Undereducated about the Unknowns

• The essentials of Nutrition come down to the idea of Energy Balance or how energy is taken into the body, generated, and then expended. A positive energy balance is when more energy is taken in and then stored resulting in weight gain while a negative energy balance is where less energy is taken in than used so fat stores must be used. Remember that the goal of eating food is to make energy which is represented by the molecule ATP (produced by the Mitochondria!). However, depending on the kind of activity done, we may not have enough stored ATP in the body to cover the activity and thus have to use other means of ATP production.
  • When we are at rest, the activities we do such as swiping your thumb on a screen and moving your eyeballs to read do rapidly deplete the amount of stored ATP—this is why you can sit all day without feeling winded. If we perform a more intense activity, such as walking, the stored ATP is used incredibly quickly (lasts <10sec) and we have to use Aerobic Metabolism to create ATP while doing the activity. Aerobic Metabolism utilizes oxygen to make ATP and is incredibly efficient which enables us to do low-impact activities for an extended period, like walking down a hallway. As the impact level of the activity increases or the length of time increases the body switches from Aerobic Metabolism to Anaerobic Metabolism which is ATP production when oxygen is not available. This isn’t to say that your muscles have 0 oxygen when you are running but more that oxygen demand (moving the muscle) is much higher than oxygen supply (oxygen capacity of red blood cells). As such, the body utilizes Anaerobic Metabolism which produces ATP for energy but also Lactic Acid which causes that muscle pain after exercising.

• To make it simple, Aerobic Metabolism is used in low-impact activities while Anaerobic is used short bursts of high-impact (like a 2-min workout) OR prolonged high impact activity (like crossfit or HIIT exercises). Now that we understand that, we can see what kind of energy source is used in what kind of metabolism. As you can see, Fatty Acids are part of Aerobic Metabolism but only after about 1.5-2hrs of activity. What this means is that in order to burn fat you need to burn your Liver glucose stores (called Glycogen) first and then you can start burning fat. So the 20 minute treadmill run while great for raising your mood and improving blood vessel health may not touch the fat in your belly.
• This brings us to the other aspect of Nutrition—diet. Now this is where the lack of words to describe the science is cumbersome. Someone’s food intake, aka their diet, is different from dieting (cutting out certain foods) which is different from following a Diet (capital D), a more strict set of food guidelines. I don’t have the training to discuss what is a good Diet but I can talk about what are the necessary components of what makes up a good diet (lower case d). In general, it is all about ensuring you have the essential nutrients and reduce the intake of weight gaining foods. Essential nutrients like Vitamins, Minerals, Trace Elements, essential Amino Acids are required from our food in order to live and there are lots of sources online about which foods create balanced meals that fit your preferences. What is nonessential is carbohydrates, proteins, and fats (except omega-3 fatty acids). Yeah, kinda weird to think that the main components of our foods are nonessential but what that means is that we can change it up as needed to fit your current need.
  • Carbohydrates are a group of macromolecules that consist of carbon, hydrogen, and oxygen and are very energy rich. Carbs come in two flavors: nondigestible and digestible. Nondigestible carbs are the dietary fiber we need to ensure that our stools can form solidly and move along the intestines. There are lots of types of fibers but the one for weight specifically is Viscous Fiber which forms a gel in the intestines to reduce sugar and fat absorption. Unprocessed oats, flaxseeds, asparagus, beans, and Psyllium Husk are great sources of Viscous Fiber which help reduce the amount of fat and sugar we take in from our food. Digestible carbs on the other hand are the sugar we normally think, the sweet stuff like glucose, sucrose, fructose, and starches. All digestible carbs can result in weight gain but it all depends on the amount you eat. The essential of a diet is not what you eat but how much you eat; so yes you can have some cake one day but you should abstain for the next few days.
  • Unsurprisingly the fat we eat can be absorbed into the body and used to make fat that is stored. Animal products and processed foods are highest in fats that are likely to be stored while plant based fats and oils are less likely to be stored (more likely to be immediately used as energy).
  • Finally proteins which are not required for weight loss but are essential for muscle gain and the best way to promote further energy expenditure after exercise is to promote muscle synthesis. Essentially, when we exercise the muscle is damaged either by the flexing of the muscle or by the lactic acid produced and so needs to recover with protein in our diet. In order to use the protein the body needs to spend energy which can be done in the form of using more stored fat. Thus, eating protein while trying to lose weight can provide additional benefits.
  • So what does this all mean in terms of the exercise we were talking about before? Well remember that in order to burn fat someone needs to exercise about 1.5 hours to burn through stored glucose stores. Now this can be really cumbersome but the way around this is to starve the Liver of glucose to rebuild those glucose stores. By keeping a low-carb diet, your liver wouldn’t be able to use dietary glucose to rebuild the Glycogen stores and instead have to use more fat! As such, keeping the amount of glucose in your diet low aids in getting to the 1.5 hours sooner and can facilitate using fat as a main energy source when you are at rest.
• Now diet and exercise is all well and good but there is a big factor here that we have to consider: ability to diet and exercise. Yes physical ability is a major aspect but this is why this section is titled Undereducated—for individuals who are lower socioeconomic status (SES) they have a harder time achieving the necessary diet and exercise goals to find significant weight loss. Is this because they are uneducated? No, most Obese people of any SES know that eating better and exercising will make them lose weight, but performing those actions uses another major commodity: time. Unfortunately, those of lower SES face several challenges that make it extremely difficult to lose weight: often they are working lower wage jobs meaning that more time is spent working and less time available for exercise. Combine this with the higher cost of living, especially when caring for children, and lower SES correlates heavily with buying cheaper foods which are often not the most nutritious. If a parent has to feed 4 children with a few dollars, they will use sources of food that maximize the value of that dollar—this means processed foods filled with salt and fat to make them taste good. This is part of the benefit of food stamp programs which enable lower earning families to purchase more nutritious foods. But this is where the undereducated part comes in.
  • For many people they think that a weight loss meal is salad, and while its not wrong, its a lot of what is in the meal. Part of my work in college working in a food kitchen was helping families understand how to maximize the benefit of the canned or frozen vegetables and fruits they have access to rather than feeling that healthy food is only fresh produce. A person can accomplish the same nutritive goals on frozen or canned vegetables as they can on fresh or raw foods and often on a smaller budget. I highly encourage those who are on a limited budget to get in touch with their local food bank—often they can connect you with a dietician who can guide you through how to cook nutritious meals on a small budget and for a large family. Please know that diet and exercise is extremely possible even with added time constraints.

