Is Obesity a Willpower Problem? The Biology of Weight, Diets, and GLP-1s

23:49Dr. Austin Baraki:But to the point of, you know, a lot of our endocrinology is, and our hormone signaling systems are oriented around homeostasis. That's kind of explains what we're observing here of somebody, you know, losing weight and then the body responding in a way to kind of tilt the balance of these hormones in the direction of arexogenic hormones and away from anorexogenic hormones to promote food seeking behavior, calorie intake, weight regain to restore that kind of perception of homeostasis from a physiologic standpoint. Yeah. Yeah.

24:20Dr. Jordan Feigenbaum:So when people are saying, look, it's actually not about calories. It's all about hormones. I can like make a charitable argument that in many ways that that is true, but I don't think they're talking about these hormones. And we should also say these hormones don't change predictably in everyone. Maybe I should better phrase that they don't change the same way in everybody. So maybe predictable. Yes. If you lose weight, we generally think that these hunger promoting appetite promoting hormones will go up and these satiating feelings of fullness hormones will go down. But to the level they change can can vary massively between individuals.

24:56And so two sort of distinct phenotypes emerge,

25:01Dr. Jordan Feigenbaum:obesity sensitive and obesity resistant. And so the people that are obesity sensitive generally would have a larger response here when, when trying to lose weight, their appetite promoting hormones will go up more than somebody who's obesity resistant. Who's like, look, I'm going to do whatever is in my power to not gain weight. And that's not a conscious choice. That's a biological thing that's happening underneath. And if you track that down to like, well, why does that happen? It's like, well, it's genetics. And so then like, dang it, we're back to the genetics thing again, or we had hormones.

25:31Dr. Jordan Feigenbaum:But anyway, so you can make a charitable case for both of those sort of arguments. But the problem is they're reductionist to say it's all about genetics is reductionist to say it's all about hormones is reductionist. It's complex to say the least. Now that's the hunger side turned up. That's only half the story here. The other half is on the burning side, how many calories you burn or use, expend, otherwise just existing. And that tends to drop too. Now, Austin, we say something like resting metabolic rate. What do we actually mean when we say that?

26:01Dr. Austin Baraki:If you were purely at rest, just lying in bed, not doing anything, as you often describe, the amount of energy that is needed to, quote unquote, keep the lights on in your body to operate your vital organs, to keep blood flowing, things like that. So just the number of the amount of energy that is required to maintain your physiology and your homeostasis purely at rest just to stay alive. This amount of energy does tend to decrease in the context of weight loss, and it is not exactly in alignment or what we might predict just purely based on the amount of change in body size alone or the amount of weight loss alone.

26:37Dr. Austin Baraki:And that's kind of spawned this whole conversation around the idea of quote-unquote metabolic adaptation that's been, you know, I feel like a perpetual topic in this space for many years now. Yeah, yeah, exactly.

26:50Dr. Jordan Feigenbaum:And so, you know, people will say things like, look, if you cut calories and lose weight, your metabolic rate is going to go down. It's like, well, your metabolic rate, which is the amount of energy you use per unit mass, right, per kilo of tissue, that doesn't really change, but you have less mass. So, you know, if you lost weight by definition. So yeah, your total daily energy expenditure is likely to decrease. Now, when that changes disproportionately to how much weight you've lost, that is metabolic adaptation. And so at that point, yes, the actual metabolic rate has maybe gone down. And if it happens to a large enough effect, that is you're effectively resisting further weight loss via that mechanism.

27:31Dr. Jordan Feigenbaum:So yes, you tend to see, particularly in folks who have this maybe obesity sensitive sort of phenotype, that their metabolic rate and their total daily energy expenditure will go down more than is predicted. Because again, their body's fighting against that weight loss harder than somebody who's obesity resistant. And those folks, when you try to overfeed them, for example, they do just the opposite. They're like, well, I'm going to ramp everything up because I don't want this smoke or these calories don't want that smoke. And I'm going to push back. um the best modern sort of look at this uh comes from the biggest loser competition and so we talked about danny cahill in the opener uh but him and the rest of his competitors were actually followed by for six years by a team at the nih after the 30-week competition their resting metabolism had fallen by about 600 calories a day six years later when much of the weight had come back, it was still running lower, about 700 calories a day under the prediction.

28:32Dr. Jordan Feigenbaum:So it persisted. It was a transient. When you stack these two things together, if you lose weight, your body raises the sort of hunger hormones, decreases the satiety hormones. And then on top of that, you're burning less calories because of this metabolic adaptation. You can see the problem here clearly. Maintaining weight loss is very, very challenging for many folks. And if that's and you lose weight and you watch it come back while everybody, maybe also including you as chalking it up to weak willpower, we'd like to push back against that and reframe it as this. Look, the appetite going up and the calorie burn going down, that's biology.

29:09Dr. Jordan Feigenbaum:It's not necessarily you choosing to feel hungrier than normal or consciously influencing your own metabolism. When I see these things on social media, you got to know about your metabolism. It's like, does knowledge of the Krebs cycle really inform your choices here? I think this is the most common experience when it comes to weight loss for many folks, particularly in the modern era. So, so Austin, imagine this, you got a patient that comes in, they're 40, it's a 44 year old female with a BMI of 34. She's lost 40 pounds twice in her life. She's regained all of it twice. She convinced she's convinced she just lacks discipline.

29:43Dr. Jordan Feigenbaum:And her last doctor agreed and said, look, you just got to eat less and move more. What do you actually say about why the weight came back? Do you actually go into any sort of explanation there? Does that help frame your discussion at all?

29:53Dr. Austin Baraki:Yeah, this often comes up in the course of the conversation because, yeah, I know this person. I know many of many of these these patients for sure. And so I first just try to characterize what did it feel like to them to go through that journey? What was it like? What did they perceive to be the biggest challenge for them? And a lot of times it's multifactorial. A lot of times it's I was OK when I was perfect about tracking every morsel of energy that went into my mouth and able to rigidly stick to this exercise program nonstop every day. And it felt to me like the moment I didn't do either of those things that it all went off the rails.

30:31Dr. Austin Baraki:That was a very common sentiment that is expressed. It's like unless I was perfect, it felt like the weight came kind of like rushing, rushing back. And whether or not that is physiologically what happened, that is what the experience feels like. And I think that that is an illustration of the power of the underlying biology in fighting back against your best conscious efforts. And to be honest, you know, we are kind of fighting at a disadvantage against our own biology in these in these ways. Right. It would be great if we were in full conscious control of all of our biology when we wanted to be.

31:06Dr. Austin Baraki:I think it would drive us crazy if we had to be if we had to consciously decide to make sure our heart kept beating. But, you know, if we had maximum control over all of these things, it would be it would be great. At the same time, because we don't have that degree of control, think about the paragons of body composition, fitness, leanness, and competitive bodybuilding. Why are so many of them using GLP-1 agonists like Retta? If it was the case that they're just superior beings with moral fortitude and ability to exert such perfect control, they wouldn't be using these things. But they're just like, yeah, it makes dieting way easier.

31:40Dr. Austin Baraki:And it's like, yes, because these tools mitigate, it puts you back in the advantaged position over that underlying biology. It ties your that that biology is like hands behind its back so that it cannot fight back quite as effectively. And that's usually the way that I frame this conversation with folks is, yes, when we are able to successfully lose weight, that is a remarkable achievement. But the underlying biology, the body kind of wants to fight back. It's almost like we analogize it oftentimes to a coiled spring that the further you pull it taut, the more aggressively it's going to want to snap back unless we have some additional help with something like one of these one of these tools that can kind of put us back in the driver's seat and give us a little bit more of an advantage over that biology.

32:24Yeah.

32:25Dr. Jordan Feigenbaum:Yeah. I, you know, bodybuilders are also, are always, you know, are, are often anyway, held up with these sort of counterfactuals. You're like, look, you're saying that people can't lose weight or it's difficult for them to lose weight because genetics, the environment or whatever. Well, look at all these bodybuilders. And I'm like, yeah, let's look at it. Generally speaking, most people who engage in competitive bodybuilding did not start out as individuals with obesity. And further, when they diet down, prep for, and ultimately compete, the weight changes are all short term. Really, they are.

32:54Dr. Jordan Feigenbaum:Whether it's a six month prep period, you get down to stage weight, what happens directly after that? Well, they gain weight, comes back, and they kind of go back to where they were before. It's exactly as predicted. And so we're not saying again, that you can't lose weight in the short term, certainly more than one out of 10 people when they do a diet, even with well supported, lots of resources available, a lot of coaching for lifestyle stuff. Yeah, more than one out of 10 people are going to lose clinically significant weight loss. Whether they maintain that for one year, two years, more years, well, that is the question.

33:27Dr. Jordan Feigenbaum:And that's really what we're getting at at a population level. We're not saying everybody needs to go on a 16 week prep, you know, to get ready to get on stage. But yeah, let's look at bodybuilders. The best people arguably in the world for getting lean have challenges maintaining that leanness. And, you know, again, not because they're bad people, just because one, the leanness that they're trying to achieve and maintain is below that lower guardrail. That's the thing. One of the two biology is undefeated. Yes, exactly. It's undefeated. So the body defending this range is half of the story. Now, the other half, and we're going to talk about this after the break, is that you're probably not choosing nearly as much as you think you are.

