48: Strategies for Fat Burning with Dr. Ben Bikman

hello and welcome to this week's episode of the metabolic classroom I am Professor Ben bman biomedical scientist in all things metabolism and professor

of Cell Biology one of my great Pleasures is to explicitly study fat tissue I am a fat scientist that is one of the cell types that I explore the

most whether it's cells fat cells growing in my lab in a Petri dish or whether we are taking biopsies of fat from humans to to study how fat tissue

works the Dynamics now we have been exploring several aspects of fat tissue today is the happy ending um in the past we've been talking about some of the

Endocrinology of adapost tissue so what are the hormones that come from it we've been talking about some of the drugs that influence it and we're going to revisit this a little bit we've been

talking about sex specific effects and how fat cells grow uh and even they shrink and we're going to revisit some of how they shrink today because the

topic for today is strategies for fat loss and there is a lot to unpack here so let's see what we can do in the time that we have I never like for these to

be too long I'm sure you feel the same way after all most students do so the first topic or to provide a bit of an

overview first I want to cover um once again touch on drugs but that was explicitly a Topic in a previous metabolic classroom so please go back

and watch that entire lecture for more of those details that I won't go into now um so we're just going to lightly revisit drugs with a particular mention on glp1 agonists just because those are

so popular right now then we're going to go into surgical Intervention which is not something I speak about very much but there's some really neat things to teach you about with regards to

bariatric surgeries and liposuction surgery and lastly lifestyle which of course is a very big topic that is the elephant in the room there can be no

understanding of strategies or really appreciating the key strategy for fat loss if you do not discuss um lifestyle interventions particularly of course

nutrition so let's get started for the first part first section of this discussion and very briefly because again we've discussed this at much greater length earlier uh drugs for fat

loss and specifically the glp1 agonists these are going to Encompass virtually any drug where the uh the suffix of the

name of the drug is a glutide like semaglutide or liraglutide indeed semaglutide being the most common that's the one that is in the very very popular

drugs wovi and OIC and used in other ones as well and they have different trade names even that continue to kind of Stack onto the complexity so there's a lot of different ways ways you can

call this the main mechanism of drug of action rather for the glp1 agonists is the redu the reduction in

Cravings now remember remember being me saying that because you watched it before um the earliest use of the glp1 agonists was used at a much lower dose

than is commonly used now and this was a dose that was effective at inhibiting glucagon insulin opposite whereas insulin seeks to reduce blood glucose

glucagon seeks to increase it and it's in fact a hormone that most diabetics type 1 and type two struggle with in other words diabetes is just as often a disease of too much glucagon as it is a

disease of too little or not functioning insulin in the case of type one or type two respectively so at the lower doses

glp1 Agonist drugs worked by reducing glucagon and thereby improving diet diabetes and then at these higher doses the the famous mechanism of action now

is that food is moving much more slowly through the intestines so whereas in the untreated individual they eat a meal and the food sits in their sits in their

stomach for say 3 to four hours or so before you know getting mulched around before moving down further into the small intestine for digestion and absorption the food May sit in the

stomach for up to 24 hours or something uh a much much longer time um and because of that you just don't want to eat so it really starts reducing

Cravings now one interesting note that I did not discuss before is that one of the common side effects of these drugs is sexual dysfunction or a loss of

libido so when Cravings are reduced it goes beyond just the Cravings of what you're going to eat so that's just something to consider and again they do

work no doubt about it by stopping eating you will lose weight as I elaborated earlier however up to 40% of

that weight loss can come from lean mass and then if the day should ever arrive that a person decides to get off the drug they will regain their fat Mass

very easily but the ability to regain that lean mass that they've lost is really going to be um dependent on a lot of variables particularly age and if we're talking about someone who's a

little past middle age good luck gaining that lean MK back it's going to be very very difficult if possible at all all right so that's what we'll discover for that's what we'll discuss

with regards to drugs now let's move on to surgeries um weight loss or metabolic surgeries um as it's some commonly called is something I've been very interested in for a while in in fact

ever since my dissertation work indeed my dissertation was based on exploring some of the changes in insulin sensitivity and inflammatory status and

people postgastric bypass so the first subtopic within the surgeries here that we're going to discuss is the bariatric

surgeries and there are a handful of um options here and I want to highlight the main four so the four key bariatric surgeries again sometimes called weight

uh sometimes called metabolic surgeries the first one is the most famous the longest running one which is the Rue on W Ruan y from some French terms gastric

bypass the letter y is a term because of how the intestines actually end up looking so the ultimate procedure is that you take the stomach which normally

