Dr. Jason Fung – ‘The Aetiology of Obesity’

Dr. Jason Fung – ‘The Aetiology of Obesity’

July 27, 2019 87 By William Morgan


so before I get started with with this talk I just want to say first of all this is thanks to Jeff and rod this has been really a terrific conference I’m not going to speak about type 2 diabetes and trust me it’s very hard for me not to talk about it because I deal with it quite a lot but I just wanted to say also same as Eric that we also do a clinic that is very much focused on type 2 diabetes as well as the treatment of obesity anybody you know is interested they’re also welcome to come see me and you know I’d be happy to have them sit in on my clinic as well so it’s important to kind of spread the knowledge I work things slightly differently than Eric but you know that the the bottom line is the same so we use lchf we also use internment fasting but today I’m going to talk more about obesity so type 2 diabetes is very closely related but there are intricacies about it that are you know not the same so what I really want to focus on on is the etiology of obesity and what etiology means is the underlying cause of obesity ok because this is really an important question ok and this is something that has always bothered me and really one of the important paradoxes that kind of started me on on thinking of that this is a very important paradox right why are there fat doctors right because we consider the doctors are experts in nutrition right we know that’s not true but we think that right you either have if you have both the knowledge and the ability how is it possible well there’s only two possibilities right you either don’t have the ability or you don’t have the knowledge and this is really the most important question in weight loss what is it that’s causing weight gain right what causes obesity what is the etiology of obesity right that is the question because if you get that question wrong everything you do after that is wrong everything all your treatments are wrong all your drugs are wrong the way you think about obesity is all wrong and I think that we have everything all wrong well it’s too many calories right that’s obvious we’ve been told that since we’re in grade 2 that it’s too many calories causes obesity right this is the whole idea calories in calories out of calories of calorie right the problem is I think that idea is completely and utterly incorrect so this leads to this sort of energy balance paradigm right which companies like Coca Cola they love this sort of energy balance paradigm this kind of scale of too much you know calories in or too few calories out you know and they all invoke this first law of thermodynamics right and if you’ve never heard it it’s that Oh calories can’t be created the total energy of a system is constant you can’t create it and you can’t destroy it therefore it’s either calories in or calories out now there’s really two major problems with this and one of them we’ll get into that but one of the real problems we know that this kind of paradigm actually doesn’t work at all ok and it’s not just me that’s saying if one studies show it that the failure rate of this sort of eat less move more is about 99 percent so you’re virtually guaranteed to fail right virtually if you look at books like the handbook of obesity and so josslyn’s diabetes mellitus which is one of the very authoritative textbooks of Medicine it says well reduction of caloric intake is the cornerstone of any therapy for obesity right reduce your calories right caloric reduction is the primary thing however they say none of these approaches has any proven merit right that is to say I’m telling you to reduce your calories but I know it doesn’t work ok well that’s not very good advice unfortunately it’s actually the advice everywhere right Department of Agriculture USDA handbook of obesity Jocelyn’s any textbook you read will say the same thing so there’s really two fundamental errors in this whole idea of calories in calories out the first one is that we’ve confused what the proximate cause and the ultimate causes and the second we touched a little bit upon yesterday but I’ll review it is that they consider calories to be a single compartment and obesity is really a two compartment problem that is there are different ways for your body to use that energy that you put in you can burn it or you can store it as fat right so there’s two different pathways and what’s important is which way you go not the total energy of the system but let’s talk first about proximate versus ultimate causes so what a proximate cause proximate means the most close to so if you’re worried about obesity the proximate cause of obesity of too many calories right that’s the thing that goes right before it but the thing that ultimately causes it is the ultimate cause okay so the thing is if you treat the proximate cause it’s kind of futile it doesn’t really work if you treat the ultimate cause because that’s what’s really underlying this disease that’s what is important so let me give you some examples right so alcoholism right you can say alcoholism is too much alcohol in or too little alcohol out right now that’s a fundamental law right it’s the first law of thermodynamics of alcohol right you cannot create or destroy alcohol so if you tell me that’s wrong then you’re seeing that the fundamental laws of