34:03Dr. Jordan Feigenbaum:And that's where the tripling number finally gets explained. All right, we're back here on the Barbell Medicine Podcast. We're going to talk about the idea that you're choosing most of the foods that you put in your body, not only what you're eating, right, but how much you're eating. This is the part that answers the number that we opened with, that obesity tripled because the thing making the decisions or heavily influencing the decisions, the environment, changed like a rug being pulled out from underneath us. So most of what you eat, you don't actually decide from a conscious standpoint. We kind of envision the sort of control panel and a person just flipping switches, making calls all day, but most of the time we're actually running on autopilot, on habit and whatever is in the room or in the environment around us.

34:49Dr. Jordan Feigenbaum:This isn't actually a hot take. This is not like a barbell medicine. We just created this.

34:53Dr. Austin Baraki:The model goes back to a 2008 paper called eating as an automatic behavior.

34:58Dr. Jordan Feigenbaum:And they suggest that intake is mostly triggered by the environment. It's not deliberated upon, which is why nutrition lectures and the sort of try harder mantra keep losing, you know, this battle to sort of change how people are eating. One of the best studies on this, it's almost comical to me. If you serve someone more food and they eat more, they don't notice that they actually ate more. This comes out of Barbara Roll's lab, and they've been doing this for over 20 years. In one study, they served the same people a plate of macaroni and cheese on different days, quietly changing only the size of the serving.

35:34Dr. Jordan Feigenbaum:If you increase the portion size, the intake went up by about 30 % over about 150 calories. And afterward, people rated themselves just as full as the smaller portion. In a restaurant version, an entree made of a 50 % bigger portion got people eating 43 % more of it. It's the same person, same food, same hunger and satiety ratings. The only thing that changed was how much food was in front of them. And their eating tracked what was served to them, not their appetite. Nobody at the table, quote, decided to eat more. It was just presented to them, and they thought, yeah, I'll eat this. This also isn't a one-meal novelty.

36:10Dr. Jordan Feigenbaum:If we were really good at compensating, for example, you wouldn't expect this to really move the needle when it comes to weight. When the same lab ran the similar type of study over 11 straight days, the people never caught on, and they didn't compensate by eating less later. They just ate more the whole time. In a Cochrane review, an analysis of 72 trials like this, They came up with the same sort of conclusion. Bigger portions and packages reliably drive more eating across body weights and appetites. So one of the biggest drivers of how much the whole country is eating has nothing to do with discipline.

36:47Dr. Jordan Feigenbaum:It's the size of what shows up on a plate or in a package. And that's been going up for decades. When you look at the portion sizes across different foods that we commonly eat from 1970s to now, yeah, that'll blow your wig back. Not honestly, not surprising.

37:02Dr. Austin Baraki:And I think both of us probably are people who have experienced this and we can kind of relate of like in more more often than not. If we're like going out to eat, what you are served is a serving for one, almost regardless of what that serving is. And further, and we know this from like an adjacent concept, and we've talked about this before, this idea of like food variety and sensory specific satiety and things like that, where if you have much more variation, you're ordering like five different things that come out. you're going to end up bouncing between them and end up ultimately consuming more, but it's all there in front of you as well.

37:43Dr. Austin Baraki:And so I often discuss this with folks when it comes to the environment that there are sometimes in a little bit more control of. I just had this conversation with a gentleman the other day who had described his experience and we came to the conclusion that, look, if it's in the house, it's going down the hatch. And so there were certain food items for him that we just decided were probably best not to be kept in the house because, again, if they are, they were going down. Yeah. I had a client a few years back and, you know, she had been struggling with weight her entire life.

38:15Dr. Jordan Feigenbaum:Right. And she's like, I'm finally motivated enough. I'm going to make these changes. I'm ready. And I'm like, great. Can you tell me about what kind of foods you keep in the house? Right. And she's telling me, she's like, look, me personally, I buy what you would probably consider healthy foods. But my husband, oh man, that is not the case. And also he, I feel like he's trying to sabotage me because he's hiding things around the house for me to find inadvertently, you know, these ultra processed foods package, you know, snacks and candies and such like that. And I'm like, well, what happens when you find them?

38:46Dr. Jordan Feigenbaum:She's like, well, I'm going to eat them because they're there. And like, I want to eat them. I'm like, understandable.

38:51Dr. Austin Baraki:No hate comes. I get that. But I also think he needs to be on board with this.

38:55Dr. Jordan Feigenbaum:Otherwise it's going to be very challenging. If not impossible. you set me up perfectly for this because this really gets at the heart of the matter what actually changed in the environment if we zoom out to the whole food supply the portion effect is part of that but it's relatively small compared to what happened elsewhere between about 1970 and 2010 the calories available per person in the u.s food supply went up roughly 450 calories a day Ultra-processed food, the engineered stuff, now makes up about 58 % of the calories American adults eat and about 67 % for kids. Now, we should say that just because something is ultra-processed doesn't necessarily mean it's bad.

39:35Dr. Jordan Feigenbaum:So like whey protein, Greek yogurt, whatever, that's all technically ultra-processed and can be health-promoting. But the majority of ultra-processed foods are those that have added sugar, added sodium, added fat to sort of get to this bliss point, This very tasty mouth feel that makes people eat more. And unfortunately, while it is high in calories, it's not proportionally satiating or filling. So this all changed recently, you know, over the last 40 to 50 years. And it didn't happen by accident. In the 1980s, the tobacco companies, Philip Morris and R.J. Reynolds, bought up the major food brands, Kraft, General Foods, Nabisco, and brought their scientists with them to engineer food that is easy to keep eating.

40:17Dr. Jordan Feigenbaum:There was an active lawsuit in San Francisco right now that we went through on the trial of big food episode. If that part interests you, it's in the show notes below. You can go listen to that. But today we only need one piece of it. The food around us changed a lot in the last 40 to 50 years. So did the genes change with it or not? Obviously, they did not. Now, some people are going to push back and say, look, maybe some populations are just genetically susceptible or genetically prone. And the tripling in obesity is just due to those genes finally showing up. So what happens when you test this?

40:51Dr. Jordan Feigenbaum:Take a group with shared genes, change the environment only, and see what happens. That experiment exists, and we didn't even have to, like, artificially engineer it. The Pima Indians are a clean setup for this. One population, common ancestry, confirmed genetically similar down to hundreds of DNA markers. Some lived in Arizona in the modern American food environment, and some lived in the Sierra Madre in Mexico. They were farming and eating a traditional diet. Same gene pool, but two different environments. The Arizona Pima are among the heaviest studied populations on earth. Average BMIs in the mid-30s, obesity running from about 64 % in men up to 75 % in women.

41:31Dr. Jordan Feigenbaum:The Mexican Pima, same ancestry, sit at a BMI in the mid-20s with obesity around 6 % in men. Type 2 diabetes prevalence was around 38 % in the Arizona Pima and near 7 % in the Mexican Pima. And you can watch it happen inside individuals, not just across an environmental border. If you track immigrants to the U.S. by how long they've lived here, in one big analysis, obesity was about 8 % among people in the country for less than a year. They live in the United States for less than a year. And about 19 % amongst those who've been here for 15 years or more, climbing toward the U.S. born rate the longer they've been in this environment.

42:11Dr. Jordan Feigenbaum:It's the same people. They didn't swap out their genes at the border. That wasn't required. The food that they were living around is what changed. Now, again, some pushback here. These are cross-sectional snapshots in time, right? Not the same people tracked start to finish necessarily. And the two Pima groups differ in physical activity too. Obviously, one group farms and the other is in the modern sort of obesogenic environment, which is not just related to the food supply, but also we habitually do activity-wise day-to-day. and their genes aren't perfectly identical. It's not just a bunch of twins that we're studying.

42:43Dr. Jordan Feigenbaum:None of that really saves this willpower narrative though. It just kind of fills in some of the gaps around this environmental argument that we're making. So this is the answer to the number that we opened with. Genes set your guardrails and over 40 years, the environment kind of moved the whole population up against the top one, right? And we don't have any predators. So that top number may have shifted even higher in some of the population as well. Obesity didn't triple because 100 million people lost their willpower or got dumber all at once. It's because the environment, particularly the food environment around them changed and biology, again, remains undefeated.

43:22Dr. Jordan Feigenbaum:So Austin, why, in your opinion, is ultra-processed food so easy to overeat? Is there like a mechanism behind this? What sort of stories do you hear from your patients that sort of corroborates that or makes you kind of think, Like, look, there's something in this food that is unique.

43:38Dr. Austin Baraki:There's a couple of layers to this question. It is an interesting one on multiple of these levels. One is just what is an ultra processed food? And there's certainly been a lot of discussion and debate and controversy around this, including topics like the NOVA classification system that has some some pros, but also some some cons and some some limitations. because as we have discussed before, you alluded to a little while ago on this episode, that just simply the degree of quote-unquote processing alone, like doing things to a food, does not necessarily automatically or inherently make it less healthy.

44:12Dr. Austin Baraki:There's also the aspect of like food fortification, and that is more often beneficial than it is likely to be negative on these kind of things. And there are some elements of vagueness and subjectivity to that classification. So it's not something that I think you or I regularly rely on, at least practically when we're working with folks. But it has some general heuristic value, I suppose, to decide what is classified as highly processed or quote unquote ultra processed. But I think that our best understanding of this is that many of these foods are in many ways deliberately designed to just light up all of the areas of our brain that we like to have lit up.

