Weight Loss Surgeon: Why Exercise and Calorie Cutting Doesn’t Work | Dr Andrew Jenkinson

0:00Dr Karan: Dr. Andrew Jenkinson, thank you so much for joining me. This is a very topical theme right now. Weight loss, weight gain, body weight, obesity, especially with the rise of GOP-1 medications. I want to just rewind a little bit before we get into the nuances of weight loss. For the best part of 10 or 12 years since I was in, you know, even before that, maybe in medical school, I was always trying to lose some bit of weight, you know, weight I accumulated because of stress, overeating, and then the busy life of being a junior doctor and medical school finals. And I always ended up losing weight and then putting weight back on, losing weight, putting even more weight back on.

0:39Dr Karan: And I was in this vicious cycle. I'm a 90s kid. I grew up in the 90s. And in the early 90s and even the early noughties, I was always told that weight loss has some sort of moral value because you're not exercising enough and you're not using enough willpower to just stop eating. How dangerous is that mindset, do you think for people trying to lose weight? Yeah, I mean, I think it's just a total misunderstanding of weight regulation, which is great that we can talk about this, Dr. Karen, thanks for the invite. Your experience of, you know, putting on a little bit of weight due to stress and poor eating because of short hours and then trying to lose it recurrently with low-calorie diets, exercise regimes probably, and then regaining it and more is something that, 90 % of my patients who eventually come to bariatric surgery describe.

1:31And it's fascinating and it's basically a description of how biologically we control our weights. It's impossible to lose weight and keep the weight off by calorie restriction. You've got to understand how our body biologically controls our weight. It's all about the hypothalamus. So a hypothalamus is this pea-shaped or pea-sized part of our brain right in the middle of our brain that really controls our metabolism and our drives to eat and our satiety. It also controls our thirst. If you understand how that works, then you can slowly and gradually lose weight to a much healthier level.

2:11Dr Karan: When people think about weight loss, a lot of people talk about calories in versus calories out, thermodynamics, and the overall calorie balance equation, which makes sense. And I think that is irrefutable that you need to be in a deficit to lose weight. And you need to be in a surplus to gain weight. I mean, no one's arguing that, but that's a very reductionist view of thinking about things. And going back to what I was saying earlier, this kind of 90s, noughties, and even now this misconception that it's about willpower and you can almost mentally, neurologically drive yourself into losing weight alone, I guess we have the evidence now that 40 to 70 % of your weight and weight gain is determined by genetics.

2:55Dr Karan: There's also all these lifestyle factors and environmental factors as well. You know, one thing which going back to the other thing I was talking about exercise, I guess, again, there's like this fallacy that people who have excess weight or who have obesity are not moving and not exercising, right? They're maybe lazy, quote unquote. And I came across an interesting study where they looked at the calories burnt by members of the Hadza tribe in Tanzania. They're miles and miles of foraging, hiking, trekking all day long. They're always moving, but they're only burning around two and a half thousand calories a day, which is roughly the same as someone sitting in a desk job in London, also burning two and a half thousand.

3:33Dr Karan: This person in the desk job is likely having a worse diet and sedentary most of the day, but the Hadza tribe are more active, but they're both burning the same amount of calories. So it's not just about exercise, right? Yeah. I mean, I love that study. It's fascinating. And that's by Herman Posner, a famous anthropologist who's really, you know, dug down into metabolism. And he used a really accurate method of measuring our energy expenditure. It's really, really difficult to measure it normally. He used something called doubly labeled water, which is really expensive. but it's something that actually will measure how much energy you've expelled per day and he compared these hunter-gatherers in Tanzania the Hazda tribe with city dwellers office workers in New York and London and the results were stunning they have the same energy expenditure despite the Hazda tribe you know walking 20 ,000 steps a day and running and whatever and the explanation for that is something we can't control.

