation.
Now we know and I’m sure you’ve talked about epigenetics and metabolic programming. What our mothers did while we were in utero and maybe even our grandparents and our fathers, that has an effect on how our genes are expressed later in life.
It’s like, so is that a choice? Was that our choice necessarily? Some people will say, “Well, that’s just a small contributor.” Well, then we start adding more and more things in like whether your breastfed or not. Again that was not necessarily a choice of our mothers either. Maybe they didn’t have a good milk supply. The blog that I made, a lot of moms came out and we’re like, “You’re mommy shaming.”
I’m like, “No, I promise. I understand people have trouble breastfeeding. Maybe the baby didn’t latch. Maybe they just didn’t have a good milk supply.” These maybe some small factors. Some people argue that biological plausibility in there. Whether you had a C-section or a vaginal delivery may have an effect and I’m sure you’ve probably looked at some of that coming out with the hypothalamic pituitary adrenal access of coming through the birth canal may have shaped our initial stress when we came out into life. That may have programmed us in some sort of way. Maybe there’s the difference in their microbiome because of our mother’s vaginal flora, whereas with a C-section we came out sterilely.
That may have an effect. Again these are all maybe small little contributors, but things we never had a choice about.
Ari Whitten: Well, yeah. Just to interject real quick, just to point out to everyone listening, all of those factors that he just mentioned are all things that are occurring like before you’re even born and in the first year of life.
I mean you just listed off what? Eight different factors that are proven to effect later risk of having overweight or obesity just within the first year you were born. It’s hard to say that it’s your choice or your willpower.
Anything to do with your laziness or gluttony when you have like eight different variables that are influencing this before you are even conscious enough to make a choice.
Dr. Spencer Nadolsky: Yup. Then you go on as you’re growing up, maybe your parents, one of them has to work an extra job, so you’re with the other parent and the one parent has to just order pizza because they’re working late and they’re tired.
Maybe they have obesity, they have sleep apnea, so they’re sleeping on the couch. That’s what I show in the cartoon. Whereas Steve’s family, they’re sitting at the dinner table. They have fresh vegetables. There’s actually a lot of data showing your taste for these types of foods begin very early on, maybe even in utero where if the mother eats more vegetables, the kid will actually enjoy vegetables later on in life, which is crazy. It’s just the things that you just can’t control.
Then maybe some of these habit things. Maybe your father went and worked out with you. Got you into sports early.
Whereas maybe Joe who had overweight or had obesity at a young age was put on off label antipsychotic for mood. I see these a lot. They have mood disorders or they’re acting funny. The doctor says, “Well, we could put him on Adderall or all sorts of things.” Adderall would probably make you lose weight obviously, but it’s just some sort of mood issue and they’re going to put him on an antipsychotic off label. Someone argued with me that that doesn’t happen. Well, there’s a lot of data that it does and I’ve actually seen it multiple times. That does happen.
That will make you gain weight through multiple mechanisms on appetite, maybe nutrient partitioning, et cetera, which we can …
Ari Whitten: Even on label use of like SSRIs.
Dr. Spencer Nadolsky: Yeah. Anything like that. Was that a choice because the mood issues were coming from maybe just the parents were too busy working trying to make ends meet and didn’t have time to maybe do the parenting. Again I’m not shaming people. This is just life that happens. Then you go on and eventually you see someone like Steve who’s very lean, had the proper epigenetic and genetic propensity to be lean and also had the habits reinforced from childhood. You say, “That guy works extremely hard. He’s disciplined,” and then you see someone like Joe who has this obesity and who went through all these different things. We don’t know his story, but this is what you see when you see somebody and you just say, “That person’s lazy.” Right?
Some of these biases I try to get people really thinking about. We don’t know these people’s stories. Yeah, sure. Maybe. Maybe someone just doesn’t care and maybe they don’t mind having that obesity. Maybe they have some laziness, but it’s a lot more complex than that.
Then when trying to lose weight, again these things, those cytokines or adipokines, these hormonal milieu as some people say, maybe preventing us from then losing the weight that we already gained. Then people are like, “You’re just not trying hard enough.”
This person’s tired.
You have The Energy Blueprint. These people are fatigued and then you’re telling them they have to prepare their meals. You have to go out and do all these hours of exercise when they just don’t feel well to do it.
The science of fat loss – The primary reason why your fat loss efforts can be futile
I try to get people really thinking about that to try to empathize a little bit. It’s hard. I mean I’m trying to actually gain weight right now and that my body is fighting me from gaining weight. I can only imagine how frustrating it is for someone that has a lot of weight to lose and their body’s fighting them so hard to not lose that weight.
Ari Whitten: Just to clarify, you’re talking about gaining muscle mass?