44:54Dr. Austin Baraki:there is this these these types of hunger that we've talked about before as well there's kind of the more physiologic homeostatic kind of hunger type mechanisms the things that are really you know much more closely oriented to energy intake that you need to fuel those metabolic processes to keep yourself alive or for fertility or for pregnancy or whatever the case is there's some physiologic drive to it but then there's the what's called hedonic hunger aspect of things and And this is an interesting way to describe it because I've also heard, you know, modern anti-obesity medicines like GLP-1s and things like that called by like the CEO of Lilly.

45:31Dr. Austin Baraki:I believe I heard him in an interview describe them as anti-hedonic drugs, which I found to be a very interesting descriptor because they're to some extent targeting that mechanism a bit more. because when they're applied properly to a clinical population, we're not aiming to eliminate the homeostatic hunger that's like, oh, we're just making sure we're trying to prevent you from getting the minimum calorie needs that you need for your metabolic rate. We're trying to better align your overall calorie intake on that dimension while maybe reducing the amount of excess energy consumption that led to the body fat accumulation, oftentimes by way of these hedonic mechanisms.

46:05Dr. Austin Baraki:Not exclusively, but a big part of it relies on that. So many of these foods that are so easy to overeat, they really light up those kind of hedonic mechanisms, making them very enjoyable to eat. There are often either flavor profiles, textural profiles, various other unique elements of them, while also offering very little in terms of satiation value. They do not tend to be very filling. And this is on purpose and also on accident as a result of the same types of things that light up our brains don't tend to be. Oh, my gosh, I can't take another bite of this like incredibly delicious thing.

46:38Dr. Jordan Feigenbaum:Yeah, that's really interesting that the, you know, being describing these drugs, these medications as as anti hedonic medications. I've been calling like behavior change agents for a while because they changed the behavior. But that's interesting. So so one of the pushbacks people often have against GLP ones, for example, is are like, well, look, some people get on these. They don't change their dietary habits because they're still eating junk food. Right. And actually, I almost think that's a proof of concept. So thing one, a proof of concept of how durable the sort of desirability of these foods are.

47:09Dr. Jordan Feigenbaum:So it's not just that they taste awesome, right, and have all these unique engineered characteristics. Again, by design, they are heavily marketed to us. They are ubiquitous. They're cheap. You can't outrun them. They're everywhere, right? So the idea that people are just going to stop eating them, you know, cold turkey, highly unlikely. However, with the modern advances in pharmacology, people are eating less of them, which is the goal. Really? So even these drugs can stop people from eating as much, which is ultimately what you would want. It may be sure in a perfect world, everybody who started GLP-1 would overnight become a well-trained chef.

47:47Dr. Jordan Feigenbaum:They would have the resources to procure and prepare all of the food, all the meals they're going to eat in their home, in their domicile. Yeah, super. Oh, sorry, go ahead. No, but in a less perfect, maybe more realistic world, you're still exposed to the modern food environment. And like, look, you might have some food that falls in the ultra processed range or whatever. And some people would frown upon morally, but guess what? They're going to eat less of them, which again is how the medication is supposed to work. If it were to truly target this stuff at the level of the brain. And ultimately, again, the outcome outcomes are undeniable.

48:25Dr. Jordan Feigenbaum:So I find that really interesting.

48:26Dr. Austin Baraki:Yeah, I agree. It is admittedly super frustrating to have conversations with some of these folks that you're that you're talking about. And also why I tend to not have very many of these conversations, most often arguments on social media, because many of them at the outset will be like, look, it's just all about calories. You just need a calorie deficit. And it's like, OK, well, if we have a medicine that facilitates people getting a calorie deficit, you'd be on board with that. Right. And then suddenly it's like, well, no, because they just end up eating less and they don't end up changing their eating habit.

48:50Dr. Austin Baraki:It's like, oh, OK, so if I showed you evidence that overall people tend to actually shift their eating habits, they tend to purchase less of these kind of like ultra processed foods. Their intake of healthier foods tends to go up. You'd be in favor of that. Right. It's like, no, also not like that. It's just like, you know, you're playing chess with a pigeon. It's pointless. Just move on. These people, you know, they're too wedded to their position. It's like if your position was, you know, as stated at the outset, then, you know, it would seem to logically follow that you'd be in favor of using these tools because they're achieving the outcome that you're most interested in.

49:20Dr. Austin Baraki:But if you add a moral layer on top of it, or you feel like you are better because you can do this maybe more consistently or more effectively than someone else can, or if it's in your business interest to do so because you're a coach or something like that, then, you know, it's going to be a we're going to have a hard time changing changing minds on that front. Fortunately, we do have plenty of friends and colleagues in this space and coaches and folks like that who are just like, yeah, let's use the best tools we have for the job because we actually view this as a mission for, you know, the broader, you know, public health for society, for the world.

49:54Dr. Jordan Feigenbaum:Yeah, we actually care if the people get better. But in speaking to that question, you know, again, people have been fighting about this for a long time. Is it only calories and macros that drive how much we eat or does how processed the food is change intake on its own? And Dr. Kevin Hall's team actually addressed this. It turned the fight into an experiment. They admitted 20 adults into a research ward and controlled everything. So just think, it's not like you're going to prison where you're being punished, but effectively the intake is controlled meticulously. Two weeks eating mostly ultra-processed food, two weeks mostly unprocessed.

50:36Dr. Jordan Feigenbaum:The order was randomized. The key move here, the two menus were matched for calories offered, protein, carbohydrates, fat, sugar, salt, and fiber intake. eat as much or as little as you want. So if you match the macros and the calories on offer, and the only thing left different is the processing, any gap in how much people actually consume comes down to the processing itself. And since everyone lived on the ward, in the ward, nobody needs a food diary. You don't need to rely on that. The results here. On an ultra-processed food diet, people ate about 508 calories a day more and gained about a kilo in two weeks.

51:18Dr. Jordan Feigenbaum:The same people on an unprocessed food diet ate less and lost about a kilo, roughly a kilo each way in just 14 days. Now the catch here, this was only 20 people. It was only in two weeks. And by the way, it's in a research ward. So this is the ecological validity, like in the real world where, you know, things are more or less ubiquitous, have more or less effort to go ahead and procure them. Yeah, it's different. This is mostly a tight mechanism study. And researchers will still argue about why ultra-processed food does this. Is it because of the energy density, how many calories you have per unit volume of food?

51:53Dr. Jordan Feigenbaum:Is it the texture? Is it the mouthfeel? Is it the marketing, right? A lot of children's textbooks, for example, in school have been sponsored by various food organizations and have their stuff advertised to them from the time they get into the education system. So we see the directionality here, but yeah, as far as the why, that is still, it hasn't been settled yet. But in any case, same person, the same amount of willpower, the same so-called choices. If you change the food that's in the room, the intake's gonna move by about 500 calories a day. That's the food environment doing the eating for you.

52:30Dr. Jordan Feigenbaum:Every few episodes, someone asks if eating more protein is gonna wreck their kidneys. Now, for most people, the data on that is very reassuring, but lead in your drinking water is a different conversation. The EPA and CDC agree there is no known safe level of lead exposure. The EPA's health-based goal for lead in drinking water is zero, and we're nowhere close to that. The problem is that there are millions of lead service lines still in the ground across the country. So the pipes, the solder, and the plumbing between the treatment plant and your faucet break down over time, and that's how lead gets into the tap water.

53:01Dr. Jordan Feigenbaum:There's a federal mandate to replace them, but it's on a 10-year timeline, and most of that work hasn't started yet. In adults, chronic low-level lead exposure has been linked to all sorts of things like kidney damage, high blood pressure, and cardiovascular disease. And these are claims from the WHO and CDC's position. The thing is, you'd never know from looking at your water or tasting it. That's why I've started filtering my water with Cove Pure. It's a countertop reverse osmosis system. There's no plumber, no installation needed. You plug it in, it sits on your counter. And reverse osmosis is one of the most effective filtration methods for removing lead, PFAS, arsenic, and nitrates.

53:33Dr. Jordan Feigenbaum:The first thing in the morning when I'm filling up my kettle to make coffee, I use CovePure. It's got a touchscreen where you pick the temperature you want, hot, cold, or warm, and it dispenses instantly. It also has preset cup sizes so you can keep track of how much you're taking in. For America's 250th birthday, CovePure is giving you$250 off at covepure.com slash bbm. That's c-o-v-e-p-u-r-e dot com slash bbm. This podcast is brought to you by Factor. Eating well isn't a willpower problem for me, and it's probably not for you either. It's a setup problem. There's something healthy in the fridge that I should be making, and then it's 8 p.m.

54:08Dr. Jordan Feigenbaum:I've been at the track all weekend, or the workout went too long, and then the gap between should cook and will cook is roughly the size of the Grand Canyon. So if left to my own devices, I'll order something for delivery and feel great about it for approximately 11 minutes. That's the gap that Factor closes. Fully prepared meals designed by dieticians, made by chefs, delivered to your door, and they're ready in two minutes. No planning, no grocery run, no cooking. They've got meals built around whatever you're after, whether it's weight loss, more protein, overall healthy nutrition, GLP-1 support, and a muscle pro collection if you're training hard and you care about recovery.