4:36So this is our basal metabolic rate. So actually the bulk of our energy expenditure is just our basal metabolism, which is heating our body, our heartbeat, our immune system. Just existing. Breathing. Yeah. If you don't get out of bed, you're still going to use 70 % of your total energy with this process. Now that energy expenditure is very, very, very variable. And I would equate it like a dimmer switch. It can go up or down depending on whether you want to save energy, become more efficient, go into battery saving mode almost, or actually if you want to burn off a load more energy because your body doesn't want to put weight on.

5:13And that's the explanation for that. The house of tri became just really, really efficient. They didn't burn as much energy with their basal metabolism. They would have had low blood pressure, radiocardial, so low heart rate, but they would have been a bit colder. All of these things saved their energy. And you know, exercise is really, really overstated. It's really, really difficult to lose weight with exercise unless you give up your job and you go to the gym for two hours a day. It's like almost impossible. Because of this, you know, re-adaptation of the body, we just become more efficient at expending energy in the gym and then we just save it when we're sleeping.

5:47Dr Karan: You talk a lot about in your book about, you know, the set point of your body fat and weight. And I've, you know, seen that phrase talked about a lot, I guess, you know, almost like a thermostat. If you set the thermostat and temperature of the room at 20 degrees, if it drops below 20 for whatever reason, the heat will kick back in. If it goes too high or go back down, there's like some auto regulation, which happens. So I guess similar to the Hadza tribe and these, you know, city dwellers, the Hadza tribe are exercising a lot more. So there's a lot more calories potentially burnt. So the body tries to pull that back and claw it back to preserve as much energy by dropping the blood pressure, dropping the heart rate, making them colder, all those sort of things.

6:30Dr Karan: And I guess there's that same philosophy is also applying to weight loss as well. If someone is, for example, if I'm trying to chronically restrict my calories in an attempt to lose weight, my body is going to assume I'm in some sort of famine, hunger state, and try to cling on to energy reserves and make further weight loss increasingly harder. So that's why it becomes harder to lose weight. and also why you might bounce back in yo-yo to weight gain because your body's in that sort of worried energy deficit state. Yeah, I mean, there was a fascinating, one of the original studies, the Minnesota starvation experiment.

7:07I think it was during the war, actually. Conscientious objectors who didn't want to go into combat volunteered because they wanted to help the country in America, volunteered to basically be confined and semi-starved. So they went down to, I think from 3000 calories a day, they were working, you know, they had active jobs in the farm of the compound and they went down to something like 1500 kilocalories a day and they all lost a lot of weight, 25 % of the weight. They became actually quite skinny. When the researchers looked at their energy expenditure, you know, this basal metabolism we talk about, it, you know, claps by a lot more than you would be expected by the reduction reduction in body size.

7:50And then you look to the reason for that and it's this decrease in sympathetic neurological system drive, the SNS drive. And this is something that I think is fascinating. So in medical school, we're taught about the fight or flight response, this way we can switch on energy, we can switch on the afterburners if we're going to be in a fight or we're being chased by a wild animal and it makes us really really strong it makes us you know all the glucose goes into our muscles and our energy expenditure goes up you know and this is for survival and then conversely when you know we're relaxing parasympathetic nervous system comes into effect the dimmer switch is turned down we use less energy blood pressure comes down we have a bradycardia, we feel colder, maybe less energy to the brain.

8:42And we're taught in medical school that this is the fight or flight response, but actually, you know, the secondary and probably more important function of that system is energy or weight preservation. So if you're on a diet, you're going to go to parasympathetic tone, you're going to decrease your energy expenditure. Actually, conversely, if you overeat, and there's a lot of studies showing people who overeat don't put as much weight on as you would expect. So energy expenditure increases. And most of the people in our Western societies do overeat. So we have this situation where a population overeats, has got increased sympathetic tone, so high blood pressure, tachycardia, they feel a bit hot.

