Dr. Sarah Stombaugh:
This is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight Podcast.

Announcer:
Welcome to the Conquer Your Weight Podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here’s your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh.

Dr. Sarah Stombaugh:
One of the questions and one of the biggest debates that comes up on the internet when I talk about weight loss is what is the role of calories in versus calories out? Because what is absolutely true is that we cannot as humans violate the simple thermodynamic principle and calories in versus calories out is a very incomplete way to think about the way that our body utilizes energy. So if you’ve ever felt really stuck in your weight loss journey, I want you to listen up today because we’re going to talk about what is the role of calories, how are our bodies utilizing energy and how do we work with our body rather than feeling like we’re fighting our body in order to achieve weight loss? Because here’s the truth. If calories in versus calories out was as simple as that, we would all just follow a 1,200 calorie diet.

If we were trying to lose weight, we would lose weight, we’d be able to maintain weight long term and there’d be none of this yo-yo dieting. There’d be no marketing for any of the weight loss products that are out there, but we know that that is absolutely not true. Why is it that two people can eat the exact same thing yet have different effects in their body? Maybe one is the losing weight while one is gaining or maintaining weight. Why do people feel like when they’ve had weight loss attempts in the past and they’ve had recurrent weight loss attempts that every time it gets harder and harder than it was before? Why do people who have insulin resistance, whether it’s chronic obesity, whether it’s prediabetes, type two diabetes, PCOS recently renamed PMOS, this polymetabolic syndrome. Why is it that people who have underlying insulin resistance feel like they are fighting their bodies all the time?

That’s what we are going to talk about today, not just what is a calorie, but how is our body utilizing energy? So first, let’s get really clear, what is a calorie? Because this is something that’s really not always even talked about because it’s simply a unit of energy. So a calorie is how much energy it takes for a food to be combusted for it to be burned. So how much energy does it take to burn a specific food item? Now what’s interesting is that food is not just energy. It also comes with hormonal signaling of how that type of energy is supposed to be used. So we think about macronutrients, we think about carbohydrates, we think about protein, we think about fat. When we eat a food item, it’s going to be maybe just one or some combination of those different macronutrients and that is going to send signals to our body about how much energy is available and how we specifically use that energy.

And so this is where it becomes really interesting because different foods have very different signals to our body and we know that having a diverse amount of fats and carbohydrates and protein, having all three of these food groups really make sense and really matters. So we’ve seen over the last few years these huge shifts in what was the low fat or keto era or low fat first and then we saw this big shift to keto, so a really high fat diet, low carbohydrate, which crosses over quite a bit with keto, but maybe not necessarily in full ketosis. So those are being really high fat diets to a very low carbohydrate diet. And certainly what we’ve all seen in the internet and the last couple of years is emphasis on high protein. And I think where all of these diets get it wrong is that actually each of those macronutrients plays a very important role in our body.

Now what’s really interesting, let’s talk about each of these macronutrients and how they signal differently in the body. So carbohydrates, people love picking on carbohydrates, but what’s interesting is carbohydrates our body’s preferred energy source. Our body can break down and utilize carbohydrates very rapidly. And so our body loves carbohydrates for energy. Our brain especially loves carbohydrates. So what’s interesting though is even though it’s our body’s preferred energy source, our body doesn’t require carbohydrates. So this is why people, for example, who go in on a ketogenic diet, they have this very high fat diet. They have very, very low carbohydrates. Their body tips and ketosis where it’s using fat, it’s using ketone bodies for energy. So carbohydrates are really valuable in our body. Our body likes them for energy. Certainly anyone in athletics, especially endurance athletes, really like the effect of carbohydrates on their body because they give them that ability to really keep going when you’re thinking about endurance athleticism, things like marathon runners, triathletes, things like that.

