Muscle for Life with Mike Matthews - Spencer Nadolsky on Reasons to Use and Avoid Weight Loss Drugs

Episode Date: February 1, 2023

There’s a weight loss drug revolution happening right now. Medicines containing semaglutide (like Ozempic and Wegovy) used to treat diabetes have recently gained FDA approval for obesity, and many people are turning to drugs to help them lose weight. Weight loss drugs aren’t new—previous medications like fen-phen turned out to be dangerous, and even taken off the market. However, these newer drugs appear much safer and even more effective. So, are these medications the solution to the obesity epidemic, an unfair “easy-out” for people who need to learn to eat less and move more, or just the latest attempt by Big Pharma to cash-in on a problem created by Big Food? To help discuss the matter, I invited friend and obesity specialist Dr. Spencer Nadolsky back onto the podcast. In case you’re not familiar with Spencer, he’s a Board Certified Family Medicine Physician, author of “The Fat Loss Prescription,” and a Diplomate of the American Board of Obesity Medicine. He knows his stuff when it comes to hormones, fat loss, and yes, memes (which you can find all over his instagram). He’s also been on the podcast before to talk about PCOS, thyroid health, and heart disease. In this interview, Spencer and I discuss . . . - Why some people can’t seem to lose weight with diet and exercise - The latest weight loss drugs and how effective they are - How GLP-1 (glucagon-like peptide-1) receptor agonists like semaglutide work and help people lose weight - The disadvantages and side effects of weight loss drugs - Who should and shouldn’t take these medicines and who might have trouble coming off the drugs - What really causes obesity (genetics versus environment) - The role of Big Food in the obesity epidemic and how to fix the problem - And more . . . So, if you’re interested in learning about the latest science in the weight loss drug field, or have ever scoffed at the idea of someone taking a weight loss medicine when diet and exercise alone should work, listen to this podcast and let me know your thoughts! Timestamps (0:00) - Try Fortify today! Go to https://buylegion.com/fortify and use coupon code MUSCLE to save 20% or get double reward points! (6:21) - What are the most popular obesity medicines and how effective are they? (18:01) - Should an overweight person try obesity medicines first if they haven’t tried fundamental lifestyle changes? (20:58) - Why wouldn’t you consider these drugs for just anyone? (25:18) - Can this medicine help some people rewire their habits? (29:48) - What are the driving factors of obesity? (41:13) - What are your thoughts on big food companies and their responsibility with obesity? (46:17) - Where can we find you? Mentioned on the Show: Try Fortify today! Go to https://buylegion.com/fortify and use coupon code MUSCLE to save 20% or get double reward points! Spencer’s Instagram: https://www.instagram.com/drnadolsky/ Spencer’s TikTok: https://www.tiktok.com/@drspencer

Hello, this is Muscle for Life. I am Mike Matthews. Thank you for joining me today for another episode. In this episode, I interview my buddy, Dr. Spencer Nadolsky on weight loss drugs, because a lot of people are talking about, well, one drug in particular, semaglutide, also known as a Zempic and Wegovi, or Wegovi. I guess I'm not sure exactly how to pronounce that, but that's the drug that I am getting asked the most about. And there are a couple of others though that are quite popular, and there's a lot of controversy surrounding these drugs, whether they are a good thing, a bad thing, a good thing for some people under some circumstances, and a bad thing for other people under different circumstances, and so on.

And as Spencer specializes in obesity medicine and has prescribed these drugs to many people and seen firsthand both the good and the bad, I thought he would be the perfect guest. And Spencer has been on my show several times before. He's talked about PCOS, thyroid health, heart disease, and he was happy to come back and talk about obesity medicine. And so in this episode, you are going to hear from Spencer on a variety of things related to weight loss. He talks about why some people practically just can't lose weight and keep it off in any meaningful amount with just diet and exercise. Now, of course, they could. It is possible. But again, practically speaking, it does not work well for many people. And Spencer gets into some of the nuance that is lost when

people take extremes, when they say that obesity is purely genetic and there's nothing that can be done about it whatsoever. And diet and exercise is really just a waste of time for the people with wrong genetics. That's one extreme. And then you have the other extreme, which is like the fitness fanatic who says that ultimately a calorie deficit is a calorie deficit. And if you choose to not maintain a calorie deficit, that's your problem. That is your fault. And if you just had enough discipline, if you just had enough willpower, if you wanted it bad enough, you could lose the weight, but you don't, so you can't. Spencer also talks about the latest and most effective weight loss drugs and who they are appropriate for and who they are inappropriate for because there are disadvantages. There are

side effects. There are reasons to not take these drugs like you might just take vitamin C. And Spencer also shares what he believes will be the optimal approach to weight loss medicine. Basically, how to best marry the medical approach with the lifestyle intervention approach for the best long-term health outcomes. Before we wade into it, many people say that you are as old as you feel, and there's definitely some truth there. But for us physically active people, for us fitness folk, it's probably even truer to say that we are as old as our joints feel because healthy, functional, pain-free joints make our workouts more enjoyable and more productive, as well as everything else we do, really. And that's one of the many reasons to be a stickler about eating right, about training properly, about getting

enough rest and recovery. In some ways, your joints are a reflection of how well you take care of your body on the whole. And supplementation can help as well. And that's why I created Fortify. It is a 100% natural joint supplement that reduces joint pain and enhances joint health and function and in people who already have healthy joints. It is not just for people with joint problems. And the reason Fortify is so effective is simple. Every ingredient is backed by peer-reviewed scientific research and is included at clinically effective levels. And those are the doses used in the studies that found benefits. And all that is why I've sold over 90,000 bottles of Fortify and why it has over 904 and five star reviews on Amazon and my website. So if you want healthy, functional and pain-free joints that can withstand the demands of your active lifestyle and even the toughest training, you want to try Fortify today.