9:28Actually, they think quite clearly. And it could be actually an explanation of why Western populations have high blood pressure. that could be the secondary effect of you know the observation that they should be putting more weight on but actually they're pumping away with their hearts and the dimmer switch has turned up

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10:22Dr Karan: If you want your whole health to thrive, start by feeding the ecosystem that runs the show. Head to www.loamscience.com to try loam and exclusively for you just because you're listening to this podcast get an additional 10 % off with the code pod 10 again that's pod 10 to try loam and get an additional 10 % off loam health grows here so you know when we're thinking about weight i mean we've talked about genetics and the environment as well but fundamentally there is a gut-driven and neurological process, which also makes us physiologically want to eat food and also know when to stop. And that system can be miscalibrated and sometimes dysregulated.

11:04Dr Karan: People with obesity, it may be dysregulated, you know, and they have this food noise, which is a popular phrase these days to describe that urge to eat. But fundamentally, it comes down to hormones. Can you explain what are these hormones that are driving and influencing our appetite? Yeah. So I think first, before we talk about what goes wrong, we should talk about, you know, the system that we're all born with, you know, biologically to control our, uh, the, the amount of energy we, we store in our body. On average, a human should be aiming or biologically it's aimed to store around 60 days of energy.

11:41So if we are in a famine or we're sick and we don't need anything for 60 days, we're okay. We have stores until you know after 60 days it starts to eat into our you know vital organs and we're getting energy from muscles and things like this so 60 days is the target you know and it's controlled by this hormone called leptin which comes from our fat so the more fat we have the more leptin is produced leptin goes into our bloodstream and it acts as a signal the level of a leptin in our bloodstream acts as a signal to that little part in our hypothalamus in our brain the hypothalamus that controls our weight basically.

12:20If the hypothalamus senses high leptin levels, it sort of knows we've got too much fat on board. You know, we're storing more than 60 days of energy. It will automatically work on that and decrease our appetite, increase our satiety, and actually put up that dimmer switch of energy expenditure. And automatically, without thought or effort, but our weight will come back down. Conversely, it works if we lose a lot of weight, we've been sick or we're in a famine situation, fat stores decrease, leptin levels decrease, and you get this voracious appetite, decreased satiety and battery saving mode as far as our metabolism is concerned.

13:03So that's how it works. We should be storing around about 60 grams. And it's all to do with leptin signaling to the hypothalamus. When it goes wrong, it tends to be, well it is due to increased insulin levels so insulin and leptin share a signal pathway on the in the hypothalamus so the more insulin you have the more dilute that leptin signal so suddenly you have a situation where you may be storing a lot of fat but actually the message to the brain is blocked by insulin and you get something called leptin resistance and in fact the brain can't see much leptin. So the worse it gets, the fatter you get, the more you get inappropriate responses from the brain because it can't see, it's blinded to the leptin.

13:51So you feel a lot hungrier and you have no satiety and actually your metabolism decreases. So all of these, when you understand it, all of these, what we would say, maybe character flaws of people suffering with their weight, being a little bit greedy, eating a little bit too much and being a little bit lazy, they're consequences of leptin resistance. So it really explains in, you know, really eloquently what is happening with weight, with weight regulation. So that, and that, you know, if you've got leptin resistance, then your weight is set at that level. If you try and lose the weight, you're going to get this response from the body.

14:31Dr Karan: I guess a lot of people talk about we are now living in a obesogenic environment, which I guess is in part true, perhaps it would be more accurate based on what you've said to say that we live in a insulogenic environment where maybe the consequence of ultra processed food, by that I mean high fat, high salt, high sugar, devoid of fiber, making us consume more, chronically raising and having excess sugar driving up the insulin and increased adiposity, also driving up the insulin with insulin resistance. And as a byproduct, the high insulin and insulin resistance, you're getting the leptin resistance.

15:07So we cannot feel the satiation level

15:12Dr Karan: so much. We don't feel the fullness signals as much as maybe we used to before we, you know, mutated the environment to such a degree. On that note, now that you've got this set point and people struggling with, you know, weight loss and who are obese have that leptin resistance, how can someone begin to shift away from that leptin resistance and move the needle on their weight set point. Yeah. So obviously the worst thing you could do is go on a calorie controlled diet, which is what actually most nutritionists and doctors will still tell you to do. It's your fault. Go on and reduce your calories and go to the gym.