Carbohydrates are really, really important. And while when we think about carbohydrates, we often think about sodas and candies and cookies and all the pastries and all sorts of different dessert items. What’s also true is that fruits and vegetables and whole grains are predominantly carbohydrates. Now they may have a little bit of protein or a litle bit of fat in them as well depending on which thing we’re talking about, but all of those whole forms are also carbohydrate. So I think a lot of times we get really in this idea that carbohydrates are bad, but carbohydrates can be incredibly important. And carbohydrates, the way our body utilizes carbohydrates is by sending an insulin or we eat carbohydrates and when our buddy eats carbohydrates, it will release insulin in order to take that energy and store it away for later. We’re going to talk about this in a minute in the context of insulin resistance, but what that insulin does is it takes the carbohydrate and it helps it to be utilized for energy.

So it brings it around to all the different cells in the body, says, “Hey, do you need any energy right now? Let me deliver this glucose to your cell for energy.” And if we have more energy than our body needs, then that insulin takes that excess energy and stores it away as fat for later. Now interestingly, protein is utilized in a very similar way but has a different role in our body. It’s really important in certain cell signals. Everyone knows about it in the context of muscle building in tissue repair. It’s really important in fueling our body in a very even way. So when we eat protein, it helps with getting full. We get that satiety from protein and it often sticks with us for a longer period of time. It has really good thermogenesis of food, meaning that our body takes more energy to break it down.

And so that can be really important when we think about food that sticks with us and helps last four hours after eating a meal. But interestingly, insulin is also important in our body utilizing protein and especially when we have more protein than our body needs for muscles for tissue repair, for enzyme building. For example, it’s going to take that excess energy or that excess energy and simply use it as that for energy. So this is where sometimes those really high protein diets may actually mismatch what your needs are day-to-day. And so that’s why sometimes you hear me say like, “Oh my gosh, you were eating too much protein.” So we’re not going to dive into that too much in today’s episode, but we do have other episodes talking about how much protein that we’re eating and if you have any questions about that, reach out, let us know.

I’d love to make more content around that. Make sure you speak individually with your own physician about great recommendations for nutrition and a protein goal for your own body. Now next, as we think about the different macronutrients, we’ve talked about carbohydrates, we’ve talked about protein. Let’s talk about fat. So fat is really important as well. So fat plays a role in hormone production. It helps to build our cell membrane. So we have fat in all the different cell structures in our body, so really important in that way. Fat gives us an energy level that feels very stable. So when we eat foods that contain fat, we feel full, we stay full for longer, but what’s also true about fat is that it’s very energy dense. So there are nine calories per gram of fat that’s consumed, which is more than twice as energy dense compared to carbohydrates or compared to protein, for example.

So fat is very important, but it is important to be mindful of fat because it is a way that we can accidentally get way more calories than we need. But what’s really good about fat and why it became very popular in diets like the ketogenic diet, for example, is that it doesn’t require any insulin to be utilized. It’s broken down in the GI system and can be directly absorbed into our bloodstream and utilized for energy. And so in this way, fat helps keep us fueled for longer. You hear people talking about the clarity that they feel when they’re eating a high fat diet. We just have to be mindful because when we have a food that is that calorically dense, it means that we have to eat a much smaller volume of it. But all of these things together play in is how is our body breaking down utilizing this energy and what sort of signal is being sent?

Now one of the things that gets really out of whack and one of the big reasons why I say calories are just a part of the picture is that insulin resistance can throw everything just wonky. It makes it really difficult to understand or to appropriately use our insulin or to use our energy rather when we have insulin resistance. So let’s talk about what is insulin resistance. Insulin resistance develops for a lot of different reasons. This can be because of genetics. So genetics are a major driver. There can be other factors in our life like stress, like getting poor sleep, sometimes whether it’s maybe being a overnight shift worker, maybe it’s conditions like sleep apnea or restless sleep. So even that we are sleeping, the quality of sleep that we’re getting is not very good. It can be hormonal shifts during things like perimenopause, for example, and decreasing levels of estrogen can drive increased insulin resistance.

Many different things can contribute to insulin resistance. What we also know is that insulin is this energy storage hormone. So as we were talking about before, when we eat carbohydrates and to some extent when we eat protein, insulin is going to take that energy and help to break it down, help to use it in different cells and say, “Hey, do you have what you need? If not, we’re going to take it and store it away as fat for later.” Now what’s really interesting with insulin resistance is that we see higher levels than expected of insulin. So the body’s ignoring the signal of insulin and so our body starts making more and more insulin in order to shove that energy away for later in order to sort of force our body to utilize that energy because it’s protecting us from having high blood sugar. If our body was not able to increase those insulin levels, then our blood sugar numbers would become elevated and that progression is what turns into prediabetes or ultimately type two diabetes.