is a big you know bulbus thing that is capable of incredible distension which then sort of connects down not sort of connects down in further into the small intestine the first part of the small

intestine called the duodenum and what happens is that they go up the surgeon will come up and cut out um almost all of the stomach and so that what is left as the as the food is

coming down the throat the esophagus the food just has access to a small little pouch so there is only a pouch of a stomach left and then as I said normally the stomach feeds right into the into

the dadum however what's happened is that further down the dadum it's been cut and then the new cut has been brought up and inserted into the pouch

so you are bypassing the stomach and the first part of the dadum now that matters because the dadum is really where the rubber meets the road when it comes to

digestion that's where you have the input of all of these pancreatic enzymes all of these proteins that are going to break down your food bile acids are coming in at the top part um at the

dadum so you end up bypassing all of those things as well um as a result the person with the smaller stomach they're eating much less than they were before

so it's basically leading into this chronic state of fasting and even what they do eat because of the byass of the dadum or the at least the first part of

the dadum they don't even digest it as well and so they're eating much less they have compromised digestion and if you can't digest your food very well then you can't absorb it so it's

essentially creating like a forced fast that's essentially how the gastric how the Ruan y gastric bypass works now of course you can imagine there are

consequences to this indeed a lot of them the obvious one being um the poor uh nutrition require absolutely requiring

supplementation um there are some things that you simply now cannot get like vitamin B12 for example so there are some uh this becomes a lifelong supplementation and in some instances

indeed um direct vitamin injections that a person has to get in order to prevent serious nutritional deficiencies but it works the person will lose substantial

weight now one of the problems however with the intestines is that they are a very Dynamic tissue it's very possible for a person to lose all that weight but

then slowly start eating more and more and more and pushing that little stomach pouch and growing it into something slowly bigger now you'll never regain the first part of the duodenum so the

person will always have some compromised digestion and in fact that itself causes problems like diarrhea but even still the person can begin to eat a lot more and thus it is possible to gain that

weight back because the person begins eating again as much as they were before all right that's the most famous One the Ruan y now the other one the

next one is increasingly common which is laparoscopic adjustable gastric banding in this case there is no actual snipping and cutting of the intestines what the

what the surgeon does is come in where the esophagus comes down and meets the big bulbus stomach they actually just put a little pinched band around the top

part of the stomach basically pinching off not totally off but narrowing off a small pouch so kind of artificially creating a small pouch by again putting

this band on that will kind of narrow it up so as you're eating food it starts to fill this little fake stomach pouch very quickly but then eventually the food does go through

that narrowed pinched band that's where the band comes in narrowing pinching the stomach it will move down go into the rest of the stomach and then move through an unaltered duodenum for

eventual complete digestion and absorption but because of that pinched off stomach the person of course does eat a lot less because it's going to be very very uncomfortable you're going to

feel that food literally pushing down at the bottom of your esophagus if you eat too much and so this forces um a controlled appetite and of course

because you aren't cutting apart the intestines there are far fewer complications to this compared to Ruan y gastric bass but it's also less

effective next we have laparoscopic sleeve gastrectomy and in this case the sleeve term ends up really being uh really explaining what has happened here

as I elaborated earlier the stomach is like this big kind of bulging sack and what happens is they essentially cut off off the stomach that is bulging out and

make the stomach into a tube or it looks like a little banana um essentially so the esophagus is a tube that's coming down normally it reaches the stomach and things bulge out a lot and then it

Narrows again to come back into the dadum of the small intestine essentially it turns it into just one tube all the way down and that means food isn't able

to churn and get worked around a lot in the stomach and so you lose out on a lot of digestion and the food just passes through very quickly so the likelihood

of diarrhea goes way up but also there is compromised digestion um which and you eat much much less so once again through this forced fasting you are

going to get a um some weight loss indeed substantial weight loss and it while of course this is much less complex than the Ruan y gastric bypass

there is still um a lot of consequences and there always is anytime you start cutting the stomach apart um it's just the the the likelihood of infection and

leaking um just really starts to Skyrocket all right now the last one is is kind of a hybrid of the first one the Ruan y gastric bypass because

you are bypassing part of the small intestine the dadum remember that matters because that's where most digestion occurs if you bypass the datum you're not going to break down food very

well and if you don't break down the food to its small smallest molecular parts then you can't absorb it so you're not getting it and the food just passes through you now so the last one it's

this hybrid as I said of the bypassing the duum and the sleeve um so this is called the Bop pancreatic diversion with the Dual switch so this is like you are

creating the sleeve in the stomach making it just a tube like a banana and then you are also cutting at the dadum and connecting that up to that new um