today. Go to buylegion.com, B-U-I-L-E-G-I-O-N.com slash Fortify and use the coupon code MUSCLE at checkout and you will save 20% on your first order. And if it is not your first order, you will get double reward points. So that is 6% cash back. And if you don't absolutely love Fortify, just let us know and we will give you a full refund on the spot. No form and no return is even necessary. So you really can't lose. Go to buylegion.com slash fortify now. Use the coupon code muscle at checkout to save 20% or get 6% cash back and try Fortify risk-free and see what you think. Doctor, actual doctor, by the way, Nadolski, thank you for coming back on the podcast. Always a pleasure. I feel like I need to say that

because you don't always know, just like Dr. Jill Biden, like what kind of doctor are you exactly? Yeah, who is this? Who is this memeologist, meme-making, woke cuck? Vaxxed and boosted. Boosted up.

Let's just focus on obesity medicine which is something that i've been getting asked more and more about recently and for reasons you'll go into particularly semaglutide i think i'm pronouncing that correctly i should have probably checked that pronunciation and so anyway i've been asked a lot about, and this is your area of expertise, and not only from a research perspective and understanding what these drugs are and how they work, but also with patients, right, and seeing firsthand results. And so I wanted to bring you back on the show to have a discussion about these drugs. And maybe we could start with what the most popular weight loss or obesity medicines are

right now and a little bit about just how they work and maybe how effective they are. People will probably say like, why does anybody ever need an obesity medicine? Are you kidding me? You just get into a calorie deficit, you eat clean and you eat some chicken and broccoli and you lose the weight. Well, so the issue is most people understand what to do from the most part. Now, you know, maybe there's some little nuances here of how to actually get into a deficit if you don't really understand, you know, how many calories or whatever in your foods. But like a lot of people have done these types of diets and different programs, even with some of the best coaching out there. And if you look at even studies looking at gold standard intensive behavioral therapy, where they're meeting with a coach once a week, they get the physical activity guidelines and

even supervised physical activity, both lifting and aerobic exercise and really intense dietary behavioral therapy. there's a small percentage that do really well with it. And we see them, we see them on the internet, there's people that have lost a million pounds with keto, a million pounds with whatever. And you see the highlights. What we don't see are the majority, unfortunately, don't do nearly as well. If we look at averages, you know, the big study that everybody points to because it was so big, it was called the, called the look ahead trial, thousands of people. And they did this intensive behavioral lifestyle.

And over the course of now we're getting, you know, past 10 years or whatever we, you know, you want to make sure people are losing at least 5% of their weight. But for someone that's 200 pounds, that's 20 pounds or 10 pounds. If 10% is 20 pounds. So 10% is really good. 5% is okay. So they lost 10 pounds and people are like, that's not great. Over what period of time?

So when they look at these studies, it's generally a year long, but then you want to extend it to see how long they're keeping it off. That's like a good gold standard trial to look at to say like what actually happens to people that have this really good lifestyle and just the majority of people won't lose a lot of weight, what people would hope to lose. And so you're like, well, what's going on here? Well, when you look at some of the, what we call like the pathophysiology or the reasons people aren't losing weight, they look in the mechanisms and people get hungry when they're trying to lose weight and keep it off. You know, we could we could debate on, you know, set points and whatever.

Actually, I'm friends with some of the scientists that go into that. And there's some people like, no, no, there's no actual set point, whatever. I'm not an expert in that other than I need to understand it a little bit. We just have biological drivers that fight against us. Our biological drivers are a lot related to appetite. You've talked about non-exercise activity, thermogenesis in the past. Some of that kind of goes down, but a lot of it is our drive to eat. And so we're surrounded by yummy, high calorie foods all the time.

Your coworker brings in donuts and cookies every day and you're trying to eat well, but there's only so long that you can stay away with it when you're, especially when you're in a calorie deficit, trying yourself, because you're, it's just like your brain's going, eat that, eat that. And you're like, no, I'm going to eat my chicken or whatever the heck, whatever the heck you, I'm going to drink my protein shake, whatever. Some people are able to do it. They do great. But a majority of people, unfortunately, just can't do it. So we look at weight loss medicines as kind of that next step. And the thing is, a lot of people were burned because if you remember fen-phen, which is fentramine, fenfluramine back in the 90s, the fenfluramine component caused

heart valve issues, valvulopathies. And so that burned a lot of people are very skeptical of weight loss medicine. But these medicines in general, there's some that work slightly differently. But in general, they work up in the brain to help people with appetite. Phentermine is still around. That one is around in the 50s, but that's when they combined it with finfluramine, which was a serotonin-like agonist. They put it with phentermine, which is kind of a sympathomimetic amine, they call it. It's kind of like amphetamine-like, but it's not addictive. Works up in the brain, norepinephrine, and helps people with appetite. Those were kind of the mainstay drugs. It wasn't until recently we got

