Dr. Lucy Burns – ‘The Hormonal Approach To Treating Obesity’

Dr. Lucy Burns – ‘The Hormonal Approach To Treating Obesity’

October 2, 2019 0 By William Morgan


Good morning everybody.
My name is Dr. Lucy Burns and I’m talking today
on the hormonal approach to treating obesity.
I’d like to thank Rod Taylor from Low Carb Down Under
for inviting me to present to what I hope will be
the first of many low carb presentations for doctors.
So, my credentials: I’m a medical doctor,
graduated from Monash University last millennium
did my RACGP, and have recently completed
my Lifestyle Medicine Physician training
and a Certificate in Medical Hypnosis,
and I run a weight loss clinic called Epiphany Medical Weight Loss.
So I thought I’d talk today about obesity.
We often hear about the term, the Battle of Obesity,
how are we going to tackle obesity?
I think it is well known that GPs are at the forefront
and in a great position to tackle the big issues.
Some of the problems I guess that we are incurring
is the sheer number of people who are obese,
and that the term, obesity,
is quite a stigmatized term these days.
It’s no longer just a medical term
indicating that your BMI is over 30.
It’s used with a lot of stigma attached
and so that, in itself, can be a problem
bringing up weight issues with patients.
The other things that we are dealing with
is marketing giants who well know
people’s propensity for sugary, salty, fatty foods
and marketing exactly to that sweet point.
And that these particular foods are extremely addictive
and in fact, food scientists are employed by these companies
to make sure their products are addictive.
To counter that, we’re battling
poor nutritional science in the past.
Many studies that are cited have flaws
and those have been well exposed by people recently.
And then, as doctors, our main issue is Medicare.
We are rewarded, as GPs, for high throughput, six-minute medicine,
and that those longer, perhaps more difficult conversations
don’t receive the same financial recompense.
And of course, really, it’s actually all simple.
It’s just diet and exercise, and that’s really all there is to it, right?
Well, no, that’s not all there is to it,
and in fact, we’ve known that for a long time.
So, the old adage of “Energy in, energy out”
is fine if you’re a chemical lab.
But humans aren’t chemical labs.
We have no calorie receptors in our body;
we have hormonal receptors.
So it’s time that we actually addressed
the issue that these are hormonal problems,
not calorie problems.
And we’ve known about that since about 1950
with the, Minnesota Semi-starvation Study
that was done after the Second World War,
where a group of men were all studied over a 12-month period.
They were fed a 3,000 calorie diet
for the first three months
and then their diet was restricted
over the next six months,
starting from 3,000 calories down to 1,500,
and then gradually reduced
in order to maintain
a 1 kilo a week weight loss.
Some of those men got to be eating
only 500 calories a day,
and interestingly, their behaviors changed
and their body changed.
So they became cold in the middle of summer,
they became sluggish, they became depressed,
and they became obsessed with food.
That sounds quite familiar to many people
who have done long term dieting,
that you become obsessed with food.
Interestingly, these men started hoarding things
like cookbooks and cooking implements.
That was that although could think about.
They then fed them, after the six months,
back to their 3,000 calories a day
and lo and behold, they put on
all their weight plus more,
and hence, the birth of yo-yo dieting.
And yet we still recommend that to people.
We still recommend long-term very low calorie diets
or long-term diet-and-exercise, all one word.
I was going to put a picture of a dead horse up
but it seemed a bit mean.
So, we are still flogging a dead horse.
Many patients still go to their doctor
who’d just say, “Lose weight, diet and exercise.”
That’s the only tool that they can give them.
And frankly, it’s not good enough.
Our metabolic processes are very complicated
as demonstrated by this slide.
It’s not an easy calories in calories out.
There’s this whole plethora of machinery that goes on.
Our bodies are a very well-oiled machine and they work beautifully.
There’s input mechanisms and output mechanisms, feedback loops,
all designed to keep us at our optimal weight.
Unfortunately, they no longer work
once we end up with excessive weight.
So, the hormones that are managing our body weight,
our body mass and our appetite,
we start with the insulin.
Insulin’s job is to maintain our glucose at a steady state
and it does this by pushing glucose
into muscles, into liver.
Glucagon’s job is to keep our glucose at a steady state,
so when we don’t have the input coming in
we still have a lovely blood sugar between 4 and 6.
There’s other hormones, incretins,
which are secreted within our gut
and respond to our food, and also act on insulin.
We have leptin; it’s our satiety hormone.
It’s onr one that tells our brain we’re full.
Ghrelin is our hunger hormone.
Peptide YY, other hormones and adiponectin.
And again, these hormones
have only been discovered, really,
in the last 30 years or so.