Dr. Spencer Nadolsky: Yeah, I’m trying to gain muscle mass right now. By doing that, I’m trying to eat more and more and I’m actually not doing as much cardio, which is a bad idea because I feel better talking about energy wise when I do have that in my regimen. Yeah, I’m trying to, but my body’s fighting me. My appetite’s going downwards. People that are trying to lose weight, their appetite gets cranked up high due to some of these hormonal changes adaptations.
Ari Whitten: I think that’s a good point because part of I think what ties into this whole idea of is it a choice, is it just gluttony and sloth, is this whole concept of the body fat set point system and if we have regulatory mechanisms built into our body that are controlling all of this.
Dr. Spencer Nadolsky: Yup. The whole set point theory is basically our bodies want to keep us in this homeostasis, right? Our bodies want to keep us in a certain range. Just like our bodies, our kidneys work to keep our blood PH at a certain level, our sugar levels at a certain level, our thyroid at a certain level. All these things have checks and balances. For some reason, what happens when we gain weight, for some people, not everybody, again this is an individual thing, for many people that gain weight, their body set point resets at a higher level. When you try to lose weight, the body fights it with all sorts of different things, appetite being one, subconsciously not moving as much, not fidgeting, not taking as many walks that you normally would.
These things all fight to keep your body from losing more weight and then to make it regain that weight to keep you at that higher set point. Someone like me or maybe even you, someone that’s trying to gain weight, our bodies are fighting actually to then keep you at that lower weight. It’s really interesting. Again this is very individual. It doesn’t happen for every single person.
The science of fat loss – The two types of obesity
There’s some more complex stuff like hedonic obesity versus metabolic obesity, basically changes in the brain that override these things. It gets really complex, but it’s cool stuff.
Ari Whitten: Well, actually let’s go into that for a sec because I agree. That’s a really interesting topic. Can you explain the difference between hedonic and metabolic obesity?
Dr. Spencer Nadolsky: Yeah. I’ll try. This guy from Yale, I’ve read his papers a few times over the past few years. It’s a relatively new concept and I’ve seen him lecture a few times. I’ll send you some of the papers afterwards if you don’t have them already. Basically and I wish I could show the graph on the paper, but the people … They have a certain set point, but they’re able to gain the same amount of weight that someone that has the higher set point, but their body is trying to fight them. Their metabolic rate goes super high to try to fight them to bring their weight back down, but there’s a dysfunction in their brain, the reward pathway. I’ll just explain the reward pathway real quick in the simplistic terms.
Think about after a meal when you’re super full, right? You think you’re full anyways, but then you still want that piece of pie, right, or something really sweet even though you’re like, “You know what? I’m full, but for some reason I can eat a few cookies and whatever.”
That’s kind of that reward pathway, the wanting of food. The whole dopamine center, mesolimbic center. What happens is that in this hedonic obesity, there is dysfunction there. Even though your body’s fighting you in ways to ramp up your metabolism to try to get you to burn more calories, there’s so much dysfunction that you’re able to overeat that. Whereas somebody that has metabolic obesity, their set point is up at that level.
Like someone with hedonic obesity would have maybe the set point of like you or I, but they’re able to overeat that and overcompensate for that, whereas somebody with metabolic obesity would just … Their metabolic rate wouldn’t be such that it’s trying to overcompensate. They’re set at that new point and they’re just eating and burning as many calories as what the set point is showing. Yeah. Sorry. I’m not that great at explaining. I wish I could show the graph that he shows in his papers.
Ari Whitten: Yeah. I’ll just rephrase in different words so maybe people can get a different perspective on it. Basically it’s like somebody who is very overweight or has a lot of overweight and their body fat set point system, the system of certain brain regions in correspondence with certain hormones, is regulating their new fat set point at that higher level.
Their body wants to maintain that versus let’s say someone whose leaner, who basically is just in a state of chronically overriding their set point because they’re being driven to consume more food basically based on a pursuit of highly rewarding, highly pleasurable foods.
They feel compelled to eat more to give themselves pleasure and the end result of consuming excess fuel over time is accumulating more body fat.
Dr. Spencer Nadolsky: Yup. Yeah, exactly. These people are the same exact weight, but the person with hedonic obesity will have a much higher metabolic rate, but because their brain is … There’s something dysfunctional in that reward pathway, cakes, you name it, cakes, pies, cookies, but their body actually wants to fight them to get them back down to where they should be, but their brain is overriding it. Very cool stuff.
Ari Whitten: Now, question, I’m actually interested in reading these studies because I think you’re alluding to a couple I haven’t seen yet. I’ve seen some overfeeding studies that they’ve done. I think like James Levine has done with … Even there’s been some overfeeding studies with identical twins. Just so people understand, overfeeding basically means they take people and they forcibly have them over consume calories with the intention to get them fatter. In these studies, what I remember them determining was that NEAT, non-exercise activity thermogenesis, was actually the critical factor between whether people actually got fatter versus whether they stayed lean.
