Dr. Jeffry Gerber - 'When Weight Loss Stalls'

hello did you ever notice the engineer seems to be first and the doctor follows in the footsteps the world must be upside down but anyway this is a very important topic that I'd like to discuss today because of the clinical and practical significance so first disclosure standard disclosures I have no financial ties to Big Pharma Diagnostics or medical device companies to expand the disclosures I have no financial ties to the food industry I'm the owner as Erin said of a medical practice I'm the author of eat rich live long along with either comments I'm a board member of heal clinics and I organize these medical nutrition conferences so did you ever notice when you look at weight loss figures and graphs in clinical trials that they take on this appearance of a check mark and by that I mean during the first six to twelve months you see this weight loss maximum weight loss and then you hit this plateau at the bottom and then the weight starts to creep back up what's going on well I have some examples so here's the scheie study that doctor I ain't felt mentioned this morning and you can see in the purple that well low-carb wins when you compare it to other diets but there's a check mark in all of them and so my interpretation is a little bit different and dr. ayan felts that there's something going on with all these diets that you see a checkmark here's a bariatric surgery study and you can see that the big gastric bypass on the bottom in the red you get the maximal weight loss but there's the check mark here's this famous Stanford A to Z study again no argument the low carb diet wins but the weight starts to creep back up so the question is what's going on here why does the weight come back up how can we prevent that and what can we do to stay healthy so look you know we're all low-carb advocates here in the room but when it comes to the question of the long term is low-carb enough so I want to look at a couple diets and here's some pot pie charts looking at macronutrients and we're using the color palette from My Fitness Pal and interestingly they use fat in the red color a little bit of subliminal messaging there but here's your typical low carb high fat where 70% of the calories in the red come from fat 20% in the green from protein 10% carbohydrate and the focus again is on the macronutrients a variation would be the Paleo diet where you perhaps eat a little less fat a little bit more protein a little bit more carbohydrate but poorly represented as you're not focusing or you're not addressing the macronutrients the nutrient density and the quality of the food that of course is important then we have your typical low-fat low-calorie diet where calories is all that matters and since fat is energy dense you should eat less and replace it with carbohydrate up to 55% this one's kind of humorous we call it the perfectly balanced diet where a third of the macronutrients or a third of the energy rather comes from each macronutrient this has to be correct because it's mathematical precision right and then we have the protein sparing modified fast which looks like a hype protein type of diet now protein sparing refers to sparing lean muscle mass but you'll see that it's actually a calorie reduced diet and at the end of the talk I'd like to explain how a protein sparing modified fast is very similar to low carb high fat keto and last but not least and poorly represented is fasting where you just don't eat but again poorly represented is that it doesn't account for the fact that feeding is time restricted and so it's actually been shown that eating less frequently may help to increase resting energy expenditure just like a low-carb high-fat diet but the question is we're looking at the long term and which of these diets are addressing hormones calories metabolic health metabolic disease the nutrient density so we want to take a look further so I'd like to do a couple of minutes of comparing the hormones to the calories so as you know Gary Taubes was here a couple days ago and I had first met with him here back in 2011 and what does Gary Taubes have to say about all this of course he says that adiposity is a hormonal disease and insulin is this fat storage hormone and you therefore simply focus on insulin and you'll address insulin resistance hyperinsulinemia and metabolic syndrome but the question is again when it comes to the long term is that all you need to focus on well look on the short term Gary Taubes is right because it turns out that almost two-thirds of the US population over age 45 are currently pre-diabetic diabetic or they have some form of metabolic disease so across the board it's a good recommendation to tell people to reduce carbohydrates and to reduce especially processed carbohydrates so here's a picture of a dam what happens when your insulin resistant the energy is trapped like a dam you cannot tap into it so you treat insulin resistance with a low-carb high-fat ketogenic diet it reduces insulin levels insulin resistance improves and all of a sudden you oxidize fat and it's opening up these insulin floodgates the energy is available and it comes pouring out and there's a metabolic advantage for diabetics when you understand the physiology and these high calorie diets seem to defy thermodynamics how can that be well it's just that you're not accounting for the energy properly and of course we know that eating less is spontaneous and there's a psychological antigen our patients to focus on satiety rather than deprivation that's great but in this scenario maybe calories don't matter but imagine this you have a diabetic patient goes on a ketogenic diet loses a lot of weight I will guarantee that if that individual continues to eat the same way that they were at the beginning they're going to hit the plateau and the weights going to come back up and so that brings in the aspect that yes the quantity and the calories do matter so what about the calories let's take a look at that so Gary Taubes does a nice comparison between the issue of the calories versus the insulin and he asks these two profound and simple questions the first question are we fat because we overeat that's really