But the first sign of this we see is insulin resistance. So our body has higher than expected levels of insulin. Now what this means is that our cellular signaling gets really off in terms of are we hungry? Are we full? What signals are our body sending? So remember, we talked about insulin as a fat storage hormone. So if that insulin level is high, what happens is that our body is sort of stuck in this energy storage state. So our body is not able to readily access our energy stores. So every time that you need fuel for your body, your body’s going to ask for calories and we can either get that energy from calories that we put into our mouth or from calories that are stored on our body in the form of fat storage. That’s the entire reason that our bodies store away fat for later times is to have energy available for time when food is not readily available.

So if our insulin level is high though, our body’s stuck in this energy storage form and isn’t able to access fat to burn it for energy in the way that we would desire it to. So what people with insulin resistance are often experiencing is that their body is asking them for energy, they’re not able to access their fat and so their body is going to ask them for energy through food that they’re eating. So people will experience really intense cravings, really intense hunger for food. Now one of the things that happens with insulin resistance is that we see that the blood sugar goes really up and down. So interestingly, hypoglycemia or low blood sugar is sometimes actually a presentation of insulin resistance, which is actually sort of the opposite of what we might expect because insulin resistance is a precursor to type two diabetes where ultimately the blood sugar would be getting high, but hypoglycemia, particularly when we’re talking about reactive hypoglycemia.

So we eat something that’s really sweet to really process carbohydrate and then our blood sugar drops afterwards. This is reactive hypoglycemia rather. So reactive low blood sugar that’s happening after eating a processed carbohydrate and this is very commonly due to insulin resistance. So our body sees these very up and down signals. Our body will feel that crash in blood sugar and often not only are we having intense hunger when we have insulin resistance, but we’re having intense cravings and need even for carbohydrates or more processed carbohydrates because if we’re feeling that effect of low blood sugar, our body’s going to want to get that blood sugar level back up and so the body’s going to ask for carbohydrates. So this is where it becomes incredibly challenging that if we’re just thinking about calories, we are not able to fuel the body in a way that creates these very even energy levels as opposed to this wild up and down thing.

So people with insulin resistance are both unable to access their energy stores, their fat stores properly so they’re not able to adequately dip into those fat stores for energy usage and they’re also getting the cellular signaling that, oh my gosh, I’m so hungry. Oh my gosh, I’m getting low blood sugar. I need to eat a carbohydrate. And that can come up really intensely as cravings, as food noise, as a lot of people will describe it. So insulin resistance makes it incredibly challenging to lose weight. Now the good news is that insulin resistance is reversible. So through some of the medications like GLPs that everyone is so excited about, through older medications like metformin even, and through other interventions. So we talked about the factors that drive insulin resistance, poor sleep, perimenopause, stress in our lives. Working to combat those will also help to improve insulin resistance, getting a good quality night’s sleep, regularly exercising our body.

We know that exercise is really important because it allows our body to utilize excess energy, so excess glucose in our bloodstream without any effect from insulin. So our body is able to utilize that energy very effectively. So we’re working on trying to improve insulin resistance, we’re trying to decrease that, have more insulin sensitivity. Exercising is incredibly important, especially exercising or moving your body after a meal can make a really big difference in the excess energy that your body has floating around so you’re not having to store away more energy for later. And so lots of different ways that we can work on combating insulin resistance. The foods that we eat can also play a difference. So it’s hard though, right, because our bodies are getting these really intense cravings and desire for carbohydrates, particularly those processed carbohydrates. But one of the things I will recommend is no naked carbohydrates.

