Jason  Fung  –  The  Ae/ology  of  Obesity  (presenta/on  Vail  2016)  

I'm  not  going  to  speak  about  type  2  diabetes  and  trust  me,  

it's  very  hard  for  me  not  to  talk  about  it,  because  I  deal  with  it  quite  a  lot.  

But  I  just  wanted  to  say  also,  

that  we  also  do  a  clinic  that  is  very  much  focused  on  type  2  diabetes,  

as  well  as  the  treatment  of  obesity.  

And  if  anybody,  you  know,  is  interested,  they  are  also  welcome  to  come  see  me  

and  I'll  be  happy  to  have  them  siAng  in  my  clinic  as  well.  

But  today  I'm  going  to  talk  more  about  obesity.  

So,  type  2  diabetes  is  very  closely  related,  

but  there  are  intricacies  about  it  that  are,  you  know,  not  the  same.  

So  what  I  really  want  to  focus  on,  is  the  aeCology  of  obesity.  

And  what  aeCology  means?  

Is  the  underlying  cause  of  obesity.  Okay?  

Because  this  is  really  an  important  quesCon.  Okay?  

This  is  something  that  has  always  bothered  me  

and  really  one  of  the  important  paradoxes  

that  kind  of,  started  me  on  thinking  of  that.  

So,  I  don't  know  if  you  know  who  Kelly  Brownell  is.  

This  is  one  of  the  kind  of  giants  of  the  obesity  field.  

He  created  the  learned  diet,  which  is  used  in  a  lot  of  academic  centers,  

he's  wriKen  like  14  books,  

he  is  credited  with  coining  the  terms  toxic  food  environment,  

which  you  hear  all  the  Cme,  Yo-­‐Yo  dieCng.  Right?  

So,  he  has  really  extensive  knowledge  of  obesity  and  it  reflects  it.  Right?  

So,  he's  the  Dean  of  the  Stanford  School  of  Public  Policy,  

he's  the  Board  of  Directors  of  Duke  Global  Health  iniCaCve,  

he,  in  2006,  he  was  considered  one  of  the  100  most  influenCal  people.  

Now,  that's  huge.  Right?  

I  mean,  in  the  this  parCcular  field,  he  was  probably  the  biggest  name,  

like  the  most  important  person  around.  

But,  the  problem  is,  when  you  meet  him,  

really,  there's  only  one  quesCon  anybody  asked  of  this  fellow.  

The  thing  that  people  always  wonder  is,  "Why  is  he  so  fat?"  

Right?  And  I'm  not  trying  to  be  mean.  

This  is  a  very  important  paradox.  Why  are  there  fat  doctors?  

Because  we  consider  the  doctors  are  experts  in  nutriCon.  

We  know  that's  true,  but  we  think  that.  

So,  most  doctors  including  Dr.  Brownell  

are  very,  very  self-­‐disciplined,  they  have  moCvaCon.  

So,  how  can  you  have  the  knowledge  

to  be  one  of  the  world's  leading  experts  of  obesity  

and  be  this  fellow,  who's  one  of  the  most  remarkable  people.  

You  know,  he  must  have  great  self-­‐control,  he  must  work  like,  very  hard,  

how  can  he  be  so  fat?  

If  you  have  both  the  knowledge  and  the  ability,  

how  is  that  possible?  

Well,  there's  only  two  possibiliCes.  

You  either  don't  have  the  ability  or  you  don't  have  the  knowledge.  

And  this  is  really  the  most  important  quesCon  in  weight  loss.  

What  is  it  that's  causing  weight  gain?  

Right?  What  causes  obesity?  What  is  the  aeCology  of  obesity?  

That  is  the  quesCon,  because  if  you  get  that  quesCon  wrong,  

everything  you  do  aZer  that,  is  wrong...  everything.  

All  your  treatments  are  wrong,  all  your  drugs  are  wrong,  

the  way  you  think  about  obesity  is  all  wrong.  

And  I  think  that  we  have  everything  all  wrong.  

And  really,  it's  not  just  in  people  like  Dr.  Brownell,  who  again,  

I  haven't  met  him,  but  I  think  he's  a  terrific  fellow.  Right?  