in support of calories and calories out that were gluttons and sloths but then there's a second question do we overeat because we're fat which suggested that there's a metabolic disease that starts first and that's what's driving our appetite guess what this reminds me of the chicken and the egg now we're trying to figure out what came first here I think when it is the argument about the calories and the insulin I think we have to consider both so more about the calories here's an endocrine society scientific statement from George Bray at al last year and what do they have to say about this they say that weight gain starts with a positive fat balance so you begin to accumulate fat then you see the subcutaneous fat expansion it leads to dysfunctional subcutaneous fat and then you get it's the expansion of a topic visceral fat and then metabolic disease and Sue's but what you want to realize here is that you can actually gain fat before metabolic disease kicks in it's not always about the hormones so we have these two schools these two vice of schools and they want to draw a line in the sand but what I'm suggesting to you is that the two schools come together so we have the calorie camp on one side and we have the endocrine camp together on the other side and they come together in perfect harmony and when we form a new school called the school of food energy and metabolism and best of all it's bipartisan my political statement for today now in honor of this new school I've come up with a new book title so here it is how we stay slim now you may have noticed I stole some of the imagery from carrot Gary Taubes thank you Gary but that's the real challenge and the idea that we want to combine this endocrine and this caloric centric axis together and to realize that hormones and calories are both important but this calorie in calorie out Seco model is just too simplistic so let's see if we can expand on that so of course calories in calories out is based on the first law of thermodynamics you simp simply put things into a bomb calorimeter and see what you get out but you have to understand the body obeys the first law of thermodynamics but that's not what it's interested in doing it wants to process energy so let's change this let's call it energy in and energy out and again the interesting part is that we're processing the energy we have a decision of partitioning the energy whether we can use the energy immediately or whether we can store the energy we have a decision whether we can use the store the stored energy or not and then the energy outside what do we do with the energy that's available and very important is feedback which is very common in biologic systems and two examples here our satiety and hormones so again you see it's the processing of the energy that we're really interested in knowing more about so just to summarize in some detail again nutrient partitioning I just mentioned the availability of the stored energy the feedback there's a lot of pathways going on there what are the most satiating foods that affect these pathways so we all know if you're diabetic if your insulin resistance a low-carb high-fat diet does work really well but you know if you're metabolically healthy insulin sensitive complex carbohydrates can also be filling don't boo me so did you know that it takes energy to utilize energy I think Maria talked about that so 25% of the energy is needed to metabolize protein 15% for carbohydrate less than 15% for fat now you have to consider if you eat predigested food well energy less energy has to go into metabolizing it what about increasing resting energy expenditure or the energy out now BAM Bickman talked about uncoupling protein and adipose tissue brown adipose tissue releasing energy or wasting energy that's one pathway but ketones are high energy molecules and you breathe it out and you can also urinate it now I like to think of it as not wasting energy but if you have metabolic disease these pathways serve to correct a reverse metabolic disease isn't that amazing and then of course if you increase your muscle mass that's going to help to increase reading enter resting energy expenditure and so again it's energy processing that is most important so let's shift to the clinical and show you how we apply this in the office so generally we look at for body type some patients come in so we have insulin sensitive groups and the insulin resist groups so here we have the insulin sensitive groups and the one on the left is the slim metabolically healthy individual and we hate this person because they can eat whatever they want and it doesn't seem to matter at least initially and long-term they might do okay and we joke that you never want to take nutritional advice from that in for that individual because they can eat a vegan diet they can eat a carnivore diet and they never get sick so on the right though interestingly we have the insulin sensitive metabolically individual that's overweight they have a lot of healthy subcutaneous fat unfortunately it tends to be the female population and with both these groups that really represent a smaller number in the population if you put them on a ketogenic diet they might fill them up but they're often frustrated because it doesn't do anything they want to refund and you measure their metabolic markers insulin C our PE lipids and they're fine but you have to recognize that there are insulin sensitive people and so then we have the second group the insulin resistant people and this is why Gary's right because it it does represent two thirds of the population and so the individual on the bottom left is a slim individual it doesn't have to put on a lot of fat and they become insulin resistant or diabetic very easily and we refer to them as tophi thin on the outside fat on the inside and we see a lot of Asian population that that fit in this particular category and then of course on the right we have the typical type two diabetic dare I say American it is global but they have a lot of subcutaneous and visual dysfunction dysfunctional fat and they've got a big problem and as you know putting them on a low-carb high-fat diet initially works wonders because of the physiology but