What that means is basically that certain people genetically seem to be wired in a way where they’ll burn off excess calories just by kind of spontaneous little movement throughout the day and just moving and walking more, whereas certain people seem genetically not wired to do that very well and then they end up accumulating the excess fuel as body fat. I’m curious. Is it actually a true increase in metabolic rate or is it NEAT?
Dr. Spencer Nadolsky: Yeah. You’ll enjoy it because it talks about the resting metabolic rate. The way that you can kind of … Again I haven’t done this with all my patients. I send some of them to get a metabolic cart just to show them that their metabolism is working because a lot of people think, “I just have a slow metabolism,” and they don’t. You can actually get them to do one of these metabolic carts. They’re off by maybe 10% sometimes, but they’ll actually see that they actually have a normal metabolism. What you could do is to see if they have this hedonic obesity, you would check. If their metabolic rate is actually much higher than what would be predicted based on the slope of this curve and I’ll send the graph to you …
Ari Whitten: Yeah. We’ll put it in the links for the show notes.
Science of fat loss – The insulin hypothesis
Dr. Spencer Nadolsky: If their metabolic rate is much higher than you would expect, you’d be like wow, they actually have some reward pathway dysfunction, meaning they’re just out eating their body. It’s fascinating.
Ari Whitten: Interesting. Yeah. I’m definitely excited to check that out. With that in mind, you kind of have alluded to this kind of energy imbalance as being at the core of fat gain, but you’ve also explained that it’s complex and there’s lots of layers to the story and it’s not just simply gluttony and sloth. Some people listening to this might hear that and be like, “Oh well, this guy is just saying it’s about calories in, calories out, but I thought it was about hormones or carbs and insulin.” Let’s get into some of that. What do you say to someone who’s coming from that perspective?
Dr. Spencer Nadolsky: They’re all interrelated. It is still going to come down to an energy balance. The hormonal differences will drive that though. There was this hypothesis. The calories in, calories out was the hypothesis for a long time. Then in the past 10 or 20 years or so, there has been this what they call the insulin hypothesis of obesity. What they thought was that people that eat more … I’m sure you’ve explained to your listeners how the physiology of insulin and glucose works basically.
Ari Whitten: A little bit. We did one podcast a few weeks ago.
Dr. Spencer Nadolsky: Basically when you ingest something that contains carbohydrates, it gets broken down into basically sugar or glucose in the body. Your pancreas, the organ in the middle of your belly, basically senses that and sends out the stuff called insulin. The insulin then goes to like a key to a lock or I say a key to a truck of some sort in your tissues, which would be your adipocytes or your fat or your muscle cells. It goes into the insulin receptor, which we call it the ignition. The ignition then opens everything up to where these sugar trucks come out and then take the sugar into the cells. That’s how it’s supposed to work.
Then in people with insulin resistance, we say that the batteries are dead in the sugar trucks or something like that and the trucks don’t come out to get the sugar. What were we talking about?
Ari Whitten: Insulin hypothesis.
Dr. Spencer Nadolsky: Yeah. Okay. When people eat more carbohydrates and they have more insulin, the thought was because insulin itself is what is called a fat storage hormone, it stops this enzyme called hormone-sensitive lipase. Hormone-sensitive lipase is this enzyme that breaks down your fat and allows it to go into your blood so you can burn it off. It also is supposed to up regulate this enzyme called lipoprotein lipase.
This is an enzyme on your fat and on your muscle that basically turns on to then grab the fatty acids out of your blood and then either store them in the fat or get them into the muscle where they can be burned. With that in mind, the idea is more insulin means less fat release and more fat storage. Does that make sense?
Ari Whitten: Mm-hmm.
Dr. Spencer Nadolsky: All right. Then the thought was well, then if we’re having more carbohydrate in our diet, then we’re going to have more insulin. With more insulin in our diet, we’re just going to be storing more fat and releasing less and less burn fats. It sounds interesting. The analogy that I’ve heard because I actually almost got indoctrinated by a lot of the low carb doctors. I hung out with them in medical school. I rotated with many of them. Very smart people, well intended people, but once you get ingrained into a certain dogma, you become blinded a little bit. The analogy was that think of a pickup truck and your gasoline is the fat, right? Think about taking gallons or storing gasoline in those portable gasoline storage bins, things, whatever those things are called.
You throw them in the back of the pickup truck, but you can’t use them. You’re not putting it in your gas tank. You’re actually storing these other things of gas, but you can’t actually use it. That’s the idea of what is happening when you have a high carbohydrate diet. You’re storing more, but unable to tap the energy, which would be the fat cells. Does that make sense so far?
Ari Whitten: Yeah, absolutely.