15:48We know it doesn't work because you're going to get the opposite response from the hypothalamus. It's going to like react back to that. It's going to make you even more hungry. Your metabolism going to go down even further. If you understand, you know, weight regulation, what the hypothalamus wants, the hypothalamus wants to see the leptin and the leptin is being blocked by insulin. So if you can tackle your insulin levels, average insulin levels throughout the day, you will slowly over probably months, maybe a year or two, reset your weight to a much healthier level. And just the things you mentioned, Karen, sugar is a real enemy, highly refined carbohydrates, exactly the same as sugar.

16:26So it's talking about things with, with weight, wheat in mainly, so bread, pasta, cakes, biscuits. Snacking, we have this Western snacking culture probably because we eat too much sugar in the morning because our insulin goes up and then the glucose goes up and then down when we're desperate to eat sugar again. And processed foods, obviously processed foods, this is a separate thing, but they really muck up our insulin signaling at the cellular level with this disparity of these essential omega-3s to omega-6, which is a totally different area, but it's really crucial for people who eat Western diets with a lot of processed foods and a lot of fast food, a lot of food cooked in vegetable oils, are going to really mark up their omega-3-6 ratio compared to historical norms, and that's going to affect insulin signaling.

17:18Insulin is going to get sluggish. You need more of it. It's going to block leptin. So from a dietary perspective, you know, all of those changes, try and only have sugar on a special occasion, a birthday party, refined carbohydrates, try and cut them out, try and cut out snacking, go to two or three home prepared healthy meals a day. Another factor that, you know, is mentioned in my book is natural saturated fats should not be avoided. They're good for you. They don't confer cardiac risk. We're talking about like red meat, dairy products. These are things that traditionally a dietician may ask you to avoid.

17:54What else can you eat? These things are great for satiety. They have minimal effect on insulin and actually in most parts of the world people realise these foods are really, really good for you. So those things from a dietary perspective and then from a lifestyle perspective, we know stress increases cortisol. Cortisol increases glucose and then concomitantly insulin. If we're both doctors, we know that if you put me on a prednisolone, a steroid, or I put you on prednisolone, we'd probably put a stone on within a week, you know, within a month. So, cortisol is really, really important. Sleep is important.

18:35Exercise is really important, but not because you're burning exercise on the treadmill. It's actually because you're in, you're in, you're decreasing cortisol, you're improving insulin sensitivity. So you're decreasing your insulin level. And that's why gyms are popular, not because you're burning off calories in the gym, but because you're making your insulin more efficient.

18:56Dr Karan: Yeah. I mean, going back to what I was mentioning, a personal anecdote of mine when I was cycling through periods of weight gain and weight loss, and it felt almost suffocating because I couldn't get out of this vicious cycle. So I do empathize with a lot of people going through that. And, you know, I think the most clarity I've found in weight loss and sustaining it has come over the last couple of years where, you know, I adhered to a lot of the things that we've discussed already, where I did start cooking my own meals, like the bulk of my meals, cooking that. And actually, you know, I do snack every now and then.

19:27Dr Karan: And for context, probably this is the slowest, but most sustained weight loss I've had. I've lost 15 kilos over two years, which is like a slow methodical weight loss. And it stuck with me. And, you know, I guess that also allows you to just subtly nudge your set point just a tiny bit instead of making huge fluctuations in the thermostat and turning it down and turning it up. And one of the things there was actually more fiber, more protein, but actually being quite calculative with the timing. So I would have most of my fiber and protein and most of my calories earlier in the day when my digestive function is at its peak.

20:07Dr Karan: So timing it with my natural circadian clock, and I would attenuate or decrease slowly the number of calories I'd have as I got later in the day, as my digestive prowess decreased. So I'd probably have only a few hundred calories in the afternoon and evening. And importantly, I'd stop eating at least three or four hours before bed. So maybe about six or 7 PM, I'd have my last meal. And then I'd have my breakfast at 10 or 11 o 'clock in the morning. So there's over 15 hours where I'm not eating, allowing my body just to kind of reset and regulate itself. And sort of that fiber maxing, more fiber early in the day.