into these, now they're the most popular, are these GLP-1 agonists. And the reason they're so popular is because they're extremely effective and much safer than previous drugs. The way they basically work is we have these receptors up in the brain, and that's what controls our hunger, satiety, and even our reward system. The reward system, think of it as like, hey, I'm full and satiated, but for some reason I want that cookie. Like, I'm full. I don't understand. Why would you want that cookie? Well, that's part of our reward system, kind of having you go towards that food. These drugs can not only make you feel satiated, but also kind of make you not care to have that

cookie or not. GLP-1 is glucagon-like peptide one. They're called incretins because back in the day, I don't know if it was the fifties, I can never remember the exact date, but they injected glucose into the veins versus like ingesting glucose. And you would think that ingesting or injecting glucose would spike your insulin a little bit higher and faster than, and more so than ingesting, drinking the glucose, but something about drinking the glucose made your insulin go up. And they called it the incretin effect or intestinal secretion of insulin.

And then throughout the years, they were trying to figure out what were these incretins. There's a few of them, but GLP-1 was one of them. And it wasn't until the early 2000s or late 90s where they started trying to figure out how to make an agonist of this GLP-1. Because when you inject just GLP-1 into people like our own endogenous, it gets degraded very quickly. So they wanted to see, can we make this so it doesn't get degraded quickly and actually has an effect?

And they wanted to make it for type 2 diabetes. So the first one was approved in 2005, actually, called Bayeta or Xanatide, injected twice a day, helped people with their blood sugars, and also, unlike insulin, helped people lose weight. So insulin helps with the blood sugars, but makes people gain weight in general. But these new ones, they actually help the body produce more insulin, but help people lose weight and help lower blood sugars, which is kind of interesting. And the primary mechanism through which they help, right, is reduction of appetite. So that's for weight loss. But for blood sugar, they actually lower what's called block glucagon, lower glucagon. A glucagon is a hormone that increases our blood sugar.

And if we need it, because if your blood sugar goes too low, glucagon comes out and helps release blood sugar into our blood. That's one of the mechanisms. It helps augment the pancreas's effect of releasing insulin. It helps the pancreas. It doesn't burn it out. It actually protects the pancreas as well. So that helps that. But then also helps you lose weight, which can help reduce insulin

resistance. So you don't need as much insulin in the long run there. So throughout these years, since 2005, the biota was, you know, twice a day injections, which is kind of annoying. Then they came out with something called liraglutide, which is Victoza, as people might know it. That was a once a day injection. And then actually in 2014, they increased that liraglutide and got it approved as sexenda for specifically obesity. And now people are losing about 7% of their body weight, which for a lot of people doesn't seem like a lot, but it can have an effect, of course. So that's, again, a 200 pound person losing 14 pounds. And specifically for weight loss though, the mechanism is reducing hunger. That's what I've heard from people who have used it, reached out and said, hey, this thing killed my appetite.

Like I was just talking to somebody a couple of weeks ago who was telling me that how amazing it was. Now, this is something we can get to. This is someone who actually was doing quite well with just eating well and exercising. And he wanted to lose the last 10 pounds to get his six pack. And he just wanted to make it as easy as possible. So he's like, yeah, whatever.

I'll just inject this drug. And he was like, wow, I don't even care to eat food anymore. This is cool. Yeah. So, you know, I wouldn't prescribe it to that person, which is interesting. I don't know where they got it from. But yeah, we can totally get into the indications. A friendly doctor, I'm sure.

Friendly doctor. A non-boosted friendly doctor. Okay, so that was a once a day injection. It was pretty good. Researchers still trying to figure out how do we make this last longer? How do we make it stronger? And eventually there was one called Trulicity or Dulaglutide. That never got approved for obesity, but it was pretty good for blood sugars. That was once a week. But then Semaglutide came out

and got approved as Ozempic. Semaglutide is the generic name. That's the one most people are talking about. And I'll talk about the one that just came out recently. But Semaglutide, once a week injection. They started as Ozempic for type 2 diabetes, and that was only one milligram at first when it got approved. It's actually up to two milligrams now for Ozempic, but that was a later thing. They studied in higher doses from one milligram up to 2.4 milligrams and studied it for obesity. Then they published, it was like 2021, the effects, it's called the step

trials, but step one, people losing about 15 or so percent. So they doubled what was seen in the last GLP-1, which was that Saxenda or liraglutide stuff that was once a day. Now we doubled the weight loss effects. The thing is that people get worried about like, it seems like a crutch or a bandaid, but what it really does is helps you do the things that you already know you should be doing. And like, you know, probably, hey, I shouldn't take an extra serving. You know, I should probably keep it as this plate. I should probably eat broccoli instead of the French fries.

I should probably eat apples instead of those cookies or donuts. Right. It's pretty, pretty straightforward. You know, some of it's, um, again, there's a little bit of nuance, but most people understand that these drugs help you do that without, without having to like, what I call white knuckle it or, or really strain your executive functioning in your brain. It gets rid of that food noise. What people say, there's like kind of these like little voices going, eat, eat, eat, eat more, eat more. And they basically quiet it down.