you know there's not just these four body types there's this spectrum of insulin the insulin special is a spectrum that we use clinically to determine where somebody is so we have the insulin sensitive on the left and the full-blown diabetic on the right so depending on your sex your age where you are in your life this can change and you use your metabolic markers to figure out where somebody is and this helps us clinically so why is it that we have all these different body types well the personal fat threshold helps to explain it and simply stated the personal fat threshold describes how much subcutaneous fat your body can hold before it says I'm full and then the energy needs to go somewhere else it starts to spill into visceral fat in the middle and then the organ fat on the right so I'm going to give you three examples so if you look on the left at the Vista subcutaneous fat here's an individual that tends to accumulate just a little bit of subcutaneous fat before the system fills up we have a second individual okay they can store a little bit more subcutaneous fat and then we have a third individual it can store a lot of subcutaneous fat but at some point it becomes dysfunctional uh-oh where's the energy going to go it spills into visceral fat and then that fills up that becomes dysfunctional we've got a big problem now there's almost no place to go now we find a home in the organ fat and you get fatty liver and then that fills up boy are we in trouble we've got inflammation everywhere our blood vessels turn fire hot they get inflamed the next thing you know you have a heart attack and you're a dead person so that's not a good scenario but that describes the personal fat threshold and I think if we can predict the personal fat threshold moving into the future that'll help us clinically so let's shift gears and talk about age aging gracefully and I have a little figure of the mitochondria so why is aging and the mitochondria connected well that's where cellular respiration happens and energy is processed but there's a byproduct there's actually two the byproducts are did heat and oxidative stress so I want to try to take you through this and make this simple so we have a fuel mixture that comes into the body fat carbohydrate protein so fats the triglycerides get broken down into fatty acids it goes through a process known as beta oxidation where it's cleaved and in a state of low glucose low insulin or fasting you also get ketones produced by the liver another source of energy you must remember that the triglyceride backbone is glycerol which is essentially glucose so when there's no glucose around you can tap into glycerol and then in the middle you have carbohydrate so carbohydrate runs through glycolysis and it dives down into the TCA cycle into the mitochondria and you get your energy now fat can be used for energy as well but we think of that more of a building block so here again are the macronutrients diving through into the cytoplasm of the cell and it makes its way into those little mitochondria and then your energy is produced as ATP and here's your ATP molecule and it's the third phosphate bond that has all the energy in it and when it's cleaved the energy is release released and you can use this for all the other processes in the body to make us live move and breathe now I hope I can simplify this but I'd like to talk about oxidative phosphorylation and I'm really diving into the inter inner mitochondrial membrane of the mitochondria and just remember the simplicity of the fact that we're looking at battery and a motor and if you don't understand it at the end I have not done my job so we have fuel coming in fat protein carbohydrate and that energy gets delivered to the coenzymes nadh and fadh2 and they contain electrons and hydrogen protons and they get donated or transported through the main brain so this membrane is the battery okay so what happens is the electrons literally in the yellow they run through this membrane they're accepted at the end by oxygen and the energy from those electrons are used to pump hydrogen protons across these complex C's 1 3 & 4 and so over time you see more hydrogen protons on one side than the other you've created an electrochemical potential another word for that is a battery so like any battery it wants to discharge itself so how does it do that so there's the structure on the right known as ATP synthase and we think of this as the tiniest biomolecular motor and through a process known as chemiosmosis these hydrogen protons literally fly through ATP synthase and out comes the ATP molecule now here's a schematic video of ATP spinning like a motor and spitting out that ATP and it's fascinating because your body with all the cells producing ATP amounts to your body weight in ATP per day and if that process is stopped you're dead in ten seconds or six seconds excuse me so now what I'd like to show you is to dive in a little bit further hopefully you're following and to show you that there's actually two ways to charge the electron transport chain so we just went in a little bit deeper and to show you that there's a rapid charge and a slow charge the rapid charge is glucose and the slow charge is fat so in this example we're eating predominantly a high carbohydrate meal such as bread or we have lots of glycogen stores well again the glucose runs through glycolysis through TCA cycle and the predominant energy is delivered as NADH well what happens to NADH the electrons and the protons both run through this complex one and you have to understand the clamp complex one is a very high energy state and as you move down the chain energy tends to taper off and in terms of electricity when we're talking about a high energy state we're referring to high-voltage high-current high power circuit so it's very efficient the energy rushes through it charges the gradient rapidly but there's a byproduct and the byproduct is unwanted heat and oxidative stress now what happens to fat when you eat a fatty meal such as bacon well it turns out through beta oxidation you end up producing a significant amount of fadh2 so what happens at that level well it turns out the electrons run through that complex to is