20:45Dr Karan: So it kind of fuels me, my metabolic fuel for the day and cooking a lot for myself as well. So, you know, preparing and taking time to cook something. And even in the act of cooking and preparing something, I'm smelling it, I'm engaging with it. And my gut and brain can catch up with each other instead of eating and then feeling hungry soon afterwards. So those little shifts and just taking more of the effort for me, I think it worked wonders. Yeah. And so you being mindful about what you're eating, you're also doing a bit of time restricted eating, which is fantastic. So you're eating just in this seven hour window, um, which is brilliant because when you're not eating, insulin levels are going to go down.

21:21The leptin signals ain't going to get seen again. And what you're actually really describing is creating your own food environment. Okay. we know that if we move to Japan and embrace a Japanese diet, we lose a load of weight. You can actually do that yourself. And you've done it to a degree, not with Japanese food, but just with healthy, home-prepared, old-fashioned foods and not snacking. And that is not something you're going to get a stone or two off in a week or two, which is what people really want. But actually to have some long-term strategy, it's going to come off. Next thing you know, you control your weight again.

21:59So many of my patients who eventually come to bariatric surgery describe this real fear of suddenly losing control of their weight, you know, whereas before that biological system, the leptin signal was working for them, then something happened and suddenly, you know, gain weight, start to go on diets, worst thing you can do, regain weight, et cetera, et cetera.

22:21Dr Karan: Now, you mentioned there that a lot of people do want to lose weight quickly. There's a few popular weight loss techniques that do the round on social media in tip talk i'd love to do a quick fire myth busting what works and what doesn't hot water and lemon it's interesting i've looked into it in my second book actually sama who is the guy who's gone from 120 130 kilograms down to 75 that's the first thing he started doing he said it started to burn you know and in the arab world they love it you know they think it burns off energy i can't see any scientific way it can do it apart from maybe it introduces a bit of time-restricted eating so basically the rule is as soon as you get up you have hot water and a lemon squeezed into it but you don't have anything after that for an hour so you know maybe you're starting to stimulate your appetite or something no one's in any major research into the way it works but as you know we know you mean one of the main things that as doctors we should understand is most things we don't understand correct so and if things are popular there must be something in it you know i don't know how it works but i think it might work for some people maybe some sort of ritualistic thing but um what about raw food diets fascinating so again mentioned in i think uh my first book so we looked at this situation where maybe a tribe started to eat just raw food, you know, so a group of people isolated.

23:48And actually they would lose a lot of weight because we know that as humans, fire and cooking food actually gave us a lot more energy, you know, room to grow our brains and things like this. So if you go back to a raw food diet, you will lose a lot of weight. The females in the group, you know, 40 % will become amenorrheic, they'll become infertile. So actually, of a couple of generations, that tribe wouldn't exist. But raw food, if you can manage a raw food diet, probably you're going to lose a decent amount of weight.

24:20Dr Karan: Yeah, I guess if you compared eating a raw carrot versus a cooked carrot, the raw carrot would have more of the calories locked away because of the fiber matrix. And then you soften it with food and you unlock some of the calories and nutrients. So you'd gain slightly more weight. So I guess maybe there's something to it there. Yeah. So the raw food diet isn't just Oreos. Yeah, exactly. Yeah. We, something we mentioned already time restricted eating. I think again, it's something that's not gone away. A lot of people have, you know, not dramatic results, but they'll lose half a stone or a stone by employing that.

24:53And, you know, I think half of that is, you know, it gets rid of, you know, particularly bad habits and they're probably the commonest habit people have is mindlessly eating in front of Netflix when they get back from work, you know, it's just, it gives you this really nice hedonic kick, you know, your dopamine levels go up. It's like a drug. Feel good. You watch a bit of Netflix. That's your nice bit of your day, you know, but it's terrible for you metabolically because that food that you eat tends to be high sugar, high fat or high bad fats.