And so that's the newest one, the semaglutide stuff. You only have to inject it once a week. It's approved as we go before obesity. And they're actually, I just posted this. They're actually studying it to go up to much higher doses of it. But like 7.2 and even 16 milligrams and those with type 2 diabetes, we'll see if it has more of an effect. And then the most recent one that was released called Manjaro or Terzepatide, they call it a twin creatine because there's two incretines and

there's GLP-1 and GIP. Whether the GIP has an effect more on appetite is debated, but that one in obesity, folks with obesity, that actually helped people lose 21%. So now we just tripled what we saw from the Saxenda in 2014. So in just eight years, now we saw triple the effect and just absolutely remarkable. I've never seen anything like it. I have lots of patients on these medicines. Now, granted, that one's only approved for type 2 diabetes right now. It's likely going to be approved for obesity coming up here soon. So if you're listening to this and it's approved, awesome. But it probably will be approved. But I've never seen anything like it. It's extraordinary. And we're getting close to what you see in bariatric surgery studies, which is pretty cool.

to what you see in bariatric surgery studies, which is pretty cool. And what are your thoughts? Somebody who is very overweight, who let's say they haven't tried anything, let's say evidence-based, they maybe tried a couple of weird fad diets and maybe they lost a little bit of weight and gained it back, but they've never really understood maybe energy balance and macronutrient balance. And they've never tried eating a high protein diet as opposed to a high carb, high fat. They haven't tried some simple things, lifestyle modifications that, as you mentioned, some people do succeed with. Many people,

it's not a majority, but in an absolute number, many people do succeed with a lot of the fundamentals that we preach. So what are your thoughts on that person? Should they try first to do it without drugs, without medicine? Because there usually is, there's the giveth and the taketh, right? How does that work in the context of these medicines? Or so far, does it really look to be like, no, it just looks to be all benefits and no real side effects, no long-term possibilities? I think this is a great nuanced question because, you know, there's some of these, you know, big pharma shills, if you want to call them, that would basically be like, no, everybody needs to be on drugs. Like it's even stupid to

try diet and exercise. And then there's other people that are basically like, I can't believe that we're using medicine. And the answer is that first there needs to be patient autonomy. You can discuss the benefits and risks. In general, though, if you can get somebody excited about trying an evidence-based way with very intensive coaching, I think it's worth a shot. Now, the question would be, like, if this person has like no health problems, just excess weight, there's not as much of a rush. If somebody's like, this guy's had a heart attack, he's a walking time bomb. And if we

like prolong this any longer, we don't know how much life he's going to have. You know, you could argue, hey, maybe we need to be more aggressive with that person. Maybe we just need to give them the medicine because there's no way in heck this person's going to do it. What I see though, I see most people that have done so many different programs so that a lot of the people that I see are coming to me for medicine. But if I'm in a general clinic and I'm assessing somebody for weight loss for the first time and they've never tried anything, I talk to them and most people, most people will go, you know what, let me try this more intensive program first. I think that's a fine answer. I really don't think it needs to be one way or the other. I think it's one of those things where it's like, look, if somebody's tried it multiple times, but as you're saying, if the person's kind of like naive to the whole, like trying a real,

like evidence-based gold standard type of coaching program, I think it's totally worth doing that unless they're at just such a high risk where like, we better get this weight off this person. They don't have much longer. And that's rare. You don't see that that often. And so I think that's a, it's a great question though. And I think this is where some people miss the boat, especially when you look at like tweets and whatever. And it's like, this person's a shill, this person's ignorant. You know, why can't we talk about this a little bit more? So yeah, good question. And your comment about my buddy suggests that you wouldn't consider these drugs for everyone, for anyone, if anyone, if you again, if you're a guy and you're just 10 pounds away from shredded, just just take the drug. It's going to make it even easier. Why not, though, aside from the ethics of prescribing? But let's just say you could just go to CVS and just buy the drug? Yeah, great question. So these drugs do have side effects. And while they're very well tolerated for the most part,

and the benefits far outweigh the risks for those for where it's indicated, nausea is the most common thing you see, generally goes away for most people. Some people get constipation, some people get diarrhea. There's a worry about gallstones. And I think a lot of it has to do with how quickly people lose weight with it, which can increase the risk of gallstones due to the

change in composition of the bile, which can form stones and then can get stuck in the little ducts and cause inflammation. And it can actually cause pancreatitis if the little stone gets in the wrong place. So there are risks there. The one thing I would say though, is it's kind of the same risk of like somebody who's doing this weight cycling. If somebody has like 10 pounds to lose and they can't do it with lifestyle alone, and then they use the medicine and lose it, are they going to stick on the medicine forever? Probably not. I mean, they could, I suppose. We don't know the risks of someone being healthy and very lean staying on it. But if I had to guess, I would say the risks are pretty low. But then that person's

taking an expensive medicine long term. Now, you could say, well, why not just stop it and cycle it? Well, then they're weight cycling. And, you know, I'm sure you've had podcasts about weight cycling, but it's like you risk losing muscle and then you gain some weight back. Sometimes it's fat. You try to lose the weight again and then you lose some more muscle and you start changing the body composition unfavorably. To me, that has to be the risk. Can also have negative psychological effects. Do people get caught into that yo-yo diet mentality? that yo-yo diet mentality. To me, that has to be the risk. I don't know if physiologically, other than the weight cycling,

like I said, there's nausea, there's potential gallbladder things, there's worry about pancreatitis, whether that's real or not, the signal, they do these studies and look, it's like, it doesn't seem like the incidence is different, but if somebody gets a gallstone because they lost the weight, I don't know. But I would say the weight cycling,

and if you're willing to stay on it for long term, some people think, though, why do I need to be on this long term? I would say people that have had weight issues for their whole life likely are going to have to stay on this drug long term if they start it. I have a feeling that those people who just long term, like chronically, like indefinitely until something else comes out. I mean, like, you know, are they going to somehow splice our genes? I don't even know what could change if they get bariatric surgery. Obesity vaccine. Yeah, an obesity vaccine. They're studying all sorts of crazy stuff.

