Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and to sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today’s episode. This is Dr. Sarah Stambaugh, 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 Stambaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to this week's episode of the Conquer Your Weight podcast. We are talking about metabolic adaptation, which is the changes that your body makes after you've had a significant weight loss. And this is probably the main contributor to why we can see weight regain or even why we see plateaus during the weight loss journey. So I'm really excited for us to get into this, to have a conversation about it because it helps to shed light on the sometimes the shame or the blame or just the dang frustration that comes up when we're in the weight loss journey, we're doing everything right, and then we hit a plateau or maybe things start to creep back up and we're like, oh my goodness. what is possibly going wrong. It may be metabolic adaptation that is at effect here. So we're going to talk about that today. Before we do, I would love to invite you to leave a rating or review for my podcast. If you have not done that before, I would really appreciate if you could take just a minute or two to do that for me. Apple Podcasts tends to be the best platform onto which you leave ratings or reviews. And what that does is it actually shows the algorithm that this is a podcast that's valuable. This is a podcast that's interesting. This is a podcast that they should suggest to other listeners or people who are listening for other similar type podcasts to say, “Hey, this may be other content that you like.” And we've recently had some patients who've come to us from the podcast and that just shows me how important it is to be able to get this message out. They were so excited to find that I was in their area, that I'm able to help them. And it's really been a pleasure to serve patients in that way. And so if you think, you know, it could be awkward to share a podcast with a friend or with a family member, you know, it could be a little awkward to be like, “Hey, I think you should lose weight. You should check out this weight loss podcast.” But the great thing about leaving a rating or review is that it just lets the algorithm do that suggesting for you. So you could just say what you think about the podcast and then it will suggest this podcast to other people who may be interested. If you have already left me a rating or review in the past, I just want to say thank you. I really, really appreciate it. I appreciate each and every one of you listeners. I love when you reach out with questions and today's topic is also in response to listener questions. We've been trying to address those. So also if you have questions, if there's things that you're thinking about in your weight loss journey that you haven't seen addressed here on the podcast, podcast, reach out and let us know. We would love to make an episode just for you, or as we're getting more and more episodes, we may be able to say, “Oh, actually there is already an episode that addresses that question. And here's a link to that.” So feel free also to email us anytime info@sarahstombaumd.com. We'll put that information in the show notes, show notes, so you can definitely check it out there. So let's dive into what is metabolic adaptation? Why does it even matter? But really it is often the reason why we're struggling with plateaus and certainly struggling with weight regain. And this may ring true when you think back even over your life of having had a really successful weight loss attempt at some point in the past, but then seeing that slowly over time that weight came back, metabolic adaptation is one of the biggest contributors to that. So let's talk about what is it? Well, first of all, let's talk about metabolism. A lot of times we talk about metabolism as this thing that is either good or it's bad or it's broken or it's working. It's this like big conglomerate thing. And like, I don't know how it works, but our metabolism is our metabolism. And some people have faster metabolism and some people have slower metabolism. And that is certainly true, but there are lots of different pieces of our metabolism. So when we look at how our body burns energy, what our metabolism is, there are a few different components. So we have the basal metabolic rate, sometimes also called the resting metabolic This is basically the amount of energy that it takes in order to run all of the functions in your body for your brain to think, for your heart to pump, for your GI system to digest, for your body to just do all of its natural baseline things. This is the amount of energy that it takes, the amount of calories that it takes, the amount of calories that it burns when you're just resting. So imagine while you're sleeping, you're not moving, you're not doing anything, you're just fully restful. This is the amount of energy that is burned at baseline. Now there's other pieces of this, like the thermic effect of food, which is when we eat food, the amount of energy it takes to burn that food, as well as NEAT, which is non-exercise activity thermogenesis. So this is activity that you're doing throughout the day, but you're not necessarily getting your heart rate up. This is an intentional exercise. This is like, you know, if you work in a kitchen and you're sort of walking back and forth and grabbing different dishes or grabbing a plate or you're unloading the