25:24Dr Karan: And, you know, we'll mess around with that, you know, your normal biological weight regulation system. So actually by time restricted eating, probably you're going to get rid of that evening mindless eating it's going to decrease your average insulin levels and it's going to cause weight loss so i like time restricted eating i think the 5-2 diet where you're semi-starving yourself for two days is actually quite difficult whereas the the 16-8 or 18-6 diet where you're basically limiting your your intake to six hours or eight hours a day is much better something that people can do most of the time obviously sometimes you're going to be going out in the evening with your friends but if you can do it most of the times I think it will have an effect.

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26:40Dr Karan: And I've been helping to build out the science as well. No forbidden photos on your phone, no awkward Excel spreadsheets. You just do what you normally do and Throne gives you trends that actually matter for your gut health, hydration, fiber intake, and even early warning signs you'd normally miss. If you want to be one of the early people to try this or just follow the journey, head to thronescience.com. That's thronescience.com. Trust me, it will be your gut's new best friend. Something that obviously we've made the case for in this conversation here is about how obesity is a biological, you know, a series of biological systems and, you know, very complex.

27:16Dr Karan: It's multifactorial. It's not just about what goes on in your brain. I mean, it's partially brain, but so many other things. And I guess GLP-1, the conversation about GLP-1s and the data about GLP-1s validates some of what we're saying in this conversation. There was a fascinating study that I came across where they looked at fMRI, so brain imaging studies, and they showed photographs of high calorie, high density foods to people with obesity and lean individuals. And the brain reward pathways associated with food in the obese individuals had greater activation for that same food than the lean individuals, suggesting that the signal, the appetite signal is higher in certain individuals with food noise, which, you know, GLP-1 therapy ended up suppressing.

28:03Dr Karan: The food perception scores came down for those on GLP-1 therapy. So we know that there is something there with GLP-1s dampening those hormonal signals and neurological cues. Do you think that significantly changed the conversation around obesity now that we have GLP-1s and even people who are not obese and who just have maybe minor food noise experience that neurological quietening of food cues and that urge and that temptation to eat even with independent of hunger states? I mean, if we look at energy regulation, we go all the way back to, you know, first of all thermodynamics, the amount of energy you put into your body and the amount of energy you get rid of.

28:46Like if you're trying to lose weight with a diet and exercise, you can think of it as a sort of tug of war analogy. So you've got diet and exercise, two guys pulling the rope one way, but actually the other way you've got heightened appetite, which is just a consequence of weight loss because your body's trying to pull you back, trying to get more energy in. you've got decreased satiety so you're always hungry and you've got that decrease in metabolism so the energy dimmer switch has gone down and you know it's a type of war it's a bit even uh the weight loss crew will win win 10th or early but then the weight regain crew will will always eventually win if you take away the hunger guy from that team which is what glp1s do the weight loss team is going to win.

29:31And yeah, it's the hypothalamus will control energy in, energy out via hunger, via hormones, GLP one, hormones, PYY. And it's really interesting. These drugs were discovered because, you know, we didn't really understand why the gastric bypass works. This is the type of operation that I do in my bariatric surgery. People had significant, profound weight loss for years. And they said, Oh, actually, I don't really feel hungry anymore. I don't really want to eat. I'm okay. So the scientists sort of, you know, tried to dig down into what was happening hormonally. And it does transpire that GLP-1, the drug in Manjaro and Zembic and Wegovi, goes sky high after a gastric bypass.

30:15So they thought, actually, let's see if we can copy this hormone, harness it and give it. And it's a massive breakthrough for weight regulation. But it does have some caveats, some weak points.

30:28Dr Karan: I guess, you know, there's a lot of behavioral strategies for people to lose weight, you know, the mindful eating, the type of nutrients that you prioritize, and various other things as well. Do you feel that they are now less important for people now that GLP-1s are around? Or rather, are they even more important given the data from the GLP-1 studies, which show that there's significant risk of weight regain once you stop the drug? and maybe there could be some attenuation of the effect of the drug the longer you use it as well. So do you think they're kind of less important or even more important now in the GLP-1 landscape?