So, I guess at the original 1950 study,
we didn’t understand the whole hormonal method
of weight management and metabolic processes
so it seemed obvious.
It just is no longer good enough
when we do know that there is
all these hormones at play.
We have side players, cortisol in particular,
very underrated as a cause of maintaining weight,
and we see it a lot, people that eat the same food,
and then there’s a stressful situation in their life
and they either stop losing weight
or they put weight on and they don’t understand.
And again, it’s because it’s not about what you put in.
Estrogen and progesterone, and again, we see this in pregnancy.
Women, clearly, huge hormonal upheaval during pregnancy
and then they’re more prone to weight gain.
They’re not eating, like you don’t eat
bucket loads more when you’re pregnant,
but yet you can put on 20 or 30 kilos
in such a short time.
We see it in thyroid hormone.
People who have an overactive thyroid
will often lose weight;
under active thyroid will often put weight on.
There’s a lot of work coming up on the gut microbiome
and its various impacts on weight and fat metabolism.
Nutritional deficiencies will also drive obesity
and then of course, we have drugs.
Doctors are often good at prescribing medications,
sometimes neglecting to tell the patient
that this will put on weight.
We see it specifically with insulin, Prednisolone.
So that’s your insulin and your cortisone,
and we see it with many of our psychiatric drugs, in particular.
So, just to go through insulin again; we’ve talked about it.
Now again, I went to medical school in 1990,
give or take a few years,
and during that time, I learned a lot about insulin’s job,
to help glucose into the muscles and into the liver.
I don’t know whether I was asleep, but I certainly forgot
or it just sort of fell out of my brain,
that insulin is a fat-storing hormone.
So insulin’s job, after it’s done the muscles,
after it’s done the liver, it helps the glucose store into fat.
It prevents the breakdown of fat.
So if you have high insulin,
you can’t break down your fat.
So I’ll just say that again.
High insulin means you cannot break down your fat.
What we need to do is work out, as doctors,
how much do we want to engage in this battle of obesity,
or how much do we want to help our people?
And I can tell you, not everybody is interested
in obesity medicine, and that’s fine.
Not everyone’s interested in sports medicine.
You don’t have to be interested in everything,
but do you have to engage with your patients
and you have to have a plan.
That plan can be a brief intervention.
It can be, but what it has to be is something helpful,
not something like, “You need to lose weight.”
It has to be, “Here is a tool that will help you.”
You can decide that you want to refer the patient
and again, know who you’re referring your people to.
If you’re referring them to a dietician
and they have insulin issues,
that dietician needs to understand that.
You may decide that you want to become
a leader in the industry
and go the whole hog and really help,
actually be at the forefront
of this problem of battling obesity.
Many of you have seen this;
this is Peter Brukner’s very informative
dietary way of eating.
That can be your simple brief intervention.
Just have that on your table, hand it to the patient.
If the patients are engaged, they will go away,
they will do that, and they will lose 20 kilos.
I have a different plan.
The way I do it is,
we have quite an intense intervention plan
and I will see the patient at least on eight occasions
and that’s because obesity is a big complicated problem.
It needs a big, perhaps not complicated solution,
but it needs an intense solution.
So I look at the physiological causes of obesity
and that’s what we’ve talked about with the high insulin.
And then there’s the psychological issues
that go with people
that have been perhaps heavy for a long time,
and their sense of self, it’s really fractured and very fragile.
So the key, as I’ve mentioned, is to diagnose the problem.
As doctors, we often wait until the blood glucose is high,
and then we say to the person,
“Oh, you’ve got Type 2 diabetes.
“Diet-and-exercise, all one word, see you later.”
What we need to do is be able to get to these people earlier
and say, “Listen, this is the path that you’re heading on.
“You can do something about it now, if you want to,
“before the damage has occurred.”
But doctors don’t check insulin.
So, if you don’t check insulin,
how do you know what your patient’s insulin levels are?
You don’t, so the key is we need to check it.
So, how can we check it?
Well, you can order a fasting blood insulin.
It’s simple.
I mean, we do fasting blood glucoses all the time.
A fasting blood insulin, that may give you some idea.
It will still miss a lot of people, unfortunately,
because what we need to know
is what is their response to carbohydrate?
This is the Kraft Test.
So the Kraft test, basically, it’s a glucose tolerance test
with corresponding insulin levels.
Now, Joseph Kraft did 14,000 of these tests
in the ’70s and ’80s
and has documented heaps of results,
and come up with these five or four curves.
There is a fifth one, but it’s not on this slide.
So he’s documented what a normal insulin curve looks like
and there is actually a normal insulin curve.
Then he’s documented three abnormal curves
and those three abnormal curves
are basically diabetes waiting to happen
So let’s get in early and check, and say to the people,
“You have an option here.