banana-shaped stomach uh so it is like I said a bit of a hybrid of the sleeve and the bypass naturally you're going to be eating less because of this because you

physically can't hold it in your stomach and the food is moving through very uh very rapidly again increasing the likelihood of diarrhea but meaning that you're not mulching and chumming the

food around because that's what the stomach is so good for um in part it has actually more roles than that but it takes the food and it's churning it and churning it and helping it be ready to

hit those digestive enzymes in the duum once the food leaves the stomach and I'm saying food but the actual technical

term is Kim CH H ym Kim that's the term for the churned um broken up food as it's been sitting in the stomach getting worked

around all right that is all of the bariatric surgeries or the so-called metabolic surgeries all of them res in substantial weight gain although it

depends somewhat on the procedure itself the weight gain can be regained um as the person pushes and forces the stomach to grow larger and larger if they

haven't learned the substantial discipline that comes with just eating less um and there are complications from the surgery itself anytime with all pretty much but the banding the

adjustable banding where you're not actually cutting into the intestines now let's move to lipos suction lipos suction is interesting and I enjoy talking about it because it

forces us to remember the actual problem when it comes to storing too much fat you will recall from previous metabolic classrooms and because you are such

studious students that when I talked about the problem of fat before I emphasized that the problem is not one of fat mass in other words it does not

matter how much fat you have on your body what matters is the size of each fat cell that's not the same thing right as

we've talked before about this uh people can gain weight through two different processes and we've talked about this a lot the last two episodes hypertrophy versus

hyperplasia if someone genetically has the ability to continue to make more fat cells then even though they will have more fat cells all of the fat cells are going to be quite modest in size and

because the fat cells are small the person ends up being metabolically sound they don't have insulin resistance and the complications that come with it although this is relatively uncommon

most common is that a person has fat growth through hypertrophy which is a state where the number of fat cells stays static but the size of the fat

cell is growing and that's what matters now with all of that in mind that primer reminder think about what happens with liposuction and and one other point actually when when someone is undergoing

lipos suction where are we sucking the fat from there are two main storage Depot of fat in the human subcutaneous fat which is the fat stored beneath the

skin and visceral fat which is the fat that is deeper within the abdomen behind this wall of what we call the perianal cavity it's literally walled off in that

part of the body and and this fat is the fat surrounding the intestines surrounding the kidneys worked through all of these around all of these tissues generally that's visceral and that's the

fat that is generally more problematic and generally grows more through hypertrophy and generally has more pro-inflammatory macrofagos surrounding it so very much

uh a greater contributor to cardiometabolic risk than subcutaneous fat now back to my question that I posed a moment ago where do we take the fat from with lipos suction are we cutting

in through the perenium to suck out the visceral fat or are we cutting through the skin and sucking out the subcutaneous fat yes of course we are taking the

subcutaneous fat remember that's not a bad fat that's generally a hyperplasia fat so generally smaller fat cells that are releasing more favorable hormones

all of which we discussed in last episode so lipos suction is typically performed on areas Under the Skin like

the stomach so the belly thighs buttocks and upper arm those are the general areas or lower back but all of it is

subcutaneous now it's no surprise that after someone has undergone liposuction they have less fat on their body so you could have someone who had 30% body fat

and then one hour later they now have or a couple hours later they now have 20% body fat or 20 some per 22 23% that is a

substantial loss of body fat but how did they that fat remember if big fat cells are the problem then the solution is shrinking your fat cells the solution is

not removing fat cells but that's exactly what's happened in fact you've removed the fat cells from the worst possible place namely the subcutaneous

fat Depot the healthy place and so it's no surprise the body and all of its wisdom thinks if this body if you continue to eat the same way you did

before that put of that fat on your body so however you were eating that put those 50 pounds of fat on your body your body still wants to store that much

energy but if you have gone in and removed 40% of all of your fat cells that's way too high 20% of all of your fat cells that simply now means that the

remaining fat cells are forced to store more of that energy where your body wanted to be storing a certain mass of fat or amount of energy because of how you were eating spiking insulin and

providing sufficient energy to fuel the growth of the fat that insulin is signaling those are the two variables again listen to the previous episodes for more detail on that then it's no

surprise that the rebound effect is that as a person regains the weight they regain it in the areas where they didn't strip out their fat cells because you're not going to just start making new fat

cells you're going to store you're going to force those remaining fat cells to store more fat thus promoting hypertrophy so while the shortterm benefit appears obvious namely the

weight loss it's no surprise that there is no benefit in cardiometabolic outcomes even though the person has lost a substantial amount of fat they lost it

the wrong way remember you want to shrink your fat cells not destroy or suck out your fat cells because it's the size of the fat cells that matter and so