nature don’t apply right well obviously that’s not true but that’s the same argument that people make for calories right that’s only the proximate cause right that’s not the ultimate cause and treatment is futile if you say that oh you’re an alcoholic I have advice for you drink less alcohol well you’d say well that’s pretty bad advice right so what’s the ultimate cause of alcoholism well it’s lots of different things addiction family stressors an addictive personality all of these things are the ultimate cause of alcoholism so if you think about that for a second now you can actually treat the disease because you know what the ultimate cause is right so the treatment is not telling somebody to drink less alcohol the treatment is support groups like Alcoholics Anonymous family helps Social Work friends church religion all of these things are crucially important and you’re not breaking this alcoholic first law of thermodynamics right because it’s ridiculous that’s only the proximate cause you can take the same thing as a plane crash right what causes a plane crash well the proximate cause is there’s too much gravity or too little lift right it’s a fundamental law of nature right so therefore the treatment is to have bigger wings or cut the weight of your plane right well that’s pretty ridiculous as well but again advice to get bigger wings is you don’t say wow you’re ridiculous because you’re you’re contradicting the fundamental law of gravity right that’s only the proximate cause that’s not what causes it that’s what immediately precedes the plane crash right the ultimate cause is things like human error weather or mechanical problems right so the government makes sure that people get adequate training they have maintenance and they have proper weather forecasting right and that makes sense because that’s the ultimate cause when you treat the ultimate cause it’s useful when you treat the proximate cause it’s useless so we can actually apply this pretty easily to obesity right so here’s the way we think about obesity too much calories causes obesity right that’s what everybody says but that’s really just the proximate cause if you treat that you’re going to say eat less or move more right but what’s the ultimate cause so this is the first law of thermodynamics but it’s also the unspoken accusation right and again one of these things that I think is one of the most unfair things about obesity is that what we say is that this is the proximate cause but the ultimate cause it’s your fault right that’s the unspoken accusation you let yourself go right it’s your fault you should have eaten that bagel right it’s all treatment is willpower that’s all you need right that’s what they say right but the model is incorrect right it’s only correct if this model is correct there’s another model of hormonal obesity which treats obesity as a hormonal problem right so again the proximate cause is still too many calories but what’s driving you to have too many calories well it’s insulin cortisol as well it’s hormones so in this case if you have a hormonal view of obesity then the treatment is not willpower right because all of a sudden as a nation you know were 50 years later we have no willpower in 50 years before we had lots of a part like that’s ridiculous right so the treatment then is to lower insulin right and then you have to understand then you can understand why it’s going to work so remember that in in this in this hormonal model you’re not breaking any laws of thermodynamics right you’re not saying that you’re creating energy out of nothing right and this is the one of the things that’s always leveled up these low-carb people it’s like well what you don’t believe in the law of thermodynamics no we’re not saying that at all you idiot it’s we’re saying that there’s a different cause it’s not willpower it’s insulin that’s what’s causing you to gain weight right so they never understand that but calling names is not the answer the other issue is that again they’ve fundamentally misunderstood the problem and obesity weight gain is a two compartment problem and what it means is that it’s not simply a matter of the energy in and the energy out right it’s not simply what goes in and what goes out because you can think of yourself I’m going to use a different analogy to so think of yourself as the manager of a coal-burning power plant right so every day you get 2,000 calories 2,000 tons of coal and you burn 2,000 tons of coal but that’s not the only place it can go you can also store some of it right in the storage shed right so there’s two compartments and what’s important is which way you go it’s not the total amount of energy because what happens if you decrease the energy in so instead of getting 2000 calories 2,000 tons of coal you’re only getting 1500 tons of coal right so we all assume that your stores go down well that’s only true only true if the amount you’re burning stays constant and that as we saw yesterday is simply not true okay that’s the only way it is true the other possibility is that as you reduce the amount of coal that’s coming in you reduce the amount of power you’re burning and you keep this stable again you’re not breaking any laws of thermodynamics it’s a problem with partitioning of energy right and this is the problem right so suppose you are in this situation where you get 1500 tons of coal right and