31:04I think more important, I'm an advocate of, I know GLP-1's work. I've got a lot of patients on them that we prescribe. Some people just want to stay on them all the time. But actually most people don't want to be on an artificial drug that we don't really know the long-term 10, 20, 30-year consequence of. they would prefer to get off it. Now the problem is two-thirds of the weight goes back on within the first year. Now the other problem is if you lose 20 kilograms of weight a third of that is going to be muscle mass. Now when you come off it and you put the 20 kilograms back on which will happen within two years that's all fat.

31:42So metabolically you're in a much worse place if you try GLP-1's lost weight and put it back on. The best way of using GLP-1's in my opinion is like the smart way. So you will have this period of time where appetite has just turned off, food noise has turned down, and it's much easier to do what you always wanted to do on a diet, clean up your eating habits, drink less alcohol. You know, people say that they don't want to drink with these, with these operations, um, not snack. Now, if you can do that for a year whilst you're on GLP-1s, those bad food habits will be much less ingrained and probably you will have changed habits into better ones.

32:24If you can come off it and then embrace those changes, you may put a little bit of weight back on, but you're not going to put it all back on. You're going to be in a much better place. So I think, and it's sort of ignored by most doctors and companies that are prescribing GLP-1s and actually the companies, the pharmaceutical companies themselves, but you can probably use it the smart way. And then, you know, if you think that you maybe you're going to be putting a little bit of weight on and the food noise is a bit too much, despite your lifestyle changes, you can microdose. You can just put a little dose in now and again, which I think is a reasonable thing to do with GLP-1 drugs.

33:00Dr Karan: Now, this may be a difficult conversation, well, a difficult question for you to answer because you are a weight loss surgeon. Now, the data we have from all of these GLP-1 agonists and even the dual agonists as well, the GLP-1 GIP and, you know, incoming next year, Ritachatri, the triple agonist, all of these beginning to show, you know, weight loss equivalent to bariatric surgery with clearly significantly lower risk of side effects and, you know, risk to health. Do you think someone who traditionally 10 years ago would have gone down bariatric surgery route should be considered for GLP-1 first?

33:35Dr Karan: Or what is the case still for bariatric surgery in this landscape? So still a lot of people with quite severe obesity. So body mass index over 40, maybe they're over 20 stone in weight, they're type 2 diabetic, etc, etc. If you do a gastric bypass on these patients, the risk is really low actually. The risk of complications is really, really low. It's the same as if you had your hernia repaired or a gallbladder operations. So low risk, fast recovery, you're going to get down to 12, 12 and a half stone. and if you can embrace the operation and get into good food eating behavior which is very easy because you're GLP-1, it's high after gastric bypass, it's lifelong.

34:13You know all you've got to take is vitamins. If you're over 20 stone and you go on to Manjaro you're going to probably get down to you know maybe 16 stone but you're going to be dependent on this drug. Even the better ones you're going to still be 15, 16 stone and dependent on the drug which costs 300 pounds a month are not available on the NHS. And if you come off, you're going to put the weight back on. So I think there is still a big, big place for bariatric surgery for those bigger patients. But there's a lot of patients before, you know, maybe between 16 and 20 stone. Their body mass index is, you know, 30, 35, approaching 40.

34:51No illnesses related to the obesity. These are the people that, you know, if you're 15 stone and you go on to GLP-1s, you might get to, you know, 11 or 12 stone, perfect. You didn't need to have an operation. I mean, the other problem that we see is that in the UK, this is now going into the nuances of bariatric surgery. I think there's too much of the slightly weaker operation, the sleeve gastrointestinal where we just remove two-thirds of the stomach. You see a lot of people regaining weight after that. Whereas if you do the gold standard operation, gastric bypass, not many people regain weight after that long term.

35:30So I mean, there will be figures comparing bariatric surgery, which includes a lot of this weaker operation versus GLP-1 drugs. And they'll say, oh, actually quite a lot of people regain weight after bariatric surgery, but you've got to choose the correct operation. So correct operation, good lifestyle measures afterwards is the best for these people with more severe obesity. But the less severe ones that may have had surgery before because there's nothing else available, I think GLP-1 is a good option.