54:41Dr. Jordan Feigenbaum:The food's fresh, never frozen, with over 100 meals rotated weekly, so you're not eating the same chicken and rice until you hate it. Lean proteins, whole foods, only the stuff you want, and it's pretty good too. Head over to factormeals.com slash BBM50OFF and use code BBM50OFF to get 50 % off and a free daily greens box. If that's something you're into, that's with new subscription only while supplies last until september 27 2026 see the website for more details let's talk about the cold war happening in your bed no not that i'm talking about the temperature one of you is a furnace and the other one's got cold feet like two blocks of ice and somewhere around 2 a.m somebody's stealing the covers and someone's throwing them off nobody's sleeping everyone's mad the chili pad 2.0 actually solves this it's a water-based mattress topper that controls your sleep temperature, anywhere from 55 to 115 degrees, and the dual zones are the whole point.

55:32Dr. Jordan Feigenbaum:You run your side cold, your partner runs theirs warm, and the thermostat negotiations are over. It works with the mattress you already own, so you're not buying a whole new bed. And the new nightstand remote is pretty clever. Each side gets its own thermostat, and it's got sensors that notice when you actually get in a bed and start your schedule for you. So it works even if you're the type who means well, but forgets. There's no subscription, you buy it, you own it, it's got a two-year warranty, it's designed and assembled in the USA just north of Charlotte, and a cooler bed is one of the better supported ways to fall asleep faster, and honestly, I just stopped waking up annoyed and a little sweaty.

56:05Dr. Jordan Feigenbaum:Visit www.sleep.me slash BBM to get up to$255 off your ChiliPad 2.0 with code BBM. Again, that's www.sleep.me slash BBM. This is available for Barbell Medicine podcast listeners for a limited time. Order today and get free shipping and a 30-day sleep trial. The best thing about summer in San Diego is how little I have to think about getting dressed. No coat, no layers, no checking the weather because the weather is the same heroic 72 degrees. It always is. I basically own two seasons of clothing and use one of them, which is how I ended up living in Quince. They make well-built essentials, the kind of pieces that quietly become the only things you actually wear.

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57:17Dr. Jordan Feigenbaum:I use this, and you should too. Make your summer wardrobe easier. Go to quince.com slash bbm for free shipping on your order and 365-day returns. Now available in Canada too. That's quince.com slash bbm for free shipping and 365-day returns. Something we hear a lot from people who run our programs is that they finish one and then they immediately want to start the next one. or that their goals or preferences shifted partway and they want to switch to something different, which is actually how training should work. It should adapt to you as things change. Now, the problem is buying programs one at a time.

57:52Dr. Jordan Feigenbaum:Every time that happens, well, that can be hard on the wallet. So we built Barbell Medicine Premium, one subscription and you get the entire program library in our app, all the strength, hypertrophy, conditioning, rehab, general fitness, beginner programs, and everything in between. You can switch whenever you want. And as new programs get added, you get them in the subscription. No per program fees ever. Austin and I build and maintain every program and podcast in both libraries. Same people, the same standards as everything else we put out now all in one place. It's$19.95 a month,$199 for the year.

58:26Dr. Jordan Feigenbaum:You can cancel anytime. And if you already subscribe to Barbell Medicine Plus or the programming library separately, you can upgrade and we'll sort it out so that you're not paying twice. Link is in the description below. Check it out now. and now a little weird science here. Dr. Brock, you brought this to my attention. How much of this lives in the brain versus in the character of the individual? We can look at gourmand syndrome. So a specific injury to the right front of the brain flips people into food obsession. One businessman used to skip dinner for a tennis match until a brain bleed left him unable to stop thinking about gourmet food.

59:05Dr. Jordan Feigenbaum:Another quit his job to write the fine dining column after a stroke. You damage the sort of hardware in the brain and the eating changes. No moral failure required. When you read about this for the first time, did your brain explode and suddenly did you become food obsessed? Like what happened?

59:20Dr. Austin Baraki:No, I mean, I think it fit with the broader understanding. So we know that there are critical areas of the brain involved in things like appetite and hunger and satiety and things like that. And many of the folks, for example, if there are congenital conditions or acquired conditions as an adult that can lead to, for example, conditions like hypothalamic obesity, and those have direct targeted treatments. There are drugs that specifically target hypothalamic obesity and have uniquely beneficial effects on that situation. And it's the person might have been living otherwise normal life until they acquired some sort of injury to this critical area of the brain, kind of like classic stroke syndromes.

1:00:02Dr. Austin Baraki:And this is one where suddenly people can develop insatiable appetite and can inexorably gain weight afterwards unless it's treated. This one was a bit more interesting because it's not in that prototypical area that you think of in terms of the hypothalamus, this kind of like right frontal area. And this is a relatively rare syndrome, but it's just so interesting because it led people not just to food obsession in general, but apparently like to fine dining in particular. And it's just like such an interesting thing. and how much of this is like, you know, really within our conscious control.

1:00:32Dr. Austin Baraki:It's like people who happen to have this very particular type of stroke or brain injury. Suddenly they are like seeking out Michelin, Michelin stars and things like that. Really, really fascinating. So Gourmand syndrome was a cool one to learn about.

1:00:44Dr. Jordan Feigenbaum:Do we think that Phineas Gage had a Gourmand syndrome? There was just no access to that.

1:00:49Dr. Austin Baraki:Yeah, yeah, maybe or unfortunately just hit the wrong area of his brain. Otherwise, it would have had a very different outcome. Yeah, yeah. He wouldn't be flat all the time.

1:00:57Dr. Jordan Feigenbaum:He'd be like, where's the food? Give me the caviar. All right. So, so, so look, uh, Dr. Baraki, a patient tells you that she has no willpower because she grazes every night after dinner. Um, before you say anything about willpower, what do you suggest changing first or how do you address this issue?

1:01:13Dr. Austin Baraki:Yeah, there's a lot of different ways that this could, this could pan out because, um, it, there's a lot of context that needs to be filled in here. For example, you know, what is the rest of the day's dietary intake look like? What are her habitual physical activity habits look like? Um, what is her sleep schedule? What is her work schedule? What's the environment? Who's with her in that evening time frame? Is there alcohol use involved or other substance use that can also, you know, like cannabis use and things like that that can also increase appetite and contribute to food intake? You know, but if, for example, let's say that she has decided, oh, I'm going to lose weight and go on an intermittent fasting diet and like skip breakfast and then have maybe almost nothing or even skip lunch and then I'll have a normal dinner.

1:01:50Dr. Austin Baraki:It's like, yeah, well, probably be kind of normal to still be hungry after that and to want to graze after dinner. Or if she's having substantial sleep impairment. You know, we know that when people have sleep restriction or impaired sleep quality, their appetite will tend to be higher and they'll spontaneously tend to consume greater calories the next day. If there are disinhibiting substances like alcohol or cannabis or something like that. Or again, what's the social environment? Is it has it been your adult lifelong habit with your partner that you bring out some snacks when you're watching a movie or something in the evening?

1:02:21Dr. Austin Baraki:Then, yep, food's in front of you. It's going to go down the hatch. So these are the types of things that I'm trying to illustrate or to get a sense of what's the context that is like around this behavior to better understand it before I automatically say, oh, this like pathologize it or to say, oh, like this needs a new medicine to suppress that. because there might be a lot of other things to consider first. Now, there are still some people who say, look, I sleep well, I'm physically active. I feel like I'm eating healthy handful of meals throughout the day, and I still am having these cravings, these insatiable cravings at night or something like that.

1:02:55Dr. Austin Baraki:Then maybe there's a role for certain types of treatments or interventions to try to mitigate that. And I've certainly used that, whether as part of the GLP-1 therapy conversation that I often have with folks or sometimes combination therapies using other things like topiramate or naltrexone that can also kind of more specifically target some of those types of behaviors also has some utility as well. But I don't automatically assume that that's the case and that it is going to necessitate that until I fill in the rest of the details. I've certainly had some patients who, you know, they maybe start using one of these GLP-1 medicines and they're like, I feel hungrier than ever, you know, in the evenings.

1:03:31Dr. Austin Baraki:This medicine is not doing what I thought it was. And then I find out that they're like legitimately not eating anything all day. And it's like, yeah, you're going to be hungry in the evening. So we need to actually find a way to maintain some like consistent quality nutrition throughout the day to try to balance that out. So you don't have less of these kind of swings back and forth.

1:03:49Dr. Jordan Feigenbaum:Yeah, yeah, well said. And I think ultimately just speaks to, you know, the idea that hunger and subsequently the food seeking practices, food consuming practices are not just related to biology, not just related to psychology, and not just related to the environment. It's all of them together all at once, all the time. And so if you really want to blow your mind, you can go and look at research on different sort of environmental setups where they see how much people eat. Do you eat more when you have a TV screen in front of you? Generally, yes. Do you eat more if you're in a social setting? Depends.

1:04:30Dr. Jordan Feigenbaum:Who are you with? Because you tend to mimic their eating behaviors, right? And so all of these things, it's not that they're conspiring, although I suspect if somebody had been living with obesity most of their adult life, they could say they are conspiring. The point is, it's just more complex than choosing. It's more complex than the hormones going on biologically. And it's more complex than the environment alone. It's all of it together all at once.

1:04:54Dr. Austin Baraki:And it may well be possible to say, well, I can choose.

1:04:59Dr. Jordan Feigenbaum:Yeah, you can choose like once or twice.

1:05:02Dr. Austin Baraki:What about every decision every day forever? That's that's where things get exponentially harder just for like real people living in the real world with like things to do in their life who don't need to make it their constant mission to maintain a particular body shape, body size, body composition. And that's where this struggle comes in. Yeah.