Dr. Spencer Nadolsky: It turns out it sound great to me. I wrestled in college and I was a heavyweight. I was a relatively lean heavyweight. You could still see my abs are a little bit blurry, but I was big. I was like 260 pounds. Technically with a BMI, I had obesity. I mean technically. I didn’t have the disease of obesity. I went low carb and I lost a lot of weight. It made sense to me. It just made sense this whole idea of insulin and carbohydrates preventing you from losing weight.
Ari Whitten: Real quick, I was indoctrinated into it for many, many years and I taught it to clients of mine and it does make sense. I mean if insulin … We know it has these kind of fat storing functions and carbs boost insulin levels, I mean it’s only logical that carbs have this very critical role in determining how fat or lean we are.
Dr. Spencer Nadolsky: I mean honestly the story is amazing. You can start getting these graphs and it’s showing people are eating more carbohydrates and sugar and these things are spiking insulin. Look, these people are gaining. This is why the obesity epidemic. The problem is though it’s easily testable. You can actually test this in a very controlled metabolic lab. My friend Kevin Hall had the most recent one and luckily Kevin Hall lives near me. He’s this brilliant metabolic physicist that comes up with these studies and work in this metabolic at the NIH. He lives near me. We get together and I’m able to learn from him. I’m a clinician, not an in depth researcher like he is, but it’s really cool to kind of learn a little bit more about it.
He actually tested this and there had been multiple tests like this. They basically kept protein the same and then they just changed the ratios of fat and carbohydrate in two different groups. What they found is that yes, certainly those people that were eating more carbohydrates, their insulin was higher and then the people that are eating fewer carbohydrates and more fat, their insulin was lower. They found it just didn’t really matter so much. The people with more carbohydrates still lost fat. In fact, they may have lost more because they weren’t ingesting as much fat. Now from a clinical standpoint, I don’t really …
It’s clinically irrelevant, but the point is is that what that actually helps us do is help people find a diet that they will be able to stick to for a long term that doesn’t necessarily mean they’re eating very few carbohydrates or very few fat. You can kind of help somebody figure it out for them. Now where I come in is the biggest thing and it’s appetite. Appetite and some of these other hormonal changes are what’s going to ruin somebody’s diet. It’s not the carbohydrates. I have patients that eat 10 carbohydrates, but they drink butter and they do all these other things to basically get a ton of fat.
Ari Whitten: They’ll eat 10 grams of carbohydrate?
Dr. Spencer Nadolsky: Yeah. 10 grams of carbohydrates per day and the rest of it comes from fat and protein and they still are unable to lose weight. The reason is is because they’re still in energy imbalance. You can’t overcome the physics. Now I wish and even Kevin Hall when you talk to him, it’s not like he …
Everybody thinks he’s like paid by sugar, big sugar, big pizza, all these different … Some carbohydrate lobbyists. If a low carbohydrate diet work for every single patient, I would just be pushing it so hard. A ketogenic, a very little carbohydrate diet. When you start looking at it practically, most people can’t stick to it and then in the end, it really doesn’t matter. It doesn’t matter.
What I want to do is find those things, those hormonal changes that fight people from losing the weight, which has to do with the appetite. Trying to get people despite their environment to then choose the foods that are going to not be rewiring their reward pathway and their satiety centers in their brain.
Ari Whitten: There’s so much in what you just said. I want to unpack that a little bit for people.
Dr. Spencer Nadolsky: Oh yeah, sure.
Ari Whitten: You made a transition there pretty quickly. It was like a transition that you made that I happen to know because I follow a lot of this research for many years. I know that there was literally like thousands of studies informing these little few sentences that you just said, but you basically switched. You’re like basically carbs and fats don’t matter. You basically brushed them off in like two seconds. I just want to back up because a lot of people listening to this are like, “Wait. That’s it?” I mean because there’s been dozens of books, maybe hundreds of books, thousands of articles online written on carbs versus fats and this being the critical thing and it’s low fat versus low carbs.
There’s been literally decades of debate on this subject of low carb and low fat. Basically what you just said is that and I’ll put in slightly different words, is that based on this overall body of evidence that we know from testing this very, very thoroughly in controlled metabolic ward settings and in long term diet studies, basically in the end it’s clinical insignificant. There’s just very minor differences between diets that differ dramatically in terms of carb and fat content.
Dr. Spencer Nadolsky: Yeah, that is correct. I know if somebody’s listening, they’re like, “Oh, that’s crap. The only way I was able to lose weight was on a low carbohydrate diet.” I’m sure that’s probably correct. What happens is that you’re able to stick to that. Something about that is allowing you to stick to a lower energy diet. A low carbohydrate diet, if you do it correctly, a low carb Mediterranean diet, you’re eating mostly vegetables and some protein and maybe some fruit here and there and getting some olive oil and nuts. Things that are very good for you and very ant-inflammatory. Think about that. If you were to eat more legumes, higher carbohydrates from things like legumes that are actually lower in fat, they’ll probably be fine.