then so for a while you take it out of your stores you burn 2,000 tons of coal you’re getting in 1500 so day after day you’re burning more than you take in well what’s going to happen well you’re going to run out of stores your your your body is going to totally shut down you can’t make any power and there’s blackouts everywhere right boss says get in here you idiot what are you doing that’s crazy right you’d never be so stupid as to do that right the logical thing is to simply make a little bit burn a little less energy right yeah there’s a few brownouts but there’s no blackouts there’s no looting right so that’s the thing you can do either but which one actually happens well the thing is that we’ve studied this for a hundred years and we know exactly what happened okay so this was back in 1917 they reduced the calories to like 1,400 to 2,100 so it doesn’t seem that low compared to modern standards but what they saw was this was a twelve young men and they reduced their calories about roughly thirty percent because they wanted to know what happened right and what happened was that their metabolism decreased about 30 percent well that’s pretty smart because if you don’t you’re going to run out of energy and then you’ll die its body it doesn’t want to die right and this was shown in Ancel Keys famous study right we all talked about Ancel keys for other reasons but he did this very famous study on these conscientious objectors right people who didn’t want to go to World War two he took them he reduced their calories by about 30 40 percent now he actually kept reducing them to keep making them lose weight and everybody always points this out as a reason why you shouldn’t fast but this was not fasting actually this was a calorie restricted diet so these people were eating about fifteen hundred and seventy calories a day so it’s not fasting it’s not starvation it’s a calorie reduced diet and what happened well what happened was that their metabolic rates decreased by about 40 percent pretty logical you’re taking in less energy you’re burning less energy right so you they measured all kinds of stuff is actually a terrific study hard volume shrank stroke volume shrank heart rate slowed the the one thing everybody noticed was the body temperatures dropped so they said it’s the middle of July and I’m putting on blankets right there’s also all kinds of neuropsychiatric things people obsessed about food and service some went crazy and that kind of thing right and it’s actually funny because these people were eating on average fifteen hundred and seventy calories a day which is not that far off of what most diets do but again the point is that when you reduce calories in calories out also reduces and we’ve shown this in more recent studies so this is dr. libels very famous study and what he did was he took patients with a stable weight and he put him into a metabolic lab right so he did two things one is that he actually force-fed them so that they gain ten percent of weight then he put him back to normal then he made them lose weight and he measured their metabolic rates all through so what did he find well if you force-feed these people and they gained ten percent of weight they increase their basal metabolic rate by closer to five hundred calories a day so the body not just gaining weight gaining weight gaining weight right so everybody says yeah you more calories you can gain weight well no your body is actually trying to burn it all off 500 calories a day right and what happens to those very same people as you bring them back to their initial weight well their basal metabolic rate goes back exactly the same and as they lose weight they start burning less energy so they decrease their metabolic rate by about 300 calories right so again it makes total sense if you’re again getting a lot of coal deliver to you right it just keeps shuttling it into the stores and eventually there’s no more place to store it so you stick it in your boss’s office right what is he gonna do he’s gonna fire you right is it why are you so stupid right again the body’s just not that stupid right it’s going to burn off all this energy because it doesn’t want it right and that’s exactly what happens so it’s a two compartment problem you have to see which way you’re going so this is our big hope right so you lose weight and then you hope well you know your meta metabolism is going to go down we know that’s going to happen but maybe if you maintain this weight for a long time your body kind of gets used to this new weight right that’s our big hope unfortunately it’s not really true so if you look at long-term studies so up to a year where they maintain the weight loss what you see is that the metabolic rate drops by about 400 calories a day right so it never got better right so it maintains itself indefinitely so it looks like this is what happens when you try to reduce calories and that’s why caloric reduction really doesn’t work right and we know why it we we know we already know that it doesn’t work right because we’ve all done it right but we know why it doesn’t work the other issue the other hormonal change that we get when you start to reduce calories is that you change your hormones your satiety hormones and your hunger hormones so again this was published in 2011 so about five years ago and this was a study where they took people and they