So even if you are going to have a carbohydrate or a processed carbohydrate, partnering it with something like protein, for example, to help giving you a lasting energy response can help to combat some of this underlying insulin resistance. Then over time, as we can eat foods that are really rich in fiber, foods that are rich in protein, even a little bit of fat, that will help with lasting satiety and help to improve insulin resistance, but this is where people may really benefit from the support of medications and this is why I’m such a big advocate for this space. Now one other thing that I want to address that also comes up with calories in versus calories out is that we often are not very plugged in with what is going on with our metabolic rate. So our basal metabolic rate, this is how much energy our body uses at baseline.

Now height and gender and age are really good determinants of basal metabolic rate in general. So the female who’s 5’2″, who’s married to a six foot tall male, she will notice that he eats a lot more food than he, and that is because of many different factors. But he’s a man, he’s got more testosterone, he’s got more muscle, and he’s simply a lot taller. So two people who live in very different bodies, different genders, that will make a big difference also in how much energy our body is using. But on factor that people often do not account for is things like chronic weight loss in the past. So if you’ve had yo-yos where you’ve lost weight, you’ve gained weight, you’ve lost weight, you’ve gained weight, this can really wreak havoc on our metabolic health and on that metabolic rate. What’s amazing is that if we are eating less and less calories, your body does this thing where it’s trying to protect you, but it can slow down your basal metabolic rate.

So your body sees less calories. And this is why I say calories in versus calories out doesn’t always work because if you limit your calories in, your body is like, “Oh my gosh, I think we might be in a famine.” Do not you worry. I’m going to slow down your metabolic rate. I’m going to make you very efficient at processing energy. Sometimes people feel this, people will feel tired, they will feel run down, they will feel cold, they will be shivering. Sometimes we will have these effects because our body’s slowing down its metabolic rate. We almost just want to huddle up and cuddle up and cuddle up. We don’t want to be moving our bodies too much. Our body’s slowing down its metabolic rate, making itself incredibly efficient. And it’s like, “Hey, don’t worry. I see that you don’t have access to as much food right now, so I’m just going to slow down that metabolic rate so that you do not have to worry about starving to death.” So it’s this very protective mechanism, but when we are trying to lose weight, what it means is that if we are simply focused on calorie content, what happens is that we eat less calories, our metabolic rate slows down.

So then therefore we would need to eat even less calories and our metabolic rate would further slow down and we would eat to eat less calories and our metabolic rate would further slow down. And it becomes literally impossible to do this because A, you would just indefinitely be eating less and less calories, but more importantly, your body has other protective mechanisms that are telling you like, “Hey, go seek food.” If there is a famine, your body’s protecting you by slowing down your metabolic rate. It’s also going to protect you by yelling at you to go seek food. So as you lose weight, you’re going to have very, very intense hunger because your body is raising its ghrelin levels, which is your hunger hormone. It’s going to scream at you to go seek out energy to go seek out food. And so if we are just simply trying to eat less and less and less, our body adapts to that and it does not work long term.

The good news is we can combat this partially when we think about what is our macronutrient breakdown of food. Again, this is a big reason why protein has been so popular, making sure that we get the adequate energy to support our muscles, support our body, continuing to move our body regularly. So if you’re sending a signal to your body like, “Hey, I’m using my muscles, make sure we’re getting the signal to fuel these muscles.” Moving your body regularly will help with this, but simply trying to slash calories often ends up biting us back in the butt. And so the calories in versus calories out by itself does not work. And if you feel like you’ve been fighting this, if you feel like, “Oh my gosh, this makes sense. This explains why I’ve lost weight and I’ve regained weight and you feel like you’ve just failed, you feel like you need more support in your journey, I would love to be the person that helps you with that.

I see patients by telemedicine throughout the states of Illinois, Tennessee and Virginia. My in- person practice is in Charlottesville, Virginia. I also have a great online program called the GLP Guide where for one year you will have access to all the most important information to support you on your GLP weight loss journey. We have videos that are addressing how to use the different medications, how to manage side effects of medications, what you should be aiming for from a nutritional standpoint, from an exercise standpoint, how you need to know if you adjust doses of medications, how to protect against some of this decreased metabolic rate and stuff that we’re talking about in the video today. So if you are looking for more support, I would love to help you with that. You can find that online at www.sarahstombaughmd.com/glp. Thank you all so much for joining us today. I’ll see you all next time.