Where people get in trouble is that a lot of these high carbohydrate foods that you really think of, they’re not thinking of legumes or lentils. What they’re thinking of is pizza, donuts, things that are likely higher in carbohydrates and fat and just super high in calories. It’s actually hard. I’ve tried to do one of these very low fat type of diets. I actually don’t like it. I go back to more of a … It’s more like a zone type of diet. It’s kind of mixed. When you do a very low fat diet, it’s actually hard to follow. If you did it, you would probably lose weight. It just wouldn’t be very tasty. I don’t think. Things taste dry. You know what I mean?
The science of fat loss – The best diet for fat loss
Ari Whitten: There’s another aspect to this that I’m going to unpack. You’re basically saying like all this hubbub for a few decades around carbs and fats mostly nonsense, mostly insignificant in the grand scheme of things, but the real key is not the carb to fat ratio of the diet. It is dietary adherence. What is the type of diet that you can actually adhere to and sustain for long periods of times while being in a calorie deficit that will help drive fat loss in a sustainable way.
Dr. Spencer Nadolsky: Exactly. This is what my practical clinical experience has show. This is what the study show. There’s a really cool huge trial and this is where a lot of the obesity doctors and researchers get their data. It’s called The Look AHEAD Study and also the diabetes prevention program. When you look at it, it’s really people who are somehow adhering. There’s other studies too. The Pounds Loss, A to Z Trial and all these things that tried to change the different macronutrients, change the ratios of protein, fat and carbohydrates. Really what they found is that the better you can stick to these diets, one of them, the better you’re going to do. There’s one thing out there that people say, “Well, then you should pick what you would rather do.”
If you prefer lower carbohydrate foods or higher carbohydrate foods, you should go with that diet. Well, there is a few studies in the past couple of years that actually they randomized people to either ones that they prefer or didn’t prefer and then they kind of switch them up and things like that. It actually didn’t matter.
Ari Whitten: Oh, interesting.
Dr. Spencer Nadolsky: It is interesting. If you like something more, you may eat more of it. There are lots of little things here. It’s going to come down to somehow developing the strong habits to eat in a certain pattern that’s … You’re going to have to enjoy it a little bit. You can’t be miserable. If you’re miserable, you’re not going to be able to sustain it, right? If you like it too much, you’re going to end up eating too much. There’s a fine line somewhere. It’s a tough thing.
Ari Whitten: Then if you have something like keto, I know you mentioned that so few people can actually sustain it for a long periods of time. I mean there’s other issues there whether that’s not even that relevant to whether you like it or not, but just like how compatible with the modern world is it. Can you got to a restaurant and find keto meals? It’s tough.
Dr. Spencer Nadolsky: Have you done a ketogenic diet?
Ari Whitten: Have I?
Dr. Spencer Nadolsky: Yeah.
Ari Whitten: I have done it for short periods, yeah, but I mean I find it miserable personally.
Dr. Spencer Nadolsky: I’ve done pretty much every single diet out there just because I want to know what my patients are experiencing. It’s interesting. Ketogenic diet, it’s really hard the first week or two. I taint. I couldn’t even run. I couldn’t bike. I became fat adapted, what everybody says. You go through that keto flu or whatever you want to call it. I all of a sudden had a lot of energy. The problem was social events and all sorts of other things, it just … You know what? I want some toasts with my eggs in the morning. Just one slice. I want some extra fruit here and there. I want some oatmeal. I want some pasta once in a while. It becomes something that’s just like you don’t have to follow that in order to lose weight.
I will say that we probably don’t have time to get into type 2 diabetes and all that. I do put people if they are on a lot of insulin and their pancreas is pretty much tethered out, I do put them on ketogenic diets to get them off their insulin if possible. Other than that, I don’t find it necessary to go on a ketogenic diet.
Ari Whitten: Well, that’s another thing that I really like about your work is that you’re not dogmatic about here’s the one true best way to eat, the one right way and everybody else is wrong. You actually are of this perspective where like it’s really about dietary adherence and finding the best healthy dietary pattern that you’re going to be able to sustain and let’s work with the individual patient to find what that dietary pattern is and sometimes that might be keto, sometimes it might be I would imagine maybe a low fat vegan diet or somewhere in between, a zone type diet or a paleo type diet or lots of different variations. You’re not dogmatic about that, which is really cool.
Dr. Spencer Nadolsky: Yeah. I say I’m a nutritional agnostic or whatever. If you have a hammer, everything looks like a nail or whatever you want to call it. Yeah. I try to because I mean patients will do all sorts of different things. I mean a lot of the fitness people will knock the paleo diet, but it’s like I’ve had a lot of patients they love the paleo diet. It’s not like they’re following it 100% to a T. It’s their paleo way. They’re eating a lot more fruits and vegetables. Things that we all know are good for you anyway. Anything that will get them to do it and get them in and maybe teach them later what’s really going on and that’s fine.