1:05:24Dr. Jordan Feigenbaum:Yeah. I think, you know, the idea of agency and choice and what do, I think, again, we're not saying there's nothing you can do. We're just trying to shift where you put your attention as far as, you know, focusing on making food decisions, you know, when you're at the table, that you're probably a few steps removed from where we would want those choices to be made. That would probably be made at the grocery store if possible, adjusting your micro environments, for example, and other things that sort of allow your default food-related practices to get you to arrive at not only eating the right stuff, but also the right amount and that to happen over and over and over again over the long term.

1:06:07Dr. Jordan Feigenbaum:If the eating, though, is mostly automatic and the environment is mostly running it, why are we all so sure that it's a character flaw? For that, you've got to go back a few thousand years. This one is about why the willpower story has stuck even after most of the science has stopped backing it. The idea that a body with excess adiposity, excess body fat is a moral failure, that story is old. And a lot of people, it's been doing a lot of work for a long time. Two of the seven deadly sins are gluttony and sloth, overeating and laziness. Now, for most of Western history, a person with excess body fat wasn't read as sort of a medical problem.

1:06:48Dr. Jordan Feigenbaum:right? It was read as a moral problem and maybe something that's socially unacceptable, visible proof that the person couldn't control themselves. That framing hasn't left. It's just changed clothing over the years. The Greeks blamed the humors, right? The Victorians blamed weak will, and now we say you just need more discipline. It's the same verdict, just different vocabulary. So let's put this moral story to the test. If obesity were a failure of discipline or intelligence, it would track with discipline and intelligence. You can take two of the most demanding jobs in American public life. William Howard Taft held both of them, president of the United States and then chief justice of the Supreme Court.

1:07:30Dr. Jordan Feigenbaum:And by the careful reconstruction in the medical literature, his BMI while running, while being president was around 42. That is severe obesity in a man running the country and then the court or the Nobel prize. Winston Churchill won the Nobel Prize in literature in 1953, ran a country through a world war, wrote his way to one of the highest honors we hand out, and was visibly overweight for most of his adult life. Nobody has ever looked at Taft or Churchill and concluded they lacked willpower or brains. The mistake is obvious the second you put a name and a resume next to the body. I come back to this all the time.

1:08:06Dr. Jordan Feigenbaum:If you look at people, high achievers, whether it's business, Nobel Prize laureates, whatever, clinical research, you can just go down in any profession and you're going to find highly intelligent, hardworking people who have struggled with their weight. You don't need a president to see this. Think about the most disciplined person that you know right now. They're up at five. They never miss a deadline. They hold the whole household together and they happen to be carrying extra body fat. It's not, again, a willpower or a work ethic issue. It's something else. And we've been talking about this this whole episode.

1:08:42Dr. Jordan Feigenbaum:And it even holds up when you leave anecdotes and go to the data. There's a real population-level correlation where higher cognitive test scores line up with slightly lower body weight. And people wave it around as if smart equals thin, right? A few problems with this. Problem number one, that becomes the idea that you have to teach people. Do you just need more education? if people only knew something about their metabolism, their hormones, or what's healthy. If you ask people, even those who do not have a lot of formal education, hey, what's healthier, broccoli or a Twinkie, right? And they're like, well, obviously the broccoli.

1:09:16Dr. Jordan Feigenbaum:It's the same thing about exercise. Is exercise likely to be healthy? Yes, of course. That doesn't tell you why they're not doing it. In a 2023 study, they compared over 12 ,000 siblings raised in the same family between unrelated strangers, the smarter, leaner link was there. But between siblings, once you hold the family and the upbringing constant, it basically vanished down to a difference you couldn't tell apart from zero. So that near zero difference within families tells you the original correlation was mostly shared background, money, socioeconomic status, neighborhood, the food environment they grew up around, not intelligence causing their thinness, and to whatever tiny extent a real sort of direction exists there, the better evidence actually runs the other way, from metabolic and vascular factors to the brain, not from dumb to fat, right?

1:10:09Dr. Jordan Feigenbaum:So either way, the thing the willpower crowd needs, intelligence and character driving the weight, it's the one thing we really can't find in the evidence. It would be very interesting to see that, right? Because then you'd be like, well, shoot, we just need this PSA, this, you know, a countrywide education on here's what healthy foods are. Maybe you would publish a set of like dietary guidelines every so often that would tell people how to eat. The problem is people don't really read them. That's thing one. And then thing two, even if you do read them, that doesn't change food behaviors. Because again, when you look at the different dietary guidelines and what subsequently happened, the things in the dietary guidelines don't, don't shape up.

1:10:52Dr. Jordan Feigenbaum:So it's the same argument as the genes to me. The country's intelligence and character didn't collapse over the last 40 to 50 years any more than the genes changed. The thing that actually tracks with obesity across history, across borders, across Nobel prizes is the food environment. So, so Austin, imagine this a patient who's kind of been carrying this shame version of obesity their whole life told since childhood that his weight is a character flaw. How do you take that off them or address that in the visits, assuming it came up?

1:11:24Dr. Austin Baraki:Yeah, this, you know, I was having flashbacks to multiple patient conversations that I've had as you were describing some of these very high achievers. There are many that I have interacted with over time in this weight management space. Some who we know from, you know, our training world, barbell medicine history, from prior seminars we've done, things like that, as well as other patients who've kind of found me in other ways. And really, as I was describing earlier, gone on to achieve really remarkable things, leaders in health care, leaders in government, leaders in their their sports fields, ultra endurance athletes in all different kinds of modalities and things like that.

1:12:03Dr. Austin Baraki:And so, you know, seeing the amount of skill and discipline that they have over those areas of their lives, it illustrates the very point that you're making, that this is not necessarily a very generalized character flaw that this person suffers from. And so that's really oftentimes my entry point into the conversation of getting a sense of what led them to this belief and almost trying to do what we've talked about before of like an expectancy violation kind of thing, or just like, you know, trying to find a little weakness in their argument of if it were true that this were, you know, such a flaw, such a weakness, such a deficiency that you have, how do you explain some of these other things?

1:12:45Dr. Austin Baraki:That's one potential route into the conversation. The other is that I don't always automatically try to change this person's mind on this because I don't think that that's always a smart thing to do. A lot of people don't want to feel like, you know, they're somebody's playing mind games with them or that they might feel gas lit or something like that. So there have been some folks where I've just kind of bided my time because many of these folks who are very hard charging, successful, motivated people, they're like, no, I need to be able to do this on my own. I'm like, okay, do it. Like, you know, and I, and I, and I, and that's my mentality is like, show me, but not in a doubting way, because there are certainly some people who can accomplish these things, a smaller portion of people who can accomplish these things and sustain it again, because what you're faced with is you have struggled with this with for your whole life so far.

1:13:35Dr. Austin Baraki:I have no doubt that you can do some things that will facilitate some weight loss in the short term. what you are faced with is doing that forever for the rest of your life through this constant daily, you know, waking up, going to war against the dinner plate, going to war against the pantry or whatever, you know, whatever other, you know, you perceive to be kind of, you know, your quote unquote source of weakness or something like that. And so more often, you know, than I can count, there have been folks who I've had these kind of conversations and they feel so strongly that they're like, look, I have been crushing it in so many areas of my life.

1:14:07Dr. Austin Baraki:I ought to be able to do this. I'm like, okay, I am full support. how can I help? But over time, if they either succeed or relapse or tend to not have as much success, I start to gently sprinkle in the idea of, is it more important how we get there or is it more important that we get there? And would you be open to some tools, some strategies, some other things that I have up my sleeve that can improve your odds of success? And really all it takes once we get over that hump is somebody saying, I'm willing to give this a try. I'm at my wits end or I've been trying as hard as I can and I have success, but it feels again that I have to be perfect all day, every day.

1:14:47Dr. Austin Baraki:Otherwise, it all falls apart. Well, I have a tool that can help with that. And, you know, it for one patient in particular that I can think of, all it took was literally the first 2.5 milligram dose of terzepatide when it was like, oh, I get it now. I get it now. And all of these prior beliefs that I had about myself, that was not actually, you know, an accurate understanding of what was kind of going on under the hood. Now I actually understand and, you know, making fantastic progress. And I'm like, yeah, I would, I'm going to be on this the rest of my life. You can pry it from my cold dead hands.

1:15:22Dr. Austin Baraki:And I'm like, yeah, I get it. But it took quite a journey to get there because again, I didn't jump from the outset of like, I need to change your mind. It was rather I have to like, kind of guide you, guide you there while observing. Like if you have success along the way, quote unquote, quote, on your own, great, like, cool. But I also recognize that that's a relative minority of folks. And those who, you know, use these tools, they have a higher chance of success. But I don't, you know, force it in the conversation right off the bat.

1:15:47Dr. Jordan Feigenbaum:Yeah, I do think that that's where this maybe willpower argument or narrative is kind of respawning from. I do think it has been present throughout human history, particularly as like leanness and thinness has been, you know, incentivized, we'll say. Rewarded. But now because of the availability of tools that can sort of actually change how people go about weight management, these GLP-1s, for example, and in the future multi-agonist agents, again, willpower now has been shoved to the forefront. You're like, well, look, you're doing it that way. It's because you're a weak moral character and you needed some additional help.