made them lose weight and they maintained it over a long period of time and then they measured their hormones and said after one year let’s look what’s happening okay so again the hope is that as you get used to this new weight that your body will just kind of settle down and be normal at this weight but it doesn’t so ghrelin is the so-called hunger hormone it’s a hormone that makes you hungry so even one year after right at week 62 so a year after weight loss your Delon is much higher than it was before peptide YY is a satiety hormone makes you full so if it’s lower means you’re more hungry right and again even after a year your satiety hormone is lower than normal right so the bottom line is that you’re a lot hungrier right because you’ve lost the weight and you haven’t adjusted you all you’ve done is reduced calories you haven’t fixed the actual problem of insulin so you’re hungrier and again this always strikes me as one of the most unfair things in medicine because you’re hungrier like you’re eating more you want to eat more but it’s not because you’re some gluttonous slob right it’s because your hormones are making you hungry and you’re burning less energy so as you regain that weight everybody thinks oh you went off your diet because you have no willpower right and again one of the most unfair things in medicine because we know it’s all about your metabolism which went down and your hunger hormones which went up but it all stemmed from a complete misunderstanding of obesity so it’s not a lack of willpower right you’re not some button it’s no it’s your hormones that are making you hungry and you’re not some slob because you’re not exercising you’re like burning like 500 calories a day less not because you don’t want to because you’re not exercising it’s your hormones it’s your basal metabolism has gone down now we know this happens right so again if you look at this caloric reduction its primary model which we use all the time right too many calories it’s your personal choice it’s not actually true right it’s all due to these metabolic adaptations because of the reduced energy expenditure and the increased hunger and again this is the study I referenced yesterday we know this happens because this humongous trial of the Women’s Health Initiative which is 50,000 women so here they start off baseline 788 calories a day at follow-up seven years later it’s fourteen hundred and forty five you lost 361 calories every day day after day and they gave them more fruits and vegetables and fiber if you look at energy what they did of course was they they did about a 50% carbohydrate diet right so they went up from forty four point five to fifty two point seven and if you look at fat right fat went from thirty eight point eight to twenty nine point eight great terrific low calorie low fat diet right but what happened well it didn’t work right these people who should have get lost 36 pounds every single year didn’t even lose a single pound like in ten years almost right not a single pound they should have lost like you know 210 of fat and they laws nothing right nothing right it’s not even this is one one kilogram so you’re probably talking about like a quarter of a pound you know the weight of a good bow or something like that right yeah it doesn’t work so we’ve known it for so long and yet we keep telling people over and over and over reduce your calories reduce your calories exercise more we know it doesn’t work I could have told you that and this again is the cruel hoax right this is the cruel hoax because we put the blame on people when the blame should be on ourselves on the advice that we give which is so poor so you eat less calories you lose weight right your body senses that you lose weight so you decrease your metabolism and increase your hunger right then you regain that way but since you have a lot of willpower you double down right you’re going to eat even less calories right and we’ve all done this so you lose a bit more weight but the problem is your body adjust again it reduces its metabolism and increases your hunger and you start to regain the weight it keeps going on and on and on until you can’t take it anymore because you feel lousy and the weight still coming back that’s the cruel hoax right and then to top it off everybody thinks oh yeah that guy he couldn’t stick to his diet you know the most unfair like the most cruel thing we do to people and the ultimate proof is not in some kind of big study the ultimate proof is in all of us right I can show you all this but like honestly who hasn’t done these sort of diets right my guess is like 90% of the entire population of North America has been on some kind of diet like this at some point in their lives and it didn’t work right that’s just the truth right and this is the problem right the problem is that you need to know which way you’re going and the problem is insulin because that’s what tells the body which way to go right insulin tells the body to store fat what it’s normal job is right when you eat insulin goes up and you start to store fat right you’re not breaking any laws of thermodynamics so what we see is that if you look at it from a hormonal obesity point of view right if you’re trying to really understand the etiology of obesity what you see is that it’s still too many calories in the end right that’s the proximate cause that’s not the