Ari Whitten: There’s so much I wanted to cover in this and I know we’re not going to have time to get into everything I wanted, but I’m trying to think. Do you have any other kind of keys to fat loss that you think are really important and maybe we could get into some other non-nutritional areas and maybe exercise or maybe some of the areas that affect fat loss?
The science of fat loss – Why protein is important for fat loss
Dr. Spencer Nadolsky: Yeah. Okay. We’ve established that you can lose weight whether you’re eating carbohydrates or not, whether you’re eating fat or not because that was the old thing. You had to eat low fat in order to lose fat. Well, that’s not true. It does come down to energy balance, but it’s more complicated than that because your body’s going to fight you and it’s hard to actually … It is hard to eat less and move more.
It’s hard to actually do those things. The way that I actually help people do that is realizing that appetite is probably the main thing. When I help somebody set up a fat loss diet, of course they have to be … They do have to be eating less, right? In order to make that happen, we focus on the things what we call are not very energy dense.
They have a low energy density and that means that they fill up more volume and they have fewer calories in them. Think of like spinach. You could eat a whole bowl of it and still, I don’t know, it’s like 10 calories. It’s very low calories, yet it’s very filling because it will fill up a lot. It will fill up your stomach with very few calories. You start focusing on those types of foods and also like leaner proteins.
Protein is very satiating. It doesn’t have as many calories in it. Actually you burn a little bit more. You actually burn more calories trying to digest protein than you do other types of calories. We try to do more leaner type of proteins, low fat, dairy maybe and a lot of vegetables and fruit.
How to transition into a healthier diet
Then beyond that, you kind of figure out their current diet and you say, “Well, look. If somebody’s drinking a Frappuccino from Starbucks in the morning and eating a muffin, it’s pretty easy to start making a switch there. If they’re already eating a relatively healthy diet, then it gets a little bit more complex.”
Basically, starting to form them into what they prefer, but again not too much of what they prefer and focusing on the energy balance to basically take care of that appetite, energy density as well to get them there. It’s a complex process, but with each patient you try to go that route and then just tinker with it. You can get people to count calories. You can get them to weigh their food and maybe get an idea of what portions really are.
That can be good for people, but some people don’t do well with that because it’s tedious. If they’re tired as we talked about, that’s just one more extra thing that they’re just not going to be able to do. One thing I do is a lot of meal replacement shakes and even prepackaged meals, which sounds counterintuitive because it’s like that’s not real food. Studies actually show that when you start taking the choices and guess work out of some of their day, people are able to lose more weight than if you tell them just to eat whole food in every single meal. What I do is a protein shake just replaces one of their meals, say lunch. From a practical standpoint, somebody goes to …
They’re at work and their colleagues go, “All right. It’s time to order lunch,” and you realized you should have packed a lunch if you wanted to lose some weight, but you didn’t because it takes time and effort. Then you and your colleagues go and get Thai food or Chinese food or grab some pizza. Instead, you can replace that 800 calorie or 1,000 calorie meal with a 200 calorie protein shake. Maybe not as filling as a whole foods meal with salmon and broccoli and maybe a boiled potato, but it does the job and it takes the guess work out. What happens, people are able to lose weight quicker in the beginning. Gets them motivated. Gets them feeling good and then you can start teaching them the strategies to be able to maybe prepare the food.
If people aren’t feeling good and they don’t have that energy, if you try to just tell them to eat lean proteins and vegetables, it doesn’t work so well. Making it super easy in the beginning, it works and there’s a lot of data to show that that work. People get mad at me for recommending protein shakes instead of whole foods, but there’s too much data to ignore it. I’m not saying drink protein shakes forever. You do that in the beginning to get them feeling good, so then they can start doing those other things.
Ari Whitten: I think there’s also probably some power in the monotony of it and the lack of choice. Just not having the novelty of like options of different things to eat kind of … My theory on that is like it helps retrain the brain out of hedonic eating.
Dr. Spencer Nadolsky: That’s true.
Ari Whitten: You start eating like, “Oh, I’m just going to have this protein shake. This is not a particularly pleasurable thing. It’s not pleasurable. It’s not really unpleasurable. It’s just I’m having the fuel to fuel my body and give it what it needs.” Eating is not this experience of like I sit down and what am I going to order to kind of give my brain all this pleasure chemicals. It’s just like, “Oh, I just have my fuel. It’s 12 o’clock. Time to have a fuel.”
Dr. Spencer Nadolsky: Yeah, you’re exactly right. We don’t have too much time to go into it, but if you want to look up, there’s something called sensory-specific satiety and that’s part of what exactly you’re talking about. The less variety and getting into that monotony actually retrains your brain. Then as you lose the weight quickly, there’s less inflammation and maybe less dysfunction in the brain to then allow you to then have fewer cravings actually, which it seems like oh yeah, if you diet, you’re going to have more cravings, but actually people that lose the weight, they have fewer. It maybe because of the inflammatory response is going down and creating less dysfunction and improving the brain function and the communication with the rest of your body.