the person inadvertently ends up putting this upward pressure on the remaining fat cells placing this if you will metabolic b a greater metabolic burden on the remaining fat cells they have to

now carry more energy in other words undergo hypertrophy and the result of that being that they become insulin resistant and pro-inflammatory and so if you have a woman who goes in and under

goes lipo lipos suction to suck out butt from uh fat from her buttocks or hips no surprise that she'll start to store more on her belly and even in her visceral

fat Depot especially that visceral fat because that's not one you can touch you can cannot go in and suck that out so lipos suction is absolutely something to

be done almost purely um for Vanity's sake because it's not going to improve metabolic outcomes all right so that so far has

been a discussion of drugs lightly and then more of a discussion on surgeries the bariatric surgeries and liposuction let's move now into the big part which

is the lifestyle changes EX exercise and nutrition and then a little bit of tidbit at the end some extras at the end with regards to Lifestyle so firstly exercise um my

Mantra when it comes to exercise and weight loss is that you exercise to be healthy or strong and then you eat Smart to be lean you don't exercise to be lean

if one of the reasons you are exercising is to get thin you're doing it for the wrong reason now I don't want you to stop exercising but that's not what exercise is good for even the American College of sports medicine

one of the leading authorities on exercise has stated probably reluctantly that there's really no evidence that suggests exercise alone is effective for

weight loss you just can't really move the needle much now um it might help a little and there's a little evidence to show that minute for minute visceral fat

uh is more affected that that is the fact that you're going to burn a little more relative to subcutaneous fat and that could be because visceral fat is

more responsive to epinephrine EP epinephrine is one of the stress hormones and one of its many effects is to stimulate lipolysis or fat

breakdown in order to be burned by the body well again visceral fat is more sensitive to epinephrine and so a little bump in epinephrine is going to have a

relatively greater effect on the visceral fat so in that sense exercise may help but on average you exercise to

be strong and you eat Smart to be lean and by lean I mean shrinking fat cells so that then takes us to nutrition now again this is something we've talked

more about in previous episodes um and what I always want to highlight with nutrition is the fact

that too many people get it wrong so remember the journey is shrinking fat cells and a person can start this fat cell shrinking Journey with one two

steps cutting calories or lowering insulin now most often of course people just take the cutting calories step and the problem with that is if you begin

immediately reducing energy intake but you haven't addressed your elevated insulin you are going to put your body into this state of relative energy

deficiency now what I mean by that is and this has been validated by studies including those by David lwe at Harvard uh and he's done this really well his

group explored the total energy available in the blood and by that I mean they actually measured all of the calories and nutrients in the form of nutrients in the blood and found that

when diets were increasing insulin the total energy availability in the blood was down because energy uh because insulin wants to promote the storage of energy so if you start eating less but your

your insulin is still high you're resting this is leading to a general reduction in the amount of energy available in the blood and the Brain senses this the brain senses this low

energy because it's not like the fat cells it can't store hundreds of thousands of calories the brain has to with its very high metabolic rate needs to almost constantly be relying on the

energy that's available in the blood so the brain is very sensitive to energy changes or the energy status available in the blood so if energy coming in goes down or or the person's cutting calories

but they haven't really addressed their High insulin yet um then they're going to get hungry so again if the first step of the fat cell shrinking journey is

cutting calories hunger will win this is why you never see a reunion tour of The Biggest Loser game show you will never see those people on a stage again because they've gained it all back and

in many instances they've gone even Beyond where they were before because hunger always wins if your if your strategy is based on cutting calories without without addressing insulin now

I'm not saying calories don't matter in fact I'll revisit that in just a moment but there's an order to this that is much more scientifically supported so rather than the first step being cutting

calories keep that foot in place for now on this fat cell shrinking Journey along this pathway the first step needs to be lowering insulin lowering insulin

creates a metabolically advantageous milu within the body when insulin goes down um metabolic rate will go up um substantially even up to 300 calories

higher that's a pretty meaningful amount and you also begin creating ketones ketones are simply products of fat burning and that's what happens when insulin is down remember the human

metabolism engine is a hybrid it's burning glucose if insulin is elevated or if insulin's down the metabolic engines burning fat well if insulin stays down for an extended period of

time you're burning so much fat that you almost are burning too much in the liver and then the liver begins creating ketones from all of this excess and the interesting thing about ketones is

ketones have a caloric value roughly comparable to glucose and when a person's making ketones they begin excreting them in their breath and in their urine these are calories that are

just being eliminated from the body so that is the metabolic advantage that comes with a low insulin State and at the same time because insulin is low