1:16:33Dr. Jordan Feigenbaum:And there's so many holes in that argument to me. Argument number one is like, well, what if you had hired a coach to like write some training for you, do your quote macros, whatever, is using that sort of support, you know, a failure of willpower, right? Or is it just you leveraging the resources within your control? Okay, where do you draw the line? Well, just because it's not natural, it's outside of your body. I mean, your body does make it naturally, right? And like, okay, is it okay for you to use gym equipment? That's something of modernity. So I want to talk about these medications, specifically how this kind of alters how our genes interact with our environment and subsequently our food-related practices.

1:17:19Dr. Jordan Feigenbaum:You've heard that these drugs called cheating, certainly, if you've been on the internet at all in the last few years, that they're the easy way out. It doesn't require any willpower. But let's look at what these things actually do. So GLP-1 is a hormone that your own gut makes after you eat. It's usually gone within seconds to minutes, and it's made in a relatively low amount. It is not a major player in appetite, satiety in humans. It's involved to some degree, but not a lot because, again, low amounts that you make, and again, it's gone in minutes. So it can't possibly have these huge effects.

1:17:54Dr. Jordan Feigenbaum:The medications are engineered copies of it. Pretty ingenious, actually. They reach the brain's appetite centers, the arcuate nucleus in the hypothalamus and the area of postrema down in the brainstem. There are going to be other targets that we identify, but that's what we think right now. And then they turn the dial. They switch on the neurons, the nerves that say stop eating, and they quiet the ones that are yelling, keep going. Trisepatide, the newer one, does it with two different targets. One is GLP-1, the other one is GIP. Either way, they reach the exact same machinery in the brain. We spent multiple episodes talking about this in detail.

1:18:30Dr. Jordan Feigenbaum:Now, the effect of these medications, they're not small. And that's the whole point here, okay? If this was like an incremental change where people lost just a little bit of weight and then it was really hard to keep off, these drugs wouldn't be blockbusters, right? And we wouldn't have spent multiple episodes talking about them. But to give you guys just a little refresher, probably the whole study that kicked this thing off was the step one trial published in the New England Journal of Medicine in 2021. About 2 ,000 adults on weekly semaglutide, that's a Zempic or Wagovi, lost roughly 15 % of their body weight over 68 weeks.

1:19:03Dr. Jordan Feigenbaum:They lost about 2 % on placebo. To put that in perspective, lifestyle alone, so diet, exercise, behavior change, this, that, and the other, people are fortunate if they achieve 5 % of weight loss, right? Depending on the timeframe you look at, maybe half of folks, and in the best studies we have, maybe two thirds of folks will lose that amount within, let's call it six months. Okay. Very few people will reach 10 % in the most charitable studies we have. Maybe a third of folks with lifestyle alone would reach 10%. When you talk about 15%, though, that number drops to near zero. Not nobody, but very few people achieve 15 % weight loss with lifestyle alone, mainly because it is very challenging to push back against biology.

1:19:52Dr. Jordan Feigenbaum:And again, by the way, the environment hasn't changed. The follow-up drug, if semaglutide on average, 15 % of weight loss, the follow-up drug terzepatide, so Zepbound, Manjaro, in the Sermount-1 trial, that put the amount of weight loss around 21%. Now we're getting decidedly into metabolic bariatric surgery territory, retatratide or retatrutide, however you pronounce it. No one knows. I'm going to keep saying retatratide just because it's different than what everybody else is saying. It's going to be a little higher than that. And we're going to have multiple agents coming out that are probably going to beat these numbers.

1:20:26Dr. Jordan Feigenbaum:One weekly injection and maybe in the future, one weekly pill, we'll see, nudges these appetite and satiety signals at scale in a way that produces not only significant weight loss, but in a manner where it can be sustained for as long as people are taking the medication. Ultimately, it suggests or it enhances people's ability to do the things they were already trying to do. So if anything, maybe anti-hedonic medication, maybe that's the wrong term. Maybe behavior change agent is not the right term. Maybe just call it a willpower drug. Like if If you're dead set on this willpower thing, right, and we can't talk you off it or whatever, look, this is your willpower support system.

1:21:06Dr. Jordan Feigenbaum:It's helpful. I don't love that because, again, it doesn't seem to the moral aspect. I don't love that. But, Austin, look, in plain terms, what is a GLP-1 and what should we care about beyond the scale, like muscle and like actual dietary practices?

1:21:21Dr. Austin Baraki:Yeah, these medicines essentially augment the effect of what you described as our kind of naturally produced peptides. These are called incretin hormones, and we're giving them in higher doses, pharmacologic doses, and they can have substantial potent impacts on appetite, on satiation, feelings of fullness, spontaneously reduce kind of calorie intake and facilitate improvements and rapid and substantial losses in body fat as well as visceral fat, which, as we've talked about before is the type of fat that tends to have the most harmful consequences on long-term health. And so it's not surprising that in addition to looking at outcomes from obesity, we are also seeing benefits on numerous other of the wide range of obesity-associated diseases.

1:22:07Dr. Austin Baraki:We see improvements in sleep apnea. We see putting fatty liver disease into remission. We see decreases in heart failure, in chronic kidney disease. We see improvements in many, many, many other areas of health as osteoarthritis, chronic pain, PCOS, formerly known as another condition where we're seeing some early emerging evidence of benefit as well as anecdotal in the women that I've treated with that condition using these medicines. Beyond the scale, which is firmly where I plant my flag, the scale is one crude metric of the effects of these medicines. Looking at outcomes of body composition.

1:22:46Dr. Austin Baraki:Fat loss is certainly an important one. Other metabolic parameters, things like blood pressure, blood cholesterol levels, blood sugar levels as other important areas. And then when it comes to concerns around what is often conflated, things like lean body mass or muscle mass, bone mass, things like that. Anytime, as we've talked about, when people lose weight, there's going to be some fraction of fat mass lost and then some fraction of nonfat mass or lean mass or muscle or bone that also tends to be lost, although this can be substantially mitigated and in some cases prevented. And I've had several patients send me their body composition data or that we've gotten body composition data on them and they've been able to actually improve their gain muscle mass while they have lost body fat, particularly if they were previously undertrained or untrained and using these medicines to lose body fat.

1:23:35Dr. Austin Baraki:So lastly, the nutrition piece itself, quality nutrition can take things even further to improve the health outcomes. As we mentioned a little while ago, yes, the overall calorie intake tends to decrease. That tends to deliver the bulk of the benefits. So even if you did have folks who were, quote unquote, eating the same, you know, maybe poor diet, but just less of it, they probably, if they're being appropriately treated with these medicines, you know, meaning that they started out with clinical obesity, they would probably still have net benefit. They would probably be less likely to develop diseases.

1:24:08Dr. Austin Baraki:They would probably be more likely to put diseases into remission. They'd probably be longer, likely to live longer with less disability and disease. But when it is further supported by improvements in nutritional quality, then it can really put the health impacts kind of over the top. So those are the big picture things. These medicines improve appetite regulation, lead to improvements in body composition, and lead to wide ranging improvements in health, particularly when they're used appropriately and dosed carefully for people. Yeah.

1:24:36Dr. Jordan Feigenbaum:And I think ultimately the mechanisms regarding appetite regulation, satiety regulation, I think if people would agree that the majority of the obesity issue is related to some sort of problem when it comes to appetite and satiety, right? That whether people on average feel too hungry too often compared to feeling too full, and that when they try to lose weight, that that becomes even more problematic. If people agree with that, and that GLP-1s treat that directly in many ways, then the willpower argument kind of dissolves on its own. You're like, wait, this stuff is an output of your subconscious.

1:25:20Dr. Jordan Feigenbaum:It is in your brain. You can't will yourself to feel less hungry or feel more full, just like you couldn't do. Feel less thirsty, right? That doesn't work. Or when you can't sleep, just feel more tired. Go for it. These are more complex. But if people are in agreement with all of that, then I think the willpower argument tends to dissolve. Now, I do think it's worth saying because if people say, look, fine, I agree. I agree with you guys. Look, it's at the level of brain. It's subconscious. You can't control it. It's appetite, satiety, regulation, some issue there. So you're saying it's got no agency?

1:25:51Dr. Jordan Feigenbaum:I can't do anything. Don't do anything at all. We're not saying that. We're saying we have to move your efforts, shift your efforts, your priorities, your sort of resources to a different spot. In this case, it would be either accessing healthcare. It would be changing your food environment, doing all of these sort of things together rather than just sort of just try harder, which to me is like try harder with what? Try harder to feel less hungry. try harder to, I don't know exactly where you're targeting the try harder thing, I guess. Now, I do think that it would be interesting to come at this from the other way.

1:26:33Dr. Jordan Feigenbaum:What if you had a patient, Dr. Baraki, a patient comes in, they want a GLP-1, right? And his wife thinks, look, if you do this, you're taking the easy way out. You should just, again, try harder. How does that conversation go?

1:26:47Dr. Austin Baraki:it's like you are i don't know sitting on my shoulder watching many of these patient visits i've had this go both directions where the husband is interested and the wife wants it to go the other way i would say a little bit more often the wife is interested and then the husband is the one who wants it to go uh kind of the other way and really this is just a conversation of getting to know where the person and their ideas and their beliefs come from so it's just like they should white knuckle it why just tell me you know what makes that better because my what i suspect and i don't explicitly say this right away is that they've tried to white knuckle it before repeatedly and uh you know most likely you're and and so i'm here to be uh somebody who guides them walks with them through this process and gives them the support that they are looking for kind of meeting them where they're at in this journey and so if their preference based on their worldview their beliefs their background is that they should in fact white knuckle it more power to you like okay hey, how can I help?