“You don’t have to go down your diabetic pathway.”
Kraft also demonstrated that insulin itself
is actually part of the problem,
and he was able to demonstrate
that high circulating insulin
is toxic to vasculature,
so particularly our small vessel disease,
which is why often, by the time people get to us,
they say that they’ve already got eye disease
or they’ve already got kidney disease.
So again, let’s get it early.
We can do this and help these people.
I’ve just put a couple of references there
for anyone who wanted to look up.
There’s a great summary on that website
at the bottom of the slide.
But this slide here I like.
Look, it’s a very simplistic slide
and I realize that there’s probably more at play here,
but to understand that if somebody has high insulin
and they have a new diagnosis,
then you give them the opportunity
to avoid all of these chronic diseases.
Why wait until a chronic disease presents to you
when we can treat them early?
Now I’ve got a few examples of Kraft
or modified Kraft tests.
They’re basically glucose tolerance tests with insulin results.
So this is a 45 year old woman
and that’s her glucose tolerance test.
Most people would look at that,
doctors would be very happy with that.
Normal glucose tolerance.
Even her hemoglobin A1c is good.
So that means her body is very good
at keeping her blood glucose under control
and has been for the last three months.
But when we look at her insulin,
we see even her fasting insulin is good,
but when she has carbohydrate,
that insulin spikes up high, and it stays high
for a couple of hours after having it.
So that’s telling me that she, during that time,
has high insulin, cannot break down any fat for fuel.
She is likely to get hungry
at about the two or three hour mark and eat again.
The cycle will continue.
This one here, this is a 55 year old woman.
She’s a little overweight.
Well, she’s 100 kilo, so she’s significantly overweight.
But look at that perfect glucose tolerance test.
Everyone would be happy with that.
Then we see her hemoglobin A1c, 5.5.
Again, most doctors extremely happy with that, perfect.
Look at you, lady, go!
Then we see her insulin.
So her fasting insulin is 22
It’s twice what what it should be
and when she eats carbohydrate,
it rockets up and it stays up,
and in fact, at the two-hour mark,
it is continuing to climb.
So we don’t have three and four-hour tests
like Joseph Kraft originally did.
We haven’t got the resources for that.
but we can tell you that this woman
is in fat-storage mode
and her vital organs are at risk of issues with insulin.
And then our final patient.
Again, this man is very overweight.
He is morbidly obese.
His glucose tolerance test
is still considered normal
and a lot of labs no longer do the one-hour mark,
which is where we might actually look at that result
and think “Well, 10.2 is a little high.”
His hemoglobin A1c is 5.9,
and again, a lot of people would be very happy
with that as a result.
And this is his insulin.
This man’s pancreas is going like the clappers.
He is at high risk of actually just burning out
and one day, him not having any insulin left,
or any beta cells left,
and just becoming an insulin-requiring diabetic
within weeks.
So this man, I mean…
What a great pancreas, really.
But it is saving him, but at the end of the day,
when you’ve got circulating insulin of over 500
it’s no wonder this man is storing fat
and he cannot lose it.
So to make to make it clearer,
and a tool that I use to explain to patients
and probably to myself at times,
because, every now and then,
I get confused over all the big words,
but our body is like a fireplace, it needs fuel.
There are two sorts of fuel,
we have kindling and we have logs.
So kindling is like the carbohydrate,
you put it in and it burns up and it’s hot and warm
and then it dies down quickly.
So you put some more on
and that’s pretty much
like glucose or carbohydrate.
You put them, you have something to eat,
get lots of energy,
as it dies down you get a bit tired
and a bit hungry,
so you eat some more.
What we really need to do is go out to our shed
and get a log, a fat log.
Now our shed, for a lot of us, is around our abdomens.
When you go out to your shed, if you’re insulin resistant,
or if you have high circulating insulin,
your shed is going to be locked.
It’s going to be locked with a padlock,
and depending on how insulin resistant you are
like my guy before with his insulin of 500,
He’s going to have a lot of locks
So he cannot access his fat stores.
He has a huge amount that he’s lugging around
but he can’t get them,
so he is always tired and always hungry,
and we blame him.
And so “You just need to eat less and move more.”
Has anyone ever done that
when they’re starving?
It’s really hard!
So here has no option
but to ingest more carbohydrate
to fuel his body.
Now we know that macronutrients,
so the macronutrients are carbohydrate, protein, and fat,
elicit different hormonal responses in our body,
’cause remember, obesity is a hormonal condition.
Carbohydrate moves our insulin the most, we know that.
Protein moves it a little bit, and fat, hardly at all.
A tiny bit, but hardly at all.
So we’re going, “Right, well, if this guy
“or all of these patients have high insulin,
“then we need to reduce their insulin.”