The other thing I like, is something called acceptance based therapy. It’s this idea is that we should accept what we cannot control and control what we can, accept that our bodies are going to be fighting us, accept that we’re going to get some of these cravings, but realize we do have control in that moment. Then accepting less pleasure, right?
There’s a lot of fitness people out there and fitness fanatics and people listening probably have experience this where yeah, just eat an apple instead of eating that candy bar. Duh. It’s like what? You’re like yeah, apples taste amazing. Fruit tastes amazing. Fruit tastes better than that cookie. It’s like well, no, that’s not true.
If you ever had a really well baked perfect chocolate chip cookie or whatever your go to crazy favorite snack is, you realize nothing will ever compare to that. No fruit. No vegetable ever. If you change your mindset to thinking I’m going to accept … I know this is going to be less pleasurable.
It’s not unpleasant, right? It’s still fruit.
It still has some sweetness, but I accept that this is not going to be pleasurable compared to whatever that is, french fries, cookies, cakes. I’m going to do it because it aligns with my values and what I value and we get into a goal. Not I want to lose 50 pounds, but no, I want to be there and be able to enjoy life with my children and that’s what you value.
You accept less pleasure to then have your values aligned with that behavior. It’s a very cool thing. When I teach my patients that, they’re not just like yeah, I’ll have the apple instead of the cookie. No, you accept that the apple …
You can have the cookie every once in a while. You don’t put it on a restrictive list. You realize you can have that cookie once in a while, but you’re going to accept less pleasure in that moment and still have some pleasure because that behavior aligns with what you value.
That’s the basics of it and it works. There is I called a landmark study. They compared using that acceptance based therapy to standard behavioral therapy. It’s like a 30% or so efficacy difference, meaning …
Ari Whitten: Wow.
Dr. Spencer Nadolsky: Yeah. 13% weight loss or 13 and a half versus like 9.8%, which is still very good. They had some better mechanisms. They accepted this less pleasure and realized okay, that makes sense.
Ari Whitten: Yeah, I agree. I think that is a key change and I also think that the human brain is not wired to do that very well. I think that the human brain is very wired to assess things in the moment and say, “Wow. Cookie. Donut. That looks delicious. I want that pleasure in my face.” Not, “Wow. Cookie. Donut. If I make this momentary decision to have those things, it might influence things 10 years, 20 years from now where I might not be as functional, not be able to play with my kids or grandkids.” Our brains don’t think like that naturally and I think you have to cultivate the skill of thinking like that.
The science of fat loss – how sugar addiction really impacts your health
Dr. Spencer Nadolsky: It is. The other thing is the listeners probably have heard of like sugar addiction and food addition. I’m a carboholic, right? A lot of the fitness professionals go, “Look, there is no evidence for sugar addiction, right?” Well, the people that say yes, there’s a sugar addiction because it lights up the same parts of your brain as cocaine and some of these things and then the people on the other side of the fitness professionals say, “No, there’s no sugar addiction. It’s just a correlation. Of course, it’s going to light up the same part of your brain. If you hug a puppy or anything like that, it will light up, but it’s not a true addiction,” and they’ll pull up studies. When you start looking at it from a clinical picture, people are driven that way.
When you start looking at some of the mechanisms in the brain, there is an overlap. I wouldn’t call it an addiction. I’d call it addictive-like substance for certain people that have dysfunction in the same parts of the brain. I think it doesn’t help to say, “Nope. You’re not sugar addicted.” I think it helps to empower people to go, “Yes, this does have addictive-like properties, but we can overcome it. It’s not going to be like overcoming a methamphetamine addiction or something like that.” You validate what they’re feeling and then you empower them if that makes sense.
Ari Whitten: It does, yeah. I actually happen to agree with you in that kind of middle ground between the two extremes. I disagree with a lot of people in the fitness community that are like so opposed to this idea. I think they’re not in touch with the reality for people who do have some of that hedonic dysfunction going on that these foods do really trigger them to go on binges and kind of lose control.
Dr. Spencer Nadolsky: Yes, exactly. It’s tough.
How Dr. Nadolsky works with his patients
Ari Whitten: Well, I know we’re pretty much out of time here. The last thing that I want to ask you is just what kinds of different medical complications might a person have where they might need assistance from you? I know you do some online doctoring now. I want to encourage people to reach out to you if they need help, but what kinds of scenarios would you recommend for people to go and actively seek out that help?
Dr. Spencer Nadolsky: Right. If somebody’s trying to lose weight, this is where … Classic things. People can hire a trainer or anything or maybe an online health coach and maybe they lose weight and they do fine. Most people what happens is they’re trying to lose that weight. Maybe they did and then they regained it. Maybe they failed multiple times. Maybe they just don’t have enough energy and they just don’t feel well. That’s where I take this clinicians hat and go, “All right. Somebody with untreated sleep apnea, I screen it in every patient. It’s very common in those with obesity.”