1:27:45Dr. Austin Baraki:But on the other hand, if we can get to an understanding of like, there's nothing actually necessarily better about doing it that way. And in fact, that is a path that has a substantially lower likelihood of success, particularly long-term durable success. Then if we are trying to be kind of neutral observers of the evidence of what this process can look like, the math kind of is pretty clear of, which one is more likely to give us the outcome that we are looking for and at what cost. And if that cost, whether financially or in terms of risk of side effects or inconvenience or whatever is worth it to you, then let's do it.

1:28:25Dr. Austin Baraki:Lastly, I think that what is often perceived as one of the downsides of these medicines that you need to keep using it to sustain the benefit. In a case like this, it could also be an advantage. And it's similar to the advantage that I described in the last case, where somebody might have pretty rigid beliefs around they should be able to do it on their own. And they've been trying and trying and trying and not having success. And sometimes I frame it of like it. Look, it's not it doesn't have to be a permanent commitment. Kind of like when we've talked about testosterone therapy before. You can do a trial and see how it goes.

1:28:58Dr. Austin Baraki:See if it helps you, because there is nothing that I am going to be able to say that will come anywhere close to what it feels like for you to take a therapeutic dose. of this medicine. It might not be the first dose because you might be somebody who needs more than 2.5 milligrams. You might need a higher dose. But once you hit that therapeutic dose and you actually feel what that feels like, or you notice that you aren't hanging out by the fridge and realizing like, I'm not even hungry. What am I doing here? Or you notice that you're actually losing weight without white knuckling it for the first time in your life.

1:29:30Dr. Austin Baraki:Nothing that I can say is going to actually compare to that experience. And so if it is within reach within your means, be it, you know, again, coverage wise, financially, whatever, and you're willing to just like do a trial of this, I would say that's a better, more powerful argument than anything that I can say. Because again, I don't like, look, it's your life and it's your health. I'm not there to like coerce health out of you. I'm here to be a consultant, be an advisor. I can give recommendations. You can take them. You cannot. That is entirely up to you. I would have my recommendations. And if you'd like to take them, that's great.

1:30:01Dr. Austin Baraki:If not, I'm here to support you in any other way you'd like. But again, there's nothing necessarily beneficial or advantageous about like, quote, unquote, doing it harder than using these tools that improve your odds of a successful outcome. Yeah.

1:30:17Dr. Jordan Feigenbaum:Yeah. I think we've established that it's not willpower. It's not cheating, not necessarily benefits to living life on hard mode. Before we get to what actually works, I want to do some myth busting. You know, we love this. We, you and I regularly engage with people on the interwebs for some myth busting. So this is a bit of a lightning round. These are four takes you've certainly heard before or seen before on the interwebs. We're gonna give each one of them its best shot and we're gonna push back. First take, it's simple. Just eat less and move more. This isn't wrong like math-wise. Energy balance is real.

1:30:54Dr. Jordan Feigenbaum:I kind of describe it as the final common pathway, right? Whatever intervention or tool, resource, whatever you're gonna use, it has to affect energy balance, right? And in order to lose weight, you have to be in a calorie deficit. None of that is untrue. That's firmly established. The problem is that it ignores what drives energy intake and energy expenditure. And so if you accept that energy balance is what drives changes in body weight, great. You have to go one step up from there. What influences those things? And when you realize that a lot of the food-related practices are not conscious decisions, right, they are primarily influenced by your genetic makeup and how that is mismatched to our current environment, then you're like, well, how important is it really to focus on eating less and moving more via conscious decision?

1:31:51Dr. Jordan Feigenbaum:If you accept all of that, then it's like, while true, while the math is mathing, it's not very useful to focus on this. The inputs are highly dynamic, how hungry you are, how full you feel, how much energy you expend, and you're not controlling any of these with your mind. It's not a Jedi mind trick. I think what happens here is that people who have either never struggled with obesity or are one of the relatively few people who are able to achieve weight loss and their ideal body composition through lifestyle alone, they are like these living counterfactuals. And they're like, no, look, I did it so everyone can do it.

1:32:30Dr. Jordan Feigenbaum:To which you would say, well, look, I deadlifted 765 pounds. Why can't you? 100%. Took the words out of my mouth. i mean i assume that nobody is arguing with you when they're in front of you you know in the clinic or in the you know remote visit where they're like look doc i know it's just energy balance so like i just need to eat less and move more you know if they've made it to you that's

1:32:51Dr. Austin Baraki:not something that they're saying but yeah yeah i mean it you're right that it is simple only in the form of a final common pathway and maybe it would be that simple in real life if um let's say if you were, if you were the pet of another organism in the same way that like, if, you know, a lot of people there, maybe their pet dog or their pet cat has like gained weight and they want to restore a healthy weight, they will, you know, start feeding them less and start taking them on more walks. Maybe if you, as a human, you had an owner and they started controlling your portions and feeding you less and taking you on more walks, maybe that would work.

1:33:22Dr. Austin Baraki:But you know, that's, that means you truly have no agency. Somebody else is entirely in charge of your existence. And you would also still be miserable during that because you would be desperately hungry and you would probably have other, you know, spontaneous behavioral changes and things like that as a result of the sustained calorie deficit beyond what your physiology or your biology is, you know, happy with, so to speak. Right. But it's just that's not the environment. That's not the world that we live in. You are the person who is, you know, standing in front of the options at the grocery store or in front of the pantry or in front of the fridge or dining out at the restaurant.

1:33:55Dr. Austin Baraki:And again, much so much of this is not as much within our conscious control as we would like. So while it may be simple in that final common pathway, that makes it neither easy, nor does it make it practical for a lot of people living in this world as it is today. Yeah, yeah, I think that the first, you know, myth here is, you know, it's just eat less,

1:34:18Dr. Jordan Feigenbaum:move more, it's just energy balance, right? Which on the one hand is not really a myth, But the idea that you can just do that, choose to do that folds into the second myth. Look, if I can do it, anyone can. It's just willpower. Again, we kind of deconstructed that. But also, just heads up, that's the survivorship bias playing out in real life. Can you imagine if somebody posted a hot take? Look, if I lost weight, anyone can. It's just willpower. And then every single person just in their immediate community said, hey, look, I tried. Again, on average, individuals with obesity will try on average about eight times in their lifetime to lose weight.

1:34:56Dr. Jordan Feigenbaum:And they said, look, I've tried this many times, didn't work. They all posted. And so the comments, there's tens of thousands, if not hundreds of thousands of people saying they actually didn't. Do you think that would change their mind where they'd be like, oh, maybe I'm not seeing this. I imagine it's very challenging for you to have a lived experience, right? Your N of one experiment. And then almost reject it and say, well, look, while this was my experience, this cannot be the experience for everyone or is not the experience for everyone else i feel like you and i do that on a regular basis people are like look hey do you think anyone everyone every man who starts lifting weights can deadlift in certain number 500 pounds they're like no and you're like well you guys can and we're like yeah look our genetics our environment happened to work out in a very opportunistic opportune time in our lives and we were able to take advantage of that, but that's certainly not everyone's experience.

1:35:48Dr. Jordan Feigenbaum:And so, yeah, I think

1:35:49Dr. Austin Baraki:it's a combination of knowing that the stars aligned in our favor on that particular thing, but also having like being socialized in the world and interacting with other people. Now, obviously I have the advantage of, yes, I've seen thousands and thousands of patients over the years, and that is my way of socializing and listening to what these folks experiences are like. And I have just innumerable, you know, stories and examples of scenarios where it's like, oh my gosh, if I was living in that particular situation that you are living in, where you are an adult parent struggling with obesity since you were a child, and you're trying to support your child who has some sort of disability or themselves has an eating disorder, how do you even navigate that?

1:36:33That's an example of something that I've, it's like, that is exceptionally challenging sort of

1:36:37Dr. Austin Baraki:thing to navigate. And it's like, yeah, the stars are certainly not aligned in your favor on this. And it is perfectly OK to have some additional help to use other tools when it is needed to achieve this outcome. Again, especially when it comes to your health. It's not like you're trying to do this so that you can get a leg up on competitors in a sport where it's drug tested and the rules say you can't use the drug. This is just like life. There's not USADA for life health outcomes or something like that. It's OK to use the tools that are there. And so similarly for us with like training outcomes, strength, you know, powerlifting, whatever conditioning, it's like, yeah, we've coached hundreds to thousands of people, you know, over the years and recognize it's like, yeah, there have been plenty of trainees who it's like, yeah, I don't think that a 500 pound deadlift is in the cards for this person.

1:37:27Dr. Austin Baraki:they could train all day every day they could train you know one day a week to seven days a week high volume low volume variations intensity you know all sorts of other things and it's like i don't necessarily see that that's likely to be in their future or at least in a way that is compatible with other outcomes that they care about meaning without gaining substantial amounts of weight that they don't want to gain without using anabolic steroids that they don't want to use things like that because again tools can help them get to that outcome if they want to use them in the same way that we're talking about it here yep yeah yeah underappreciated i do i do enjoy

1:37:58Dr. Jordan Feigenbaum:dropping the well look if i i deadlifted 748 pounds why can't you and they're like well we all know that there's more it's more complicated like are you sure is we in the room yeah yeah all right uh so that that's two of the uh sort of hot takes myth busting things third one here is look discipline is a muscle you just don't want it badly enough. And it's kind of like this idea that, look, you can change your habits in the short term, and then that compounds over time. And to keep it going, it's just discipline. And to some extent, there is a kernel of truth in there, I feel like, particularly if you apply those efforts upstream from the just eat less, move more, to get to the result of eating less and moving more.