And a quick buck was made

• First up we have Orlistat, a medication that does not require a prescription in the United States to use. Orlistat is an inhibitor of stomach and pancreas Lipases, a type of enzyme responsible for breaking down dietary fats. This means that when someone takes Orlistat the fats they eat are unable to be broken down for absorption and instead stay in the stool for excretion. When used correctly, about ¼ to ⅓ of dietary fat isn’t absorbed and there is a sizeable reduction in LDL (bad cholesterol). While its nice its over the counter, Orlistat has some…major drawbacks. The biggest is it’s tolerability—because Orlistat prevent fat digestion, most of the fat stays in the intestines causing oily stools, urgent diarrhea, and smelly flatulence. In its official documentation the term “explosive diarrhea” is used. Now, to avoid these unfortunate side effects a person should meals that are high in fat (no more than 30% of their daily recommended fat amount). Now this begs the question: is Orlistat effective in losing weight because of how it works or because people avoid fat like its poison to prevent explosive diarrhea? Either way someone should expect to lose around 15 lbs at 6 months of regular use which is nothing to sneeze at.
  • Speaking of over the counter weight loss aids we should talk about a few. One of the biggest ingredients included in these supplements is Caffeine. Caffeine is thought to work by increasing someone’s metabolic rate or in other words to increase the amount of energy someone uses while at rest. Part of this is because the heart is working harder (Caffeine increases heart rate) but there is some more systemic effects that are not explained by simple increased fight or flight effects. I can’t find the source I heard this from, because I believe I learned it during a seminar, but somewhere near 65% of OTC weight loss supplements have some form of Caffeine in them. Caffeine can be listed by itself or be hidden in an herb like green tea, yerba mate, green coffee beans, kola, guarana, yaupon, and dozens more. I'm not anti-caffeine, I drink plenty of it everyday but these supplements often have people exceeding the safety limit of caffeine by combining these herbs together. Caffeine can worsen anxiety, put significant strain on the heart, and isn’t recommended for pregnant women. Just be careful!