dishwasher, these are those activities that we do in our regular life, the walking to the mailbox, the walking up the stairs, getting in and out of the shower, basically every movement that you do throughout your day. Even I'm sitting here kind of laughing because I'm a big hands talker. And so I'm like waving my hands as I'm talking. And even that is non-exercise activity thermogenesis. I'm burning energy. I'm burning calories because I'm always waving my hands when I'm talking. So that's non-exercise activity thermogenesis. Then there's also exercise and exercise, of course, being any intentional planned activity that's happening. that's burning more calories than we would at baseline. So you've got our basal metabolic rate or resting metabolic rate, the thermic effect of food, the NEAT, that non-exercise activity thermogenesis, and our exercise. Now, things like NEAT, things like exercise, those can fluctuate. Even the thermic effect of food, to be honest, how much energy does it take to break down different types of food, for example, those will fluctuate and may fluctuate really significantly day to day. You can imagine a day that you know, let's imagine you work in a hospital. I'm thinking about my husband, he gets so many steps per day. He works as an anesthesiologist, but when he's working in the intensive care unit, you know, walking around the unit, checking on different patients, going on rounds, walking, you know, just up and down the hallways, you know, he'll get many thousands of steps per day, even like going to change his scrubs or walking to his car. And so those things that we do, if you imagine your typical work day, especially if you're someone who's active in your job, and then imagine that you got the flu or you got COVID and you're just totally miserable and laying on the couch, on those days, you don't have as much NEAT, that non-exercise activity thermogenesis, because you're just simply laying on the couch. So things like NEAT can fluctuate significantly day to day. Certainly exercise can also fluctuate significantly day to day, even in an intentional way in that, oh, I exercise three days a week, for example, on those three days a week that you exercise, of course, your body's going to be burning more energy on the days where you're not exercising, your body's burning less energy. So there's these pieces that will move, but our basal metabolic rate, our resting metabolic rate, that is a number that is pretty stagnant. Now it can change over time, but if we look at it day to day, or week over week, that's number is pretty stable. So what happens with metabolic adaptation is that the basal metabolic rate will decrease. Now, this is a very natural response to weight loss. If you think about it in terms of the survival mechanism, for example, and there's a famine, there's not food readily available, your body is going to decrease the basal metabolic rate to basically say, okay, let's see if we can function more efficiently. Can we burn less energy? Can we get by on a fewer number of calories? And so it's this natural response to having weight loss as a protective mechanism. But when we look at basal metabolic rate, one of the challenges is that weight loss is one of the major triggers for a decrease in basal metabolic rate. So if you imagine two people living in two different bodies, you imagine someone who lives in, let's say a 200-pound body and someone who lives in a 300-pound body, and you compare at baseline, let's imagine that these people are otherwise similar. They're both the same gender. They have similar activity levels. They have similar body composition in terms of how much muscle they have on their body and how much fat mass they have on their body. The person who weighs 300 pounds is going to have a proportionally higher basal metabolic rate compared to the person who weighs 200 pounds. So having a larger body generally will lead to a larger basal metabolic rate. It simply takes more energy to fuel a larger body. Now, one of the things that's interesting is let's say that 300-pound person lost a hundred pounds and now they weigh 200 pounds. The interesting thing is that other 200-pound person, the original 200-pound person now compared to the person who was 300 pounds and lost 100 pounds is now 200 pounds. These two people, even though they both weigh the exact same, let's even say their body composition is the same. These two people are going to have different basal metabolic rates. The person who had lost 100 pounds, their body is likely to have a lower basal metabolic rate compared to the person who stayed stable at 200 pounds the entire time. And so this is where metabolic adaptation plays a role and where honestly, I think so much weight bias and our society's weight bias comes in is because there are many patients with sometimes even very significant obesity who are eating quite a bit less than we would expect them to based on the size of their body. And it's because their body is functioning very efficiently. Their body is functioning at a level that allows them to basically utilize every little last bit of energy, for example, and lowers their basal metabolic rate. And so we see this sometimes even in the way that we feel. Our body will work to conserve energy. So it's not just that we are actually using less energy and just sort of magically doing that, but our body will do things like we feel cold. So it's very common that people who are losing weight will notice that they feel cold. They will notice