I don't know. Something in the future that could change that. You know, bariatric surgery is more permanent. But I will say that I have a lot of patients actually had bariatric surgery now coming to me for medicine, and they're going to have to stay in the medicine with their surgery long term. But I think there's a lot of people that had, that were lean, but something happened, a death in the family, a pandemic threw them off. You know, what's interesting about the pandemic, some people took it and got leaner. Some people, it just threw them off to where they

gained weight. And it's like, I see that a lot of times. I think those people have a better chance of getting off the medicine because they only had poor habits during the pandemic. And now they're in this rut. And now you got to, if they start feeling better, they can get back into their. Like for them, regression to the mean might mean going back to just being kind of lean and fit, right? Yeah. So I think they have a good shot at getting off. I think the people that struggle with their weight for a long time, I think their appetite drivers have been there since childhood and they're going to have troubles coming off the medicine. My clinic online, we're trying all these different things because there's not really much guidance around it,

actually. And just a follow-up question to that, this is inevitably going to happen for some people, but maybe is it something that could be encouraged? So you have a scenario where due to environment and some genetic factors, which we'll get into, that's one of my questions I want to ask you about. But so at a young age, they just got used to eating a lot of food and blah, blah, blah. And they now they're very overweight. They use this medicine to help them lose a lot of weight, which I think this was clear, but I'm just going to say for people who are not sure, it's a calorie deficit that drives weight loss. No, no medicine changes that.

It just, it just makes it easier for people to sustain a significant calorie deficit. So they do that, which ultimately means they change their eating behavior. Like you mentioned, okay, they started going for the apple versus the cookie because the cookie didn't appeal nearly as much as it used to. And now if both of the things are, let's say, emotionally equal, it's easy to go, I'll take the apple because that's better for me. And I don't care. I don't care about the cookie. I'll eat the apple. Right. So let's say you have somebody and they're on the medicine and they lose a lot of weight. I mean, it's certainly possible, right, that they could also use that period to create some new behaviors, like to kind of re-engineer their lifestyle. So maybe they actually could. Yeah yeah this is the controvert not

the kind it's just debated because i don't think anybody knows but this is what you're saying is my hypothesis there have to be people that if they are able to rewire their habits there are some people that have been trying to rewire their habits forever and i think those are the people that like they've just been trying forever and they struggle i think those people have that true physiologic driver in their brain and the medicine blocks that or dampens it. But I think there's other people that their habits, they can get rewired from the medicine and then if they come off the medicine, their habits are so good that even if that little

bit of that reward and appetite drivers come back, they are so ingrained in their habits. I think that maybe they'll regain some of their weight just from eating just bigger portions. There have to be a subgroup of people that do well. And there are, there are, there's a few studies showing that most people do regain their weight, not all of it necessarily, but there are people that will maintain. And what we're doing is I'm weaning people off who want to, and then seeing what happens. And some people are going, hey, I'm good. And some people are going, no, my appetite's back. And then I don't have to put them on a high dose, just a tiny little dose of it.

And I actually, instead of every week, I'm extending it to every 10 days or even longer. It's interesting stuff. And that's what they call the heterogeneity of obesity. It's not just one thing and it's not just genetics or this and that. It's a lot of different things going on that I don't think anybody can really explain clearly just yet. Yeah. Theoretically, some people could have success with, okay, so they don't have the appetite. They don't have the reward system firing the way that it normally does. Maybe use that as an opportunity to just stop buying the

cookies altogether because now you don't really care about the cookies. And if you go for months and months now where you have even a new shopping habit, you buy the foods that you buy, you found those handful of fruits and vegetables and whole grains and lean proteins that you just like to eat and you have improved your relationship with food, that when you come off the medicine, there's a fair chance, right, that that momentum will continue to carry you forward. Again, like you said, okay, fine, you regain a little bit of weight,

but you just don't go back to the previous you. Yep, there have to be people like that. And I hope we're, you know, we have a huge population in our clinic that we're trying to figure this out. I'm hoping we can run some studies and see what are the characteristics of those people. And then maybe there'll be some trials looking at that. I mean, exercise is going to be big, right?

We already know that. Okay. So imagine this. People don't like to exercise because they're in pain. Now all of a sudden you help them lose weight and now the pain's kind of gone and you help them. They're in a smaller body size. And all of a sudden it's like, I kind of enjoy this. The exercise can then be utilized

to help prevent some of that weight regain or a lot of it. It's interesting stuff. So I think you're on the right path there. Hey there, if you are hearing this, you are still listening, which is awesome. Thank you. And if you are enjoying this podcast, or if you just like my podcast in general, and you are getting at least something out of it, would you mind sharing it with a friend or a loved one or a not so loved one even who might want to learn something new? Word of mouth helps really bigly in growing the show. So if you think of someone who might like this episode or another one, please do tell them about it. Can you talk to us about some of the primary driving factors of obesity? You had mentioned before we started recording,

there was a 60 Minutes clip that made the rounds on social media of somebody saying it's just genetic. And that turns into an argument kind of like where people with obesity are just victims of their bodies and that's why they just need drugs. And what are your, what are your thoughts? Yeah. So it's an interesting, interesting discussion because so for anybody listening, I'm sure they saw some somewhere a headline or maybe even saw the clip 60 minutes. Very actually a very smart physician researcher, Dr. Fatima Stanford. She's a Harvard physician researcher going on 60 minutes. And it looked like almost like the clips were spliced up. But the way it made it seem like is that diet and exercise don't matter.