35:59Dr Karan: So a more aggressive option for a more aggressive treatment and stratifying the patient population. The good thing is though, Karen, these drugs are really highlighting the fact that it's not some sort of character flaw causing obesity. It is a biological process that can be blocked and you can lose a lot of weight because of that. Yeah, I think GLP-1s are proving what a lot of people, experts in this space have known about for years. Obesity is a chronic relapsing condition and GLP-1 is simply a long-term medication, just the same way as a type 1 diabetic requires insulin or someone with high blood pressure requires an antihypertensive medication.

36:39Dr Karan: people with obesity may require glp1 therapy lifelong or at least for a significant period of time to solve a disease condition and the consequences that obesity can do for cardiovascular health metabolic health now if we sat down in 10 years time and we're having a similar conversation what do you think the therapy would evolve and what would it be like for obesity in 10 years time So this is where we could get a bit philosophical, you know, it's probably we're going to have, you know, half or two thirds of the population on drugs to control their appetite because the food environment is terrible.

37:19You know, I think that's the way it's going to go. You know, we're going to have these, a lot of people on drugs that, yeah, we don't know the consequences in 30 years time. It could cause dementia or whatever.

37:29Dr Karan: Well, I mean, one in 10 Americans have tried or are on a GLP-1 therapy right now. So anyway, we're sort of getting towards that sort of dystopian world where the Western populations, America and Europe, are on, most of them are on these drugs to stop them eating the toxic food that's in the supermarkets. A better way of actually understanding, of actually going forward is to understand that the toxic foods in the supermarkets are causing the problem that people are on the drugs for, you know. you've got to address that and we've got to start seeing processed foods as you know hedonic drugs you know something that you know it's not going to kill you if you have it now and again but you know if it's just available and it's cheaper than fresh foods and there's no restrictions on it in by the government we're going to get a population just needs these expensive drugs all the time So it's much better that governments understand the cause of obesity.

38:27It's not a sudden global decrease in willpower and greediness. It's the toxic foods that we have from the food industry that are designed for us to get a little bit addicted to them. If those foods were treated a little bit like tobacco, high taxes, adverts saying, educating people about what they do to the population, we may get in this in a space where a little bit like tobacco now it's quite unusual in the uk to see people smoking you see it occasionally but you know in the old days everyone was smoking all the time so that would be the the positive outcome in 10 years but i don't think that's

39:07Dr Karan: going to happen if there was one habit that you wanted every listener to adopt from this conversation that would meaningfully help with their metabolic health and weight loss what would that be? I mean, we've got to get, we've got to get people's insulin levels down. So only eating foods containing a lot of sugar or highly refined carbohydrates, you know, that break down into sugar or processed food that disrupts your, your omega-3-6 profile and, and, and, uh, influence insulin, insulin signaling. So these three things, sugar, highly refined carbohydrates like wheat and processed foods that have been in the factory and can sit on a, sit on a shelf, uh, and not go off for six months or a year.

39:46If you can only have those foods, don't give anything up because you're going to start thinking about it as a treat now and again, you know, every couple of weeks, every month. Uh, but mainly embrace old fashioned food, meat, fish, vegetables, dairy products, not snack between meals. That's, I think that's a few things I've said, but that's the basis, and that's probably what you've done to lose your 15 kilograms.

40:09Dr Karan: Yeah, it's very much about nutrition. Exercise is a huge component of allowing you to, you know, build foundations to your habit and then you fuel the exercise with the right nutrition. So, you know, they're inevitably paired together and it has untold benefits for other aspects of your health, you know, better sleep, etc, which then ties into the nutrition. But yeah, I think it's about a psychological reframe and just actually, you know, taking more effort and mindfulness about preparing. Andrew, weight loss, weight gain, the whole topic of obesity is a very challenging conversation to have. Thank you for joining today and talking with such nuance as well.

40:46Dr Karan: Thank you so much. Thank you, Karen. Pleasure.