tucked away under the mitochondria or under underneath the membrane and the electrons although they rush through at that level the hydrogen protons don't run through until later down in the electron transport chain so remember I said energy is lower there so it turns out that fat energy does charge the electron transport chain but at a much slower rate it's kind of slow charging and the positive side effect is that you get less oxidative stress and less heat so let's summarize real quick glucose rapidly charges the gradient it heats the battery it increases and and it increases oxidative stress and you compare that to saturated fat which slowly charges the gradient and decreases oxidative stress so there's a difference this is a key point of the presentation but you also know that saturated fat delivers more energy per gram and I submit to you that the concept here is that it's it's fat saturated fat that on the long term delivers more safe energy does that make sense so this reminds me of The Tortoise and the hare question is what's the competition well the competition is who's going to age more gracefully so of course the hare wants to win the race and get a jump out of the gate so it chooses the high energy fuel glucose and then it says well no I really want to win this race so I'm gonna add some nicotine some caffeine maybe some anabolic steroid and the rabbits created a fuel mixture that's essentially nitro methane imagine the oxidative stress and then we have the Y's tortoise who chooses the safe fuel fatty acid and you know the moral the story that the tortoise wins but I think it is fair to say that when it comes to fueling your mitochondria it's your choice but clearly longevity is an endurance sport we're getting there so we've been talking about the charged particles and oxidative stress we're referring to free radicals I'm not talking about flower children or conscientious objectors we're talking about unpaired electrons or charged particles we also see reactive oxygen species that can be good things and bad things it turns out the body has natural antioxidants to take care of it and so it is when the charged particles and the unpaired electrons get out of hand that we've got a big problem so the idea is to keep our mitochondria healthy on the Left producing lots of energy and low oxidative stress compared to the unhealthy mitochondria on the right that are producing low energy and high oxidative stress now BAM Bickman would refer to this as using fat to couple to the mitochondria in a very healthy way and I've just explained to you how saturated fat perhaps ketones are the healthy fuel so the fuel mixture matters there's many other things the effect of ketone themselves of signaling reactive oxygen species electron transport and Jeff folic there's a reference he wrote a paper on my de hormesis and I would refer you to that we're almost done so I'm going to show you like I said how a protein sparing modified fast is very similar to low carb high fat diet so we're looking of chart of a low carb high fat diet over time so this individual typical low carb high fat is eating 10% of calories from carbs 20% from protein 71% from fat for a total of 2,000 calories patients doing great losing weight for illustrative purposes when the individual eats less it tends to be less fat you may not even realize that so let's see what happens so overtime dietary fat drops but now we're accounting for the body fat that we've tapped into or oxidizing body fat we add the two up we're still at 71% fat that the body is using for energy 50 grams of carb 100 grams of protein 2,000 calories it appears like nothing has changed but now let me show you and define this as a protein sparing modified fast so here we're eating the same amount of carb the main same amount of protein but we're just accounting for dietary fat we added up and all of a sudden it looks like 2,000 calories is a thousand calories what's the difference mathematics that's it so I don't care how you add up the math but the point is there's less calories coming in and yes the calories and the quantity of food are important so here's kind of a summary saw slide Iver mentioned some of these things and you know about this so you want to limit processed food you want to eat real food BAM Bickman uses alliteration so I'm stealing the line from Ben to control your carbohydrate prioritize protein and fill with fat if you're doing this right appetite will be controlled but I hope you understand that sometimes you do have to focus on quantity and calories of foods and you have to not deprive people of food but to find ways to control appetite and there's little tricks of the trade so supplements are important stress sleep and sun night sunlight is also important movement and activity really to increase resting energy expenditure with increased muscle mass now I would hope that Gary Taubes and Dariush massive Arion will agree to some of the concepts here so I'm trying to bring this together so I'm going to end with one of my favorite cartoons and the caption says FDA to retool the food guide pyramid citing consumer confusion well of course we're concerned we're confused of course we're confused if these dietary guidelines are turning us into fat unhealthy food pyramids so it is our our hope that as we move into the future that these dietary guidelines will keep up with the science thank you [Applause]

Channel: Low Carb Down Under

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Keywords: Low Carb Down Under, LCDU, www.lowcarbdownunder.com.au, Low Carb Denver 2019, #LowCarbDenver, Denvers Diet Doctor, Jeff Gerber, Eat Rich Live Long, lipedema, weight loss, LCHF, Low Carb High Fat, Ketogenic Diet, protein sparing modified fast, adiposity hormonal, insulin, personal fat threshold, oxidative phosphorylation, Low Carb Conferences

Id: nkxHmrKwcwQ

Length: 30min 7sec (1807 seconds)

Published: Sat Sep 07 2019

Reddit Comments

[u/DavidNipondeCarlos]

My weight loss stalled but I did look good. Low carb put the final touch in a few months. I had lost the weight with the calorie count ten years ago ( the agony of it ). Low carb was the only way at the end. You can still drink ethanol by the way.