It's your genetics. Even if you have a good diet and exercise or whatever lifestyle plan, genetics are going to control you and they have no choice. That's the way they made it seem. And, you know, what's interesting is then the other people online are going, hey, this doctor looked like she got thousands of dollars from Big Pharma last year. And she's talking about these drugs, like, you know, kind of like I'm talking about these drugs and she didn't even mention the environment. And basically it sounds like genetics are the number one cause of obesity.

So then you got people really upset about it, you know, rightfully so. I honestly think, I think the media, you know, she probably did a ton of interviews and they probably took small little clips and made it seem the same because I know she knows. But but I mean, the counter argument to that is if she made that statement, which I mean, I saw the clip. She clearly did like you wouldn't say that. You would not say that those words in any context unless you were like quoting someone else. And then you were about to follow it up with a counter argument. You know, I know I want to give her the benefit of the doubt and say basically like, because she is very

smart. She knows that. In fact, I actually did a whole Instagram story about it because other people were so upset. So I said, because I also wanted to play devil's advocate too. So since the 1970s, I showed a graph of the prevalence of obesity. I mean, we see the pictures. You can see the pictures in it.

Some people are like, oh, this is fat shaming and whatever. It's like, no, you see the pictures of the beach of in the 1960s or 70s. And yeah, and it's and so and you can I mean, you can look at the statistics on the graph and then you can look at pictures now. And it's like, wow, we are, you know, heavier. And so, you know, I asked the question, did our genetics change? And everybody said, no, no, our genetics didn't change. I'm like, so what did change? And everybody said it's the environment.

OK, so we all agree that environment had, like environment caused it. Then I posed the question though, there are people and we all know them. There's people that they don't give a damn about their health. They're eating fricking whatever. And yet they stay in sometimes like almost underweight. And they're not like one of us. They're not into fitness to where we, we clearly are fit and we're, we're lean, whatever, because we really focus on it. These people don't, they have like the worst habits and yet they're, they're lean. And so I asked the question, did the environment cause them to be lean or did the genetics and everybody goes, well, okay, now that you put it that way, the genetics.

So the genetics caused them to be lean, but these people with obesity, it was the environment. And so the answer is, you know, there's a gene environment interaction, the genes that this, I didn't make this quote up, the genes load the gun, the environment pulls the trigger and you can see it because there's large variations in weight of what an environment will do. And so some people will say that, but your genes didn't make you eat. Like nobody puts that donut in your hand and makes you eat it. And what I describe is though, no, and people know that for the most part, these donuts and chicken nuggets or whatever, French fries aren't as good as whatever else. But most people live subconsciously just kind of going

in and out of their daily. They're not reading muscle for life. You know, they're not reading bigger, leaner, stronger, whatever. They're not into it. So they're subconscious. They're living in their environment. They're eating the cookies that Cookie Carol and Donut Dan bring in. They're often also surrounded by people who do the exact same thing. Yep.

So they're surrounded by that. So we all have this different weight variation. And some people, though, they're just lean despite this. And it's because their appetite centers and the way they respond to, you know, some of it's their basal metabolic rate, but it's not metabolism so much. But a lot of it's their appetite. The reward center is intact. They can have a cookie and whatever.

Oh, I don't care. They can go on and not eat for long periods of time and they can eat small servings and just that's just what they do. They subconsciously go through life being lean, whereas most people go through life and have more genetic propensity. Now, the issue is though- And if I can just comment there quickly,

because I've heard from so many of these people over the years. So I've heard from people who were those people and they would say, so their perception of themselves, right, is that they would eat so much food, so much junk food, eat anything and stay lean. However, when I would ask them to keep a food journal, what we'd find out is, yes, there were some large meals.

There was a lot of junk food. But if you looked at their actual calories, they had a lot smaller appetite than they thought they did. They were not eating nearly as many calories as they thought they were. And even the people around them were perceiving it wrong too, because they would see that instance of what looked like a binge, but what they wouldn't see is like the next day, they barely ate anything because they weren't even hungry. And they weren't doing it purposefully.

They just weren't eating. Yeah. It was just like, oh yeah, whatever. I was at a restaurant. It all was tasting good. And then the next day I accidentally ate 500 calories because I just wasn't hungry and just weren't eating. Yeah. It was just like, oh yeah, whatever. I was at a restaurant. It all was tasting good. And the next day I accidentally ate 500 calories because I just wasn't hungry and I forgot to eat. Yes. So on my stories, I want to make sure people don't take away that like, no, you're not destined though. It doesn't mean that like, just because your genes, you could do a polygenic risk score and it looks like all your genes are going to

make you have obese. That's not true because when you actually look at the data, you can mitigate or minimize that weight gain. You can basically turn out to look like one of us despite your genetics because you still need to pull the trigger of that lifestyle, but it requires you to be pretty conscious about it early, adopting healthy habits, hopefully from your family. So anyway, whether it's genetics, environment, it's both. It's an interaction. Some people have genetics that are just going to make them lean forever. Most people are going to have more genetics propensity towards gaining weight in this current environment. Okay, here's the other thing. So if you put all these people on an island where they had to fish, basically what it was however many years ago, there will