• One supplement that used to be on the market in the US and is now banned is Ephedra. Ephedra is preparation of the chinese herb Ma Huang which contains the alkaloid Ephedrine and Pseudoephedrine. Both chemicals are part of the stimulant class of medications and when used in large enough doses will cause appetite suppression. Essentially these chemicals stimulate the fight or flight region of the nervous system which suppress the urge to eat. This is actually the reason why stimulants like Amphetamine (Adderall) and Methylphenidate (Ritalin) are used off-label to treat Binge Eating Disorder and help weight loss. Suppressing the urge to eat helps the person eat correct portion of food or prevent binge episodes thus reducing calorie intake. One OTC product that was extremely popular in the late 1990s and early 2000s was Hydroxycut which heavily marketed itself on TV and on the unregulated internet. In 2003 the Missouri Attorney General sued the company over their claims that Hydroxycut was “clinically proven” to burn fat but the case was settled out of court. Later in 2003 the NYT uncovered hidden documents that showed Hydroxycut knew its product didn’t work and have tampered with documents in another lawsuit in Oklahoma to show otherwise. Regardless, the usage of Hydroxycut wasn’t significantly hampered but due to its widespread use and unscrupulous advertising, the FDA banned Ephedra in 2004 after 155 deaths were attributed to the herb. It was the first time a supplement was banned in the US. Hydroxycut then switched to using Hydroxycitric Acid which required a lower dose than the Ephedra based formulations. The company failed to advertise the change in dosing and dozens of cases of serious liver failure resulting in liver transplant were reported and at least one death (19yo male). Hydroxycut is now mostly Caffeine.

• Similar to the stimulants is Bupropion which is combined with the opiate antagonist Naltrexone in the product Contrave. Bupropion is an antidepressant that causes a raise in Dopamine and Norepinephrine in the brain while Naltrexone works by preventing endorphins from binding to the opioid receptor in the brain. Together its thought that Contrave works in Hypothalamus to reduce pro-eating stimulation as well working in the Mesolimbic Dopamine Circuit to reduce the reward feedback someone feels when eating. In a sense, the drugs work by causing someone to be less hungry and then reduce the pleasurability of eating. Contrave can be incredibly useful in people who are mindless snackers (such as eating large quantities of food when not paying attention) or for binge eating disorder. The benefit of using this medication over the stimulants like Adderall or Ritalin because it helps treat the cause of the Obesity (overeating) rather than just preventing the symptom (weight gain). Generally people see around a 25lb weight loss around 6 months.
  • Similar to Contrave is another combination product: Phentermine and Topiramate in the branded product Qsymia. This combo pill utilizes the stimulant Phentermine which comes from the same class as Adderall and Methylphenidate to suppress appetite and Topiramate, originally an anti-epilepsy medication that is thought to suppress appetite, increase satiety, and reducing pleasure from eating. Qsymia produces similar results to Contrave.

• Okay, this brings us to a very controversial medication in the pharmacy world: GLP-1 agonists. If you remember from earlier I described how White Fat releases the appetite-suppressing hormone Leptin due to the stomach and intestine releasing GLP-1. GLP-1 is released when the GI tract detects carbohydrate or fat rich foods and their release triggers a cascade resulting in long term appetite suppression. LIkewise it is believed that the very common side effect of nausea and vomiting reduces the desire to eat. So in a lot of ways, they are working the same as the stimulants are—reducing appetite but not really touching the reason for overeating. GLP-1 agonists like Semaglutide (Wegovy) and Liraglutide (Saxenda) are used primarily for their influence on Insulin in Type 2 Diabetics to help lower blood sugar levels and reduce A1c, a marker of overall health in Diabetes. In diabetes, the clinical benefits of GLP-1s cannot be understated on the heart, kidney, liver and many other organs. In non-Diabetes weight loss? Well…don’t get me wrong they do work—people usually see a 15 lb loss at about 6 months but they miss the mark in the same way that the stimulants do. They prevent symptoms but don’t really help the underlying cause for why someone might be Obese.
  • The other aspect that I am always weary of is when drugs become “popular” in the media and especially with celebrities. Many celebrities and social media influencers are touting the benefits of GLP-1 agonists, i.e. the weight loss, but the consequence of this fad is that Diabetics who rely on this drug are unable to get it anymore. There is a massive shortage in GLP-1 agonists for people who could use another agent with similar efficacy but are using GLP-1s due to the social media presence. Likewise the weight loss isn’t sustained—at about 1 year the weight loss plateaus and after stopping only around 50% maintained the weight loss. Compare this to the other agents we’ve talked about who had a sustained weight loss around 80% and the choice is clear. Another aspect I have against these drugs for weight loss is the use of a side effect as a selling point—the rate of nausea is about 44% which means that someone is making themselves sick in order to lose weight. This is not a life I would put my patients on.