1:38:46Dr. Jordan Feigenbaum:So I think there's some truth there. For example, changing the food environment, changing the eating environment, you know, ultimately leveraging your community if possible, like work out with the friend, something to get you doing some of these behaviors or making them more accessible for you. But the idea that, look, you just got to train this muscle and become even better at resisting the temptation. I'm like, look, the diaphragm's a muscle. You still can't hold your breath for an hour, even though you can, you know, improve your ability to hold your breath a little bit. I don't know. What do you think about this sort of take?

1:39:16Dr. Jordan Feigenbaum:Yeah.

1:39:16Dr. Austin Baraki:Habits can certainly improve, but I think you summarized it succinctly earlier is like, you know, on its own, biology is undefeated, right? And so you can have a lot of these healthy habits. And so many of the patients that I work with have actually very good, very healthy habits. They're actually exercising regularly, again, ultra endurance athletes, and they're sleeping well, and they're trying to do these things, yet they still continue to struggle. And there is that element of biology that is, you know, over enough time, it grinds you down, like they might be able to, you know, skip a meal or restrict a meal for a day, for two days, for a week, for a month.

1:39:51Dr. Austin Baraki:But over a long enough time horizon, that idea of white knuckling it forever is something that, you know, pretty much everybody is likely to break at some point if they're having to consciously restrict. Again, it's like, imagine how long could you go just living, being like moderately thirsty, just like all day, every day, just like living with that nonstop. and then being faced with, oh, right in front of you in the fridge, there is an ice cold, most refreshing beverage that you like and it's there all the time, but you're just like constantly thirsty. And for some reason, you have to be able to consciously restrict yourself from just going to the fridge and drinking it.

1:40:33Dr. Austin Baraki:You will break. You will break over that period of time, right? And so that's kind of where this tends to fall apart for most people.

1:40:42Dr. Jordan Feigenbaum:Yeah, yeah, I agree. All right, last myth we're going to bust here is, I guess, one that we're kind of creating on our own, but only if you didn't listen carefully. Diets never work. It's all genetics. Why even bother? And I think this comes from people who have been burned before. Look, if the average person with excess body fat with obesity has tried eight times on average in their life to lose weight and it didn't work, why even try? And there's some real data here where people who have had multiple negative experiences, they tend to become a little bit more resistant, not in a biological way, but they're just like, look, why am I trying this?

1:41:21Dr. Jordan Feigenbaum:And I think most of this, I'll get your take on this, is due to just our lack of tools that we had before. The environment, if anything, continues to get worse, okay? So like more and more pressures outside of our control. And if we did not have any medications, any surgery, any sort of lifestyle change programs that were maybe a little more intensive. Yeah, I kind of get that line of thinking, right? Like at some point, the Herculean effort, you run out of, you can't go to that well anymore, but we have new tools. So I don't know. Yeah. What's your take on that?

1:41:57Dr. Austin Baraki:Yeah, the idea of why even bother is not really taking a full view of the of the issue, because, again, it's more we're not just looking at scale weight here. The why even bother is because it has implications for your health, for your longevity, for your risk of preventable diseases, for your risk of death or being around for, you know, things you care about, things you want to be able to do for your family, for other things like that. So there is valid reason to improve, for example, the quality of your nutrition to remain sufficiently physically active to the extent that you struggle day in and day out with maintaining, you know, the ideal amount of calorie intake for your physiology to maintain a healthy body weight.

1:42:33Dr. Austin Baraki:Yeah, we got tools that can help with that if that is a challenge that afflicts you potentially more than more than someone else. There are certainly plenty of people out there who, you know, we all know and who tend to remain naturally very lean, who couldn't finish a plate of food in front of them. If you if you know, if you had a gun to their head, they would say, no, I'm just too full. I can't do it. And there are also people at the other end of that spectrum. Right. It's and so that's why I think the idea of why bother is because there are other implications to this that people care about more than just, you know, if it was all about like just achieving a particular scale weight for the sake of it.

1:43:07Dr. Austin Baraki:then yeah, I think you have a harder case to make of like, why bother? Because it's like, yeah, it's just a number on the scale. But there's a lot more, you know, baked into this and implications for your health, for your life, for your function, for things like that. And we have, you know, more effective tools than ever to help you get there.

1:43:21Dr. Jordan Feigenbaum:Yeah, yeah. There are a number of weight independent benefits that come from the lifestyle stuff, even if they're ineffective for many for weight management, for health management, they like biology are undefeated. So 10 out of 10 would recommend. All right, Austin, last question to you. You got a new patient. They want to lose weight, but they've had bad experiences before, which they find demoralizing because they think it says something about their character.

1:43:48Dr. Austin Baraki:How does that conversation go? Tell me more. Describe those experiences. Tell me what it was like. And really, just by listening sufficiently to those experiences, I can try to get a sense of like, what exactly about it was the thing that led to them feeling this sense of being demoralized as a result? What was the linchpin of that experience that was most, I guess, emotionally salient to them? And then trying to see, you know, is this something that they are talking to me about because they are motivated to give it another shot, to try a novel strategy, because they want another opinion? Or are they just like fed up with it all?

1:44:25Dr. Austin Baraki:And they're seeing me because they feel like they have to, because they ought to see a doctor because I'm not there to impose a treatment on somebody who is not interested or motivated to pursue it. But if they are, then again, we have tools. And I think framing it in a way of, hey, we have tools that are very safe, that are super effective, that I have a boatload of experience with that can be dosed very carefully, that are not permanent commitments. If you don't want it to be, you could try it for a bit of time and see if it fits what you're looking for. And then we can give you all the support you need along the way.

1:44:56Dr. Austin Baraki:That's basically how I would go about it. And then if there are any other kind of individual unique elements that need to be addressed or supported, or if they need other, you know, psychological, psychiatric support, things like that, then we can certainly, you know, arrange for that as well.

1:45:08Dr. Jordan Feigenbaum:We spent the whole episode on why this is hard and why it's not a character flaw, but let me bring it home with what you should actually do about it. Think of each of these as a takeaway and the strategy that goes with it. Number one, aim at the environment because that's the thing that's actually changed. Obesity has roughly tripled in the last 40 to 50 years on a set of genes that haven't changed at all, so the environment is where the leverage is. One of the highest yield things you can do is decide once, whenever you do your grocery shopping, what comes into the house, because if it's not there, it can't get you at 9 o 'clock on a Tuesday when you're fried.

1:45:41Dr. Jordan Feigenbaum:We go deep on how that environment got built over on the Big Food episode that's linked in the show notes below. Number two, when you lose weight, your body is going to fight back to some degree. The hunger is going to go up, the calorie burn is going to go down, and that varies a lot between individuals. It's going to stay that way for years. So while you're losing, it makes sense to protect the engine as much as possible. Now, one of the biggest drivers of your basal metabolic rate or your resting metabolic rate is how much muscle mass that you have. And so to the extent we can prevent its loss, we should do so through enough protein and enough resistance training.

1:46:15Dr. Jordan Feigenbaum:Generally, we can cut the losses down to at least half, maybe more compared to not doing that at all. Now, it doesn't take a lot. We're not telling you to protein max or to lift five days a week. A little will go a long way. That's honestly what we do with most of the people here at Barbo Medicine. Number three, the drugs, GLP-1s in this case, aren't cheating. They work on the exact appetite and satiety machinery this whole problem runs on, which is about the best evidence you could ask for that it was never a matter of wanting it more. If your biology was fighting you hard, that's a real medical tool worth a conversation with your doctor, same as coaching or good structure in general.

1:46:51Dr. Jordan Feigenbaum:put it all together and it's pretty simple genes in the environment set the table what you can do is go after the inputs that are actually in your reach and that's where the effort pays off so think back to danny cahill on that stage 239 pounds down having done the hardest thing that show is asked of anyone the cameras left and his body spent the next six years putting that weight back on and the whole time the only word anybody had for him was discipline that was the wrong word what he was up against was his own biology and an environment built to feed it, and discipline was never going to be enough on its own.

1:47:22Dr. Jordan Feigenbaum:That's the whole point of today. Your weight is the output of a system, your genes, the hunger your body defends, and the environment that you're making your decisions within. How badly you want it is a small piece of that, and shame has never moved any of it. What helps is understanding the system and then changing the parts of it you can actually reach. So if you spent the years losing and gaining the same weight over and over again and beating yourself up about it, you can let that go. It was never a character problem. And there's real effective help now that we just didn't have a few years ago.

1:47:52Dr. Jordan Feigenbaum:If you want a hand building that system, that's what we do here at Barbell Medicine. And it's linked in the show notes. And before you guys go anywhere, please leave us a five star rating and a review. It genuinely drives traffic to our podcast. We can keep bringing you all the latest nuance and health and fitness. For Dr. Austin Baraki, I'm Dr. Jordan Feigenbaum. We'll catch you next time right here on the Barbell Medicine podcast.

1:48:21Thank you.