the body is releasing this energy into the blood the total energy available in the blood is higher and so the brain is sensing this feast and thus says we

don't need to eat and so it's no surprise that when someone is controlling their insulin they don't need to worry about cutting food out cutting calories because they begin to

control their appetite this has been shown pretty consistently in human studies that put people into two groups the low carb keto genic group tends to

control calories on its own even though that group is often calorie unrestricted and in handful of studies they've done this they will take a lowfat low calorie

diet and compare it to a low carb calorie unrestricted diet and these people begin just controlling calories on their own they just have this improved

satiety that matters So Hunger begins to be controlled a little better and it could be because the brain is sensing all of this energy all of these ketones in the blood all of this gluc uh this

you know adequate glucose the free fatty acids the brain is sensing all of this and thus saying to the rest of the body hey we obviously are in a feasted state

we don't need to eat at the moment so hunger is just generally better controlled now with that first step the low insulin step the person's going to get pretty far that's going to be a big

step that takes them very far down this pathway of the fat cell shrinking path and you do this by controlling carbohydrates prioritizing protein and not fearing fat indeed not fearing the

fat that comes with the protein by control carbs I to elaborate on that a little further um it's basically this my my call is to be wary of the carbs that

come in bags and boxes with barcodes if if you're eating whole fruits and vegetables not drinking them but eating them I submit that you're generally going to be doing very very

well and then focus more on protein and fat because those are going to be the macronutrients that have little to no effect on your insulin and thus insulin

stays down metabolic rate stays up and energy mobilization continues so you just keep moving your energy you're breaking down all of your stored energy

all to be burned so again reducing insulin is all about managing macros control carbohydrates prioritize

protein don't fear fat now after you have done that and that has taken you very far down this pathway don't forget you had that other step you could take which is the controlling calorie step

the best way then if you feel like you need to to get a little further on that Journey because energy matters but I submit not as much as controlling insulin but if you want to take that

step to control calories then you inop adopt the fourth part of this after you've managed your Macros which is frequently fasting but just remember how

you end a fast fast matters more than how long you fast okay now I've gone a little long on that but it's worth it was worth elaborating so hopefully some of that is

very memorable and you're able to incorporate it now as a final point I wanted to mention some kind of alternate methods here which I believe contribute to fat loss but there's not a lot of

data to overtly support that claim so I'm being a little cautious about it and that is um temperature changes or or

contrasting therapies sauna or cold plunge each of them is obviously going to increase metabolic rate um one note and with the cold plunge it's obvious uh

you are shivering uh and shivering is going to increase metabolic rate all those muscle spasms but at the same time you increase your metabolic rate particularly from your brown fat which is something we've spoken about in

previous episodes that is a high metabolic rate fat and which exists primarily to keep you warm so it Stokes up the furnaces in order in increasing your metabolic rate all in an effort to

help maintain body temperature and then with SAA one of the interesting things about sauna is just the very Act of sweating requires energy

every probably 10 drops of sweat is about a calorie of energy spent so the very process of pushing water from your blood out to your skin to to evaporate

or drip off you as sweat requires energy and additionally while you're sitting in the sauna your heart rate is spiking up to 120 or 130 you are getting a little bit of a workout now there's abundant

evidence to show the cardiovascular benefits of sauna but again where I am being a little more careful is the fat loss claims so in the absence of really

well done studies I can just suspect which I do I suspect that sauna and cold plunge are also really going to help with weight loss but they have to be something that are adding on for for

really moving the fat loss needle this is something that's going to be kind of in the extras area that that the absolute largest most relevant variable

for fat loss is diet and remember remember take the low insulin step first then worry about the controlling often controlling calories will take care of themselves but if you find that you need

to go a little further on that fat cell shrinking Journey then you take the controlling calorie step by incorporating structure Ed fasts by structured I mean you have a clear plan of what you're going to eat how much

you're going to eat after the fast ends lest you fall into this pattern of a kind of bizarre form of binging and purging where you're fasting and feasting and making yourself sick and

then fasting again that's not a good way to do it but it matters so in conclusion the reason I focus on this is because and indeed a lot of this a lot of these

ideas are going to be expressed in this next book of how not to get sick um really diving down into the science behind shrinking fat cells because that is the priority it seems obvious right

you think I need to lose weight to improve my metabolic Health but when we say lose weight we need to think of it the right way we're not killing fat cells we're not freezing them off we're

not sucking them out we are shrinking them and you do this by lowering insulin and then adjusting energy accordingly all right thank you guys

until next time in the from the metabolic classroom remember more knowledge Better Health I'm your teacher Professor Ben bman I will see you next time