still be variations in body sizes just slightly it'll be small variations but now we've taken them and put in this environment where we're now going to have these huge variations in body sizes so even the people that would be in just a little bit larger back in the day when they you know had to fish and gather berries they'd still have a larger body size now this it's extreme it's extreme extreme. So now we see these BMIs of whatever, 50, 60, and that type of thing. And I will say there's a difference between monogenic, where you have like a deletion in one of the major areas that regulate appetite. Those are pretty rare, but those are the type of people where it doesn't matter the environment

or not, they're going to be voraciously hungry. You hear about people locking their cabinets because the kids are going in and eating whatever they have. They're eating the flour and the peanut butter. It's funny, but they have to lock the cabinet. They'll break down things because of some of these deletions in the brain. But I'm talking about polygenic obesity,

the common obesity that we see where we just have small little gene variations that add up that might increase our appetite. So if people have more appetite signals, it doesn't destine them to have obesity. Like you said, especially if you start early with them and you surround them. And as a parent, you do the best you can. Kids are going to demand their goldfish and whatever else that they want. And they go to birthday parties.

Interestingly enough, I bring my kid go to birthday parties. Interesting enough, bring my kid to the birthday parties and I'll notice other kids, they'll eat a couple of cupcakes, you know, a couple of cupcakes, two or three sometimes. I want another cupcake. And my kid, I swear to God, I don't, I don't, cause I don't want to cause any food issues. I'm just like, go ahead and have a cupcake. Sometimes she'll eat half of it and be like, okay, daddy, I'm full. I'm done.. I'm just like that right there is the rawest form of likely genetics. I'm not sure. So blessed. It's kind of like the marshmallow test, right?

Yeah, it's super interesting. So the whole point of bringing this up is like, what's the cause of this? Of course, there has to be an environmental thing. There's no doubt about it. You can see the pictures from the 50. You can see the graphs and our genetics did not change, but the genetics absolutely loaded the gun. I say it with the lean people that are lean, even despite this environment, their gun wasn't loaded. So despite the environment trying to pull a trigger, nothing's going to come out. So

these medicines, it's a conspiracy theorist's dream to that 60 Minutes clip. And I say this because I love my field. I think Dr. Stanford, she's brilliant. The problem is the way they made the clip, her role with Big Pharma and all this stuff. It's like, oh, gosh, they're really making a show out of it because it looks like what it looks like is that we just need to put everybody on drugs. Which is a valid concern, right? It is. I mean, because unfortunately, life is kind of that simple.

Many people are mostly motivated by money. I'm not saying Dr. Fatima is. I'm just saying, unfortunately, that is generally, that's the rule, right? There are exceptions, but that's the rule. Yeah. So it looks like, you know, she's on the new dietary guidelines and she's brilliant. And people are like putting expert and they put expert in quotes. I'm like, she deserves the label of being an expert.

However, it looks, I understand it looks bad because it looks like the whole 60 minutes things. People are basically saying it looks like an advertisement for semaglutide or a Zempic drug we were talking about earlier. And it makes it seem like, no, who cares about the environment diet and exercise? It's just genetics. You're doomed. We just need drugs. And it's like, well, hold on a second. Here's what I would say. I would say, okay, let's, let's give the drugs to those who really need it. If I had control, I would be trying to make huge policy changes in, in food. And I don't, I don't know how to do this stuff, but I'm just saying like, if we could somehow change our environment back to what it was, I have no idea. How do we, how do we change our environment? I have no idea. I have no idea. We, we'd have to dismantle big food and we'd have to dismantle

it all. Start from scratch. People would be pissed and the money that there's a lot of money running around. I don't, I don't know how you do it, man. I have no idea how you do it, but I do know we are not doomed to our genetics. If we could just get our environment back to what it was before, which will never happen, maybe there's another way forward. I do think these drugs are amazing. I love them. We should use them for those cases that need them. But at the same time, if we can prevent it from happening in the first place, then we

wouldn't necessarily need the drugs other than in more extreme cases. So that's the gist. That's the nuance that I think is needed. And people aren't, of course, doing it like that. Yeah, and to your point, unfortunately, like, okay, what's the major change in the environment? Of course, part of it is just how easily accessible, highly palatable, high caloric food is, right?

I mean, you don't even have to get up anymore. You can just pull up an app and order 5,000 calories of garbage and just eat it sitting, you know what I mean? You don't have have to get up anymore. You can just pull up an app and order 5,000 calories of garbage and just eat it sitting. You know what I mean? You don't have to go anywhere. Exactly. And so what is the solution there? Should it just be some sort of kind of top down, right?