Ari Whitten: Real quick. It’s actually super common in people with chronic fatigue syndrome. There’s some research going. It’s like roughly almost 50% of people with chronic fatigue syndrome.
Dr. Spencer Nadolsky: Exactly. When people have that and it’s not treated with a CPAP machine, they will not … It’s true that losing weight may reverse it or may lessen the severity, but they will not have enough energy to do so. If you’re like, “I’m trying to lose weight and I can’t. I’m just tired. I can’t do it. My hunger has ridiculously elevated. I just don’t have enough energy,” that’s when going to a doctor would be a good idea. Just going through it. Talk about it. Are you snoring? Are you gasping in the middle of the night? Maybe you just never talked to a doctor about it, but that’s something everybody should be talking about or screening for. The other thing is like for guys because of all these things, your testosterone can be low.
In some of those people maybe treating with … If you have sleep apnea, your testosterone could be low. Getting them a CPAP, getting them to feel better, getting them to lose weight can increase the testosterone. Sometimes it’s so low and it’s from the obesity and maybe the insulin resistance. Giving them a little bit of testosterone back as you help them to lose weight will come back. Some of these things they’re all interrelated. Depression and this can be a bad cycle as well. Thyroid, I’m sure you guys talk about thyroid. I always screen every patient. It’s unlikely that there’s a thyroid issue in people with obesity, but it is something you don’t want to miss because they’ll be pissed if you missed that.
Ari Whitten: Probably diabetes as well, right?
Dr. Spencer Nadolsky: Yeah. Diabetes as well. That’s kind of what we talked about, the insulin resistance and inflammation. That will make you more tired as well. The thing is you go through all these things. It doesn’t seem like they have this, but your appetite is still high. There are medicines that work at the certain receptors in the brain that control your appetite and there’s multiple receptors. I do some lectures on this, but there are different options for medicines that wipe out that appetite or at least may assist in that appetite so that you can stick to a diet. They’re not fat burners. People are like, “Oh, it’s a magic pill. It’s going to make you lose weight.” No.
They basically allow you to then adhere to the diet plan instead of just going, “Oh my god. I just want that brownie, that cookie.” There are actually drugs that work in the mesolimbic center in the brain, the reward pathway, to basically wipe out those cravings when you have dysfunction there. It may take a few different types of drugs or maybe a combination, but that’s what I do. I help look at that, look at all the causes of fatigue and what’s stopping you from losing weight. Then I try to assist. Some people if they qualify for surgery, if we fail conservative treatment and we go that route, but that’s end of the line usually.
Ari Whitten: Beautiful. Well, thank you so much for coming on the podcast, Dr. Nadolsky.
Dr. Spencer Nadolsky: Thanks for having me.
Ari Whitten: It’s been an absolute pleasure. To everyone listening, I really want to actively encourage you guys to seek this out because sometimes I have people on the podcast that I don’t necessarily know their work that well. Sometimes they were just recommended to me. Sometimes it’s just kind of the first conversation with people. With Spencer, I’ve been following his work for years now and he does really awesome work. He’s putting out great content. I know that he’s really paying attention to the science. He’s going through all the latest obesity conferences. I mean he’s really on the cutting edge of how to do this well.
If you’re struggling with fat loss and you have some of these different medical complications, I really highly encourage you to seek out his help. Where can people reach you?
Dr. Spencer Nadolsky: They can go to drspencer.com or on Facebook you can just search for Dr. Spencer Nadolsky. I’m on Twitter as well. I do online doctoring. Steadymd.com/drspencer. Slash Dr. Spencer.
Ari Whitten: Beautiful. Well, thank you so much. Really a pleasure to have you on and I look forward to maybe a part two.
Dr. Spencer Nadolsky: Yes. Thank you.
Ari Whitten: Awesome man. Take care.
Dr. Spencer Nadolsky: See you.
To learn more about the work that Dr. Nadolsky does, check out his personal web site here
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How Being Overweight Causes Chronic Fatigue, And The Science Of Fat Loss – Show Notes
Why body composition and insulin resistance are relevant to fatigue (0:47)
How fat really works in your body (3:05)
The science of fat gain (5:42)
The science of fat loss – The primary reason why your fat loss efforts can be futile (15:15)
The science of fat loss – the two types of obesity (17:37)
Science of fat loss – the Insulin hypothesis (23:38)
The science of fat loss – best diet for fat loss (36:20)
The science of fat loss – Why protein is important for fat loss (42:11)
How to transition into a healthier diet (43:48)
The science of fat loss – how sugar addiction really impacts your health (51:28)
How Dr. Nadolsky works with his patients (53:18)