ultimate cause the ultimate causes the insulin and if that is the ultimate cause forget about this eat less move more that’s not going to be successful anymore than drink less alcohol is more successful the ultimate treatment is to lower insulin now that you understand now you can design rational treatments right so what’s the evidence that insulin actually makes you fat well there’s all kinds of Association studies but the problem with Association study is that they don’t tell you anything right but you need our causation studies and to do that you have to give people stuff like insulin so this is the DC CT trial right so this is type 1 diabetics and what they did is they had a group which had a lot of insulin and low blood sugars and another group which had not that much insulin and higher blood Sugar’s now the group that had type blood sugar controls did have less complications but that’s not my question right my question is does that insulin make you fat and it does so at the end of 10 years 9 years you can see that the people who got lots of insulin like almost 30% of them had major weight problems right so I’m not saying that they shouldn’t get it I’m just saying that here’s a actual causation study we gave the insulin they got fat you can look at the correlation between the total insulin dose and how much weight they gain and it turns out it’s actually pretty tight right as you give more and more insulin right this is more and more insulin you gain more and more weight and again as doctors this you already know because we’ve all prescribed insulin and we all know it causes weight gain right in type 2 diabetes you see exactly the same thing so this was the UKPDS so again another trial where they gave people lots of drugs to control the blood sugars and another drug another arm which didn’t get as much drug and had worse blood sugars again that’s not my question my question is does all this insulin make you fat and once again you see that it is so the intensively treated group if you’ve got a lot more insulin a lot more drugs that stimulate insulin gain more weight so again once again moving us out of the correlation side these are direct causal inferences right there’s a fascinating study done in 1993 where they took these type 2 diabetics and they started off with no insulin right and they said well what I’m going to do is I’m going to just amp up the insulin okay give them a lot of insulin the sugars are going to be beautiful right and what they did was that they went from 0 to at the beginning they’re not taking any insulin by six months they’re taking a hundred units a day right the sugars are really really well controlled but what happens their weight again you can see there’s a steady rise right 93 97 100 102 so we’re not talking again about correlations we gave insulin people gain weight and was actually interesting about this trial in particular was that they actually looked at how many calories they were eating and the number of calories that they ate was reduced by about 300 calories per day 250 300 so even as they lost even as they took less and less calories right they should have been losing weight according to the calorie theory they gained like 20 pounds so you’re eating less calories and gaining 20 pounds what’s happening while you’re giving insulin insulin is telling your body store fat store fat that’s its jaw right so what’s going to happen is your body’s going to ramp down your metabolism until you store that fat right because that’s what it’s job is so you see the same thing with metformin metformin is a very interesting drug because it doesn’t it blocks gluconeogenesis and doesn’t ray to the same extent and what you find with that drug is that you don’t get the same weight gain so you see the conventional so people who are just on diet control in the metformin group they don’t differ but the ones who get so far know your Riyaz so drugs that stimulate insulin make you gain weight so it’s not just injecting insulin it’s drugs that stimulate insulin do the same thing and again as doctors this is not a surprise all these drugs which are called sulfonylureas stimulate insulin so it’s not simply because you’re injecting it it’s exogenous it’s that when you when you stimulate your own pancreas to release it you gain weight and the thing is that the the other the flipside is that if insulin is what’s making you gain weight then if your insulin goes down you would predict that you would lose weight and that’s exactly what happens so this is a slight Eric show so as your instant goes down and down and down what happens you can’t gain weight right the classic description of type one diabetes there’s a melting down of flesh and limbs into urine right it’s a wonderful description but because you just lose everything no matter what you eat you can give them anything you can give them no matter what you give them to eat they have no insulin so they have no signal to store fat they lose all their body fat than they die and that’s unfortunately what happened that until insulin came along and there’s a disease called diable amia which is a eating disorder where type 1 diabetics will deliberately under dose their insulin right so they’d their Sugar’s go up and you know they could die of ketoacidosis there’s all kinds of problems right so why do people do it because they lose weight they know it we