that they're feeling tired. They will also sometimes move less so that non-exercise activity, thermogenesis, that exercise, the motivation to do those things drops really significantly. So even subconsciously, our body's telling us like, hey, you should sit still and conserve energy. And so we feel fatigued, we feel run down, we feel cold, and that is the effect of the basal metabolic rate. There also are significant changes that happen in terms of our hunger signals, both in terms of hunger signals as well as satiety signals. So hunger and satiety, we think of a lot of times as the same, but hunger is really... the decision to initiate a meal where satiety is the decision to end a meal or that decision of, yes, I have, I'm adequately full. I have enough food in my body right now. So our hunger, when we've lost weight, When our basal metabolic rate has dropped, our body is trying to conserve energy and it's trying to tell us, oh my gosh, hey, I think you might be dying. Let's work a little bit harder to seek out some food, you know? And so ghrelin, which is our hunger hormone, ghrelin will go through the roof the more weight we lose and say, oh my gosh, you're starving. Go eat, go eat, go eat. Where leptin, our satiety hormone, leptin says, hey, you've had plenty. You're all done. Our leptin will decrease saying your not satiated as quickly. So you're more hungry, you're seeking food more often. And then when you do have an eating opportunity, it's harder to end that meal because you don't feel full at the same time. So this is where weight cycling can happen, where people lose weight and then gain weight and then lose weight and then gain weight is that when we've hit certain weight loss thresholds, our body is not hungry, like hunger that I don't think most people would know unless they've been through a weight loss journey. Hunger that is unbelievable, thinking about food all the time, craving food all the time, and just desiring that and seeking that out behavior is very hormonally driven as a protection mechanism to say, hey, I think you're dying. You're not getting enough energy. Make sure you go eat more. Now, the interesting thing is that when we do have excess weight on our body, we're like, why are we still using these old protective mechanisms that have been around since before food was so prolific? And that's how evolution works. These things aren't going to go away as quickly. So our body is gaining weight, or our body has gained weight in the past. And now when we're losing weight, our body is trying to hold on. It's trying to slow down how much energy we're burning. And it's telling us to go seek food so that we can work to regain that. And so we see this metabolic adaptation where over time, in theory, people may need to eat like less or less or less in order to continue losing weight. So we see this in things like The Biggest Loser, for example, and there was actually a really interesting study called The Biggest Loser Study where they looked at participants in season, I think it was season eight, And there were 14 participants of that study. And they looked at what was going on during the study and then what was going on six years later. And they looked at factors like the resting metabolic rate, that's the basal metabolic rate, their body composition, other hormonal and metabolic markers. And these were people on average who had weighed about 328 pounds. On average, they lost about 129 pounds. So we're talking about dropping down to about 200 pounds total. What's interesting is that after six years, there had been some weight regain. So on average, they had regained about 90 pounds, but on average stayed about 44 pounds below their baseline. So still maintained some of the weight loss, but not all of the weight loss. But the reason that that weight regain had happened, while there may be many factors that contribute to it, one of which was that their resting metabolic rate was 500 calories per day lower than compared to what it had been when they started out their Biggest Loser journey. And so this is 500 calories per day less than someone else who lived in the same body size. So we're talking about an average of 200-pound person who has regained weight. So they've regained weight to about 290 pounds on average. And this person who weighs 290 pounds, their resting metabolic rate is 500 kilo calories or calories per day lower than we would expect based on someone of their size. And so that means, you know, you think about that over the course of a day, but that's really for a lot of people, like an entire meal, less worth of food that they can eat. And if they do, they're going to gain weight because their body is not processing energy. They're not requiring as much energy to process as it was before. So we see this effect of basal metabolic rate and it can really, um, in some ways provide that clarity of why weight regain happens, why weight plateaus can happen. Even when you feel like, oh my gosh, I'm doing the exact same thing and now I'm gaining weight. Why in the world is that happening? It can be this metabolic adaptation effect. Now, there's certainly other things that play a role. Certainly for men and women like in their 50s and beyond, very common that the hormonal changes, the decrease of estrogen, progesterone, of testosterone, that those can play a really significant role in that feeling of, oh my gosh, I'm doing the exact same thing, yet my body is gaining weight. There's other factors that contribute. So it's