He's  put  a  lot  of  himself  into  kind  of  promoCng  the,  you  know,  

fighCng  the  global  obesity  epidemic.  

But,  I  think  that  the  way  he  thinks  about  it  it's  all  wrong.  

And  why  don't  we  think  about  this  quesCon.  Right?  

It's  about  the  last  quesCon  anybody  ever  asked.  

They  all  ask,  "How  can  you  lose  weight?"  

But  my  quesCon  is,  "What  causes  weight  gain?"  

Well,  because  we  think  we  already  know.  

Well,  it's  too  many  calories,  that's  obvious.  

We've  been  hold  that  since  we're  in  grade  2  

that  it's  too  many  calories  what  causes  obesity.  

This  is  the  whole  idea,  calories  in,  calories  out,  

a  calorie  is  a  calorie.  Right?  

The  problem  is,  I  think  that  idea  is  completely,  uKerly,  incorrect.  

So  this  leads  to  this  sort  of  energy  balance  paradigm,  

which  companies  like  Coca-­‐Cola,  they  love  this  sort  of  energy  balance  paradigm,  

this  kind  scale  of  too  much,  you  know,  calories  in  or  two  few  calories  out,  

and  they  all  invoke  this  first  law  of  thermodynamics.  

And  if  you've  never  heard  it,  it's  that,  "Oh  calories  can't  be  created.  

"The  total  energy  of  a  system  is  constant,  

"you  can't  create  it  and  you  can't  destroy  it,  

therefore,  it's  either  calories  in  or  calories  out."  

There's  really  two  major  problems  with  this  

and  we'll  get  into  that,  

but  one  of  the  real  problems  is  we  know  that  this  kind  of  paradigm  

actually  doesn't  work  at  all.  Okay?  

And  it's  not  just  me  saying  that,  "If  one  studies  show  it  

that  the  failure  rate  of  this  sort  of  Eat  Less,  Move  more,  is  about  99%."  

So,  you  are  virtually  guaranteed  to  fail.  Right?  Virtually.  

If  you  look  at  books,  like  the  Handbook  of  Obesity  

and  Joslin's  Diabetes  Mellitus,  

which  is  one  of  the  very  authoritaCve  textbooks  of  medicine.  

It  says,  "ReducCon  of  caloric  intake,  

is  the  cornerstone  of  any  therapy  for  obesity."  

Reduce  your  calories,  caloric  reducCon  is  the  primary  thing.  

However,  they  say,  "None  of  these  approaches  has  any  proven  merit."  

That  is  the  say  and  to  reduce  your  calories,  but  I  know  it  doesn't  work.  

Okay,  well,  that's  not  a  very  good  advice.  

Unfortunately,  it's  actually  the  advice  everywhere.  

In  the  Department  of  Agriculture,  USDA,  Handbook  of  Obesity,  Joslin's-­‐-­‐  

any  textbook  you  read  will  say  the  same  thing.  

So,  there  are  really  two  fundamental  errors  

in  this  whole  idea  of  calories  in,  calories  out.  

The  first  one  is  that  we've  confused  what  the  proximate  cause  and  the  ulCmate  cause  is.  

The  second  is  that  they  consider  calories  to  be  a  single  compartment  

and  obesity  is  really  a  two  compartment  problem.  

There  are  different  ways  for  your  body  to  use  that  energy  that  you  put  in.  

You  can  burn  it  or  you  can  store  as  fat.  Right?  

So,  there's  two  different  pathways.  

And  what's  important  is  which  way  you  go,  not  the  total  energy  of  the  system.  

Let's  talk  first  about  proximate  versus  ulCmate  causes.  

So,  what  is  proximate  cause?  Proximate  means  the  most  close  to.  

So,  if  you're  worried  about  obesity,  

the  proximate  cause  of  obesity  is  too  many  calories.  Right?  

That's  the  thing  that  goes  right  before  it,  

but  the  thing  that  ulCmately  causes  it,  is  the  ulCmate  cause.  

So,  the  thing  is  if  you  treat  the  proximate  cause,  

it's  kind  of  fuCle  it  doesn't  really  work.  

If  you  treat  the  ulCmate  cause,  

because  that's  what's  really  underlying  this