know it when you cut their insulin their weight goes down and recently there’s another drug which has done shown the same thing so these are the sglt2 so until recently there were no other drugs really to lower insulin but this drug which is a new drug that’s approved for type 2 diabetes actually shows that you can lower levels right you make you pee out the sugar and your insulin levels go down so these two groups the Doppler Group group are the two groups that have this drug and you can see that their insulin goes down right and what happens well their weight goes down right what’s fascinating to me so these are the three DAPA groups so all of them show weight loss what’s fascinating to me really when I look at something like this is that you can follow these people out longer to a year two years even four years now and that weight stays off right and this is fascinating because if you look at virtually every single diet study available people’s weight goes back up at around six months goes down we all know that’s right it goes back up it doesn’t why because you’ve lowered the insulin right so calorie reduction so some people say wow it’s because you’re peeing out sugar and diluting calories but calorie reduced diets don’t do the same thing but when you lower insulin which is the ultimate cause of obesity that weight goes down and stays down which never happens and that’s what’s really fascinating about it so you can look at a list of medications for type two diabetes so there are certain ones that increase the the effect of insulin or insulin itself right insolence of faunal ureas tizi deeds which are another class of drugs they don’t raise insulin but they raise the insulin fact there are drugs that don’t really affect insulin levels metformin these dpp-4 and there are drugs that decrease insulin so akribos to a small degree and these new sglt2 inhibitors and you can look at the weight effect as well and it’s identical right stuff that raise insulin makes you gain weight stuff that lowers insulin makes you lose weight so again this is strong evidence that the hormonal view of obesity is much more correct because it’s the obesity it’s the insulin which leads to the obesity which leads to the compensations that we see right these are hormonal effects you’re hungry as your body is increasing the gallon you’re decreasing your metabolism you’re not burning it off right and this is the whole thing that sets you up you don’t get fat because you’re overeating you’re overeating because you’re getting fat right which sets you up for the proper question what’s making you get fat what’s the ultimate cause of obesity and again it’s insulin now cortisol does play a role but that’s for another time and what’s interesting really is that that doesn’t you know we think that we’re really smart right in 2016 but if you go back to William Banting he understood that refined carbohydrates led to obesity right so refined him now in 2016 after this kind of 50 year hiatus where we’re talking about calories now we realize that refined carbohydrates increase your insulin which leads to the obesity and this guy dancing was in the 1850s right like a hundred and fifty goddamn years ago they knew this right it’s like oh my god we’re not that smart so this is the whole problem right if you try to treat it as a caloric deficiency and you say that it’s a personal choice you’re going to fail right if you understand that this is the disease which is related to insulin then you understand why you treat it the way we do so what raises insulin the most from a dietary standpoint refined carbohydrates right the sugars the refined grains what raises at the least natural fats right olive oil avocado butter so Marty ken Dell who’ve done some pretty amazing work actually mapped this out so he’s kind of looked at any research done on the food insulin index and what he found was that you can actually predict what the effect of insulin is based on the net carbs plus half of protein right but that still only explains about 54% of the variance but that’s as good as it gets now so again the carnet carbs ray which is carbohydrates – fiber and half of the protein which again explains why we give the advice that we do low carbohydrate moderate protein and high and natural fats right and what what’s amazing about you know conferences like this is that this really gives us a new hope because as long as we misunderstood the cause of obesity we were doomed right we couldn’t succeed there was no possible way you could succeed in treating obesity then you get type-2 diabetes then you go blind and you go on dialysis and all these problems right but what this new understanding is it gives us a new hope because now we can say wow I know what’s happening here it’s your insulin so let me say what can I do to lower your insulin right we can do this we can do that there are low carb diets there’s fiber for example there’s a vinegar there’s you know intermittent fasting there’s all these different strategies that you can now use which will be successful and that is the most important thing is that you know this is not you know a condemnation of what we’ve done right this is to tell you that this is a new dawn as long as you understand what causes obesity we can treat it we just need to get the message out there we need to get people on our side and do it thank you very much