not just changes in basal metabolic rate and this metabolic adaptation, but for someone who's had a really significant weight loss, that absolutely is a factor. So we think about, well, what do we do? what do we do about it? You know, how do we, can we prevent that from happening? Are there any treatment options? Are there factors that we can consider that are going to make this less likely? And the good news is there's absolutely things that can be supportive of this. So for one, the way that we diet matters. So when we think about weight loss, losing weight at a slow and steady rate tends to be the most effective way in order for our body to not have a significant rebound. People who lose weight too rapidly are likely to disproportionately lose muscle mass compared to fat mass, and that may contribute to further decrease in basal metabolic rate. basal metabolic rate is driven by a lot of different factors, but certainly what our body is composed of will make a difference. So when we think about how metabolically active fat tissue is compared to muscle mass, these two things function very differently in our body in a lot of ways, but in terms of how much energy it takes to keep up our muscles versus how much energy it takes to keep up our fat mass, it takes a lot more energy when we have muscle mass on our body. So when we're losing weight, losing weight in a slow and steady fashion can be important. Really being mindful of the things that are going to support our muscle mass during our weight loss journey are also important. So this looks like getting adequate protein, really being intentional about getting carbohydrates, especially after exercise or after workouts where you've tired out your muscles. Also doing exercise that's going to encourage the muscles to be stimulated, whether that is cardiovascular training. But even more importantly, resistance training. So doing weightlifting that can be at a gym, that can be at home, that can be with your body weight, that can be with heavyweights, you know, like lifting dumbbells or barbells or using different types of machines, for example, in order to support that weightlifting like cable machines and doing that resistance training as well as pairing it with adequate protein and carbohydrates when you're trying to repair your muscles, that will be really helpful in supporting your muscle match, which can help you So this kind of goes hand in hand with losing weight more slowly. Now there are where coming to a plateau can be a very normal thing. Sometimes we'll even do resets with intentional eating or intentional overeating for periods of time, which can give the body just a signal of like, hey, you're okay, you're fine, you're not dying. Look, you have all the calories that you need. It's really interesting. Sometimes people who do these intentional overeatings, you'll see weight gain initially, but then they move back into weight loss, even if they had been plateaued or stuck for a while. That would be something I would recommend doing alongside the support of a physician or a nutritionist or even a coach who's experienced in that, but that can be a helpful technique. And honestly, this is where medications that support weight goals can be really important as well. So when we look at the effect, for example, of a GLP medication like Ozempic or Wegovy, Zepbound or Mounjaro, the effect of these GLP medications on the hunger and satiety pathways allows us to just not feel ravenously hungry when our body size has changed. And so these medications can be really important in terms of supporting long-term weight reduction and weight maintenance, as well as things like metabolic surgery for people or bariatric surgery for people who are a candidate. And so interventions, whether it's medical, whether it's surgical may be important as well. So lots of different factors to consider, but metabolic adaptation, um, unfortunately is very common. You know, unfortunately it's our body's natural response to when we've had weight loss that our body's going to turn down the, you know, turn down the engine, turn down the burner, say like, Hey, let's see if we can get by with less energy. And it does that. And so it allows us to be sometimes at this really challenging place where we see a plateau or we even see a weight regain. And it feels like, Oh my gosh, I just have to sort of try harder and harder and harder eat less. less and less and less in order to create that weight loss. And if you are someone who has dealt with weight cycling where you've lost weight and you've gained weight and you've lost weight and you've gained weight, I want you to know that that story is very common and there's nothing wrong with you. There is nothing broken with you. That is the consequence of so many other things in our environment, in our food patterns, and the way that we feed people in the movement that we do in our society or the lack of movement we do. So many genetic factors and these evolution factors, so many different things contribute to this. If you have been looking for support in your weight loss journey and you are looking for a doctor, I would love to help support you. I see patients in person in Charlottesville, Virginia. I also see patients throughout the state of Virginia, Illinois, and Tennessee by telemedicine. If you're interested in learning more, you can visit me at www.sarahstombaumd.com to learn more and get started. Thank you so much for joining us for today's episode we'll see you all next time bye.