Banning certain things. But that was going to be my next question. Your thoughts on that, that these food companies, they certainly have responsibility. You have to agree with that, right? I mean, how do you get them in check? I have no idea. I don't know how you get these people in check. How do you get them to care more about public health than profit is actually part of the problem because now they've also created a huge market, a huge demand for these highly processed foods. And in marketing, and this goes back to Claude Hopkins' turn of the century,

you never try to create demands, create trends. You just work with the demands that are there. If you're looking from purely a marketing standpoint, it's too hard to change people's desires and change their behaviors. You just work with the desires that they have. So that's what these companies have done. Now, they probably also probably argue that they've spent a lot of time and money creating the market as well. It's almost like vice. It's not that hard to create a market when you're talking about delicious food that lights your

brain up. It's kind of like selling drugs. Just try it. There you go. That's, that's why drugs are great. Where I'm talking about street drugs, obviously. Yeah, I, I, exactly. People will be like, well, it's not like this stuff's cocaine. Well, you know, these have addictive like properties. And if people have the propensity and coming back to genetics, right. Certain people respond differently to that cookie. Yes, exactly. And it drivers there and these scientists, you know, they're making food people want to eat more of so they can sell more of it. The Pringles, once you pop, you just can't. I don't know.

Honestly, like it's wrong to say that it was only genetics. It's wrong to say only obviously only environment. I do think, though, like if we could somehow revert back to whatever our environment was, I mean, that's that can't happen. So then maybe there's a way forward where they use technology to then, you know, hopefully get people not to eat. But the food companies, they're not going to want that. They want people to eat their stuff. I don't know. It's a great question.

We should get should get a policymaker if food companies uh if they could get on board i think of um one of the major tobacco companies it might be philip morris like part of their pr is moving toward a tobacco free future smoke free or something like that and i don't know if that's more vaping or whatever it might just be pr and bullshit but you know think of that if that is true, where they're saying, okay, our entire brand is cigarettes, but we want to help try to move people away from smoking cigarettes that have hundreds of chemicals in them that are terrible. One of the worst things you can do for your health toward using other products. I mean, theoretically, food companies with the resources that they have available to them may be able to

you couldn't you couldn't do it quickly but maybe over the course of decades you could actually start to shift people's preferences toward you know healthier foods maybe if you applied the same level of diligence and research and money and whatever that they've applied to creating these highly processed delicious foods you know i don't don't know. It's something. It's really fun. It's kind of a fun thought. I mean, some could say then, well, what if they make an obesity vaccine that basically splices some of these genes and then make them have the genes of the lean people? I don't know. Maybe that's some future Gattaca shit that I've never even I can't even imagine. But I suppose that's possible that if they have the genes of those lean people, despite this environment, I don't see that being a solution anytime soon. I don't know. That's some scary

stuff, but I don't know. Yeah. I mean, we have to assume that's at least decades away from even being available to anybody probably. So yeah, it's a good thought experiment. I love thinking about it because I, you know, I always talk to patients and I'm like, look, you also don't blame the patient though, because people say you have to have some self-responsibility. I'm like, I get it. But if you have something nudging you to eat something all day, whereas someone else doesn't have that nudge, I don't know if that's, it's not necessarily their fault. I always say it's still their

responsibility right now to try to do something about it but like I don't I wouldn't blame them or fault them if that makes sense so yeah I mean minimally it's not productive right I mean it doesn't help them because in a way they know that ultimately of course they're even if these problems are not necessarily their fault like the genes that they have are not their fault. Of course, they know that resolving the problems, it comes down to them. It's their responsibility. They understand that.

Exactly. Yeah, that's exactly right. So yeah, you go on an island and you got to fend for yourself. Like you have no, you literally have, there's no other option. You have to, you can't eat the cookies. You can't eat extra servings

because you have to fend for yourself and go get it. So it's kind of a kind of intro, you know, and some people may think that's a little bit shameful, but it's, it's just the reality of how our environments shape us. So anyway, cool. Good discussion. Yeah. Yeah. It was a great discussion. Uh, thanks again for taking the time. I know you have a hard stop coming up here in a few minutes. So why don't we just wrap up with where people can find you and find your work and learn more about the stuff we've discussed today and obesity in general and health and fitness, all the stuff that you like to educate people on. If people are like, hey, I'm interested in these weight loss medicines, you can see we have a quiz at joinsequence.com. It's my online

clinic. You can take a quiz to see if it's indicated. It's a 27 BMI plus what's called a weight-related comorbidity, hypertension, prediabetes, that type of thing, or a BMI of 30 and above. That's a whole nother discussion. There may be some future improvements of how we diagnose obesity. It shouldn't be just BMI-centric, but that's kind of how it is. But anyway, you can take the quiz there. I don't want to go off on another tangent. Follow me on Instagram. That's where I do most of my obesity discussions at Dr. Nadolski. I'm also on TikTok. I do stupid stuff there that like TikTok's a whole different social media. That's like that summarizes TikTok, a bunch of stupid stuff. I, I hate it. But, and then I'm also on Twitter. I do some academic stuff there at Dr. Nadolski and Facebook, of course, as well.

But that's that's the gist. Cool. Well, thanks again for taking the time, Spencer. I appreciate it. Thanks, man. Well, I hope you liked this episode. I hope you found it helpful. And if you did subscribe to the show because it makes sure that you don't miss new episodes.

And it also helps me because it increases the rankings of the show because it makes sure that you don't miss new episodes. And it also helps me because it increases the rankings of the show a little bit, which of course then makes it a little bit more easily found by other people who may like it just as much as you. And if you didn't like something about this episode or about the show in general, or if you have ideas or suggestions or just feedback to share, shoot me an email, mike at muscleforlife.com, muscleforlife.com, and let me know what I could do better or just what your thoughts are about maybe what you'd like to see me do in the future. I read everything myself. I'm always looking for new ideas and constructive feedback.

So thanks again for listening to this episode, and I hope to hear from you soon.