So we can only do that by reducing their carbohydrate.
So the key to insulin resistance, or Hyperinsulinemia,
is to go onto a low carbohydrate diet.
That way the pancreas has a little rest,
doesn’t need to be producing such enormous amounts.
It has a breather and it can regenerate.
So a low carbohydrate diet
What does it look like?
A lot of people think it looks a lot like this,
processed meat and cheese and eggs.
And look, that can be part of it,
but what we offer these people is a hook.
So the hook is the bacon and eggs
and the reason we do that
is that carbohydrates are highly addictive
and people are very resistant to giving them up.
They don’t want to give up
their bread, chocolate, pasta, even rice.
It’s nurturing, it’s filling.
So we have to offer them to something else,
and the thing about the low carb diet
is it offers you bacon and eggs.
In reality, a whole food low-carb diet
looks more like this,
so yes, there’s some bacon and eggs maybe
but there’s also beef, chicken, salmon,
fish, some green leafy vegetables,
small amounts of fruit,
avocado, and dairy.
The thing that happens,
once you address the insulin issue,
once somebody is no longer being fueled
purely by carbohydrates,
that means they’re no longer as hungry.
So that gives us the opportunity then
to work on any psychological issues that they may have,
any things that, learned habits of comfort eating,
or, sugar addiction is a term
that’s used a lot
and is certainly prevalent
amongst people with obesity.
So we can get…
Putting in some of those tools,
it’s very hard to put in psychological strategies
when a person is physiologically hungry
and they can’t tell the difference.
So if we reduce the physiological hunger
with a low-carb approach,
we can then manage the psychological hunger.
I look at words that we use
that are very empowering for people,
because a lot of people
who have dieted for a long time
understand that a diet is restrictive
and they feel that they’re punitive
and that they’re going to be hungry.
The amazing thing is,
on a low-carb diet, you’re not hungry.
You get to eat lovely, nourishing, satisfying food.
And then the words that you can use
are things like “can’t” versus “don’t”.
Which is where I will now say to somebody,
“Oh, I don’t eat bread,” not “I can’t eat bread.”
I could eat it if I wanted to but I don’t.
I don’t eat bread and I don’t eat cakes.
And if people say, “Why not?”
I’ll just say, “Oh, it doesn’t agree with me.”
Just because, basically, it shoots up my insulin.
So we get the opportunity, therefore,
to address those long-standing patterns.
The other thing that people often neglect is sleep.
Sleep is another hormonal process.
Again, people think you just shut your eyes
and you go to sleep.
There’s a whole pile of hormones involved,
and we know that those hormones are Intricately linked
to that ginormous slide that I put up before
of your other hormones.
We know that if you are sleep-restricted,
it changes your leptin; it increases your ghrelin
so ghrelin, being that hunger hormone.
So if you’re chronically sleep-deprived,
you’re chronically hungry.
I kind of think, “How great!
“You can just go to sleep and lose weight, perfect.”
And then in amongst all of this,
there’s a whole pile of research coming out on gut health
and it’s very exciting.
It’s hard to wade through the wheat and the chaff,
to use a high carb term,
but there’s a lot of promising effects coming out there.
And then finally, intermittent fasting.
Again, another beautiful way to lower your insulin.
Once your shed’s open,
if your woodshed is open,
you can just get your own fat logs easily.
Intermittent fasting is a beautiful way
to be able to access those.
However, my word of warning would be
that you can’t do intermittent fasting
until your shed is open.
It’s too hard, you get too tired.
You run out of fuel and it’s a very negative, punitive approach.
Whereas, when your shed’s open,
it’s actually very easy and comes simply.
I think for long-term sustainable change,
for long-term management of obesity,
we need a long-term approach.
Certainly, the low carbohydrate diet is absolutely essential
and then followed up with psychological support,
whether that’s groups, whether it’s a caring doctor
whether it’s family and friends, Facebook groups,
but it needs to be ongoing support.
So, I guess the key points I would like to
leave you all with today
is that the vast majority of people who are obese
have insulin resistance or Hyperinsulinemia.
We need to diagnose that, as doctors,
and we need to document it.
We need to explain it to the people
so that they realize why they’re always hungry
and that obesity is a disease which is result of
and a cause of hormonal derangement.
So it’s a hormonal disease and we need to treat it as such.
Obesity is also a chronic inflammatory process.
It is infinitely treatable.
It needs a bit of work.
It would be lovely if Medicare restructured
and perhaps financially rewarded GPs
who are prepared to put in the hard yards
to tackle this problem,
but I don’t think that’s happening anytime soon.
It does require a dietary and lifestyle approach
but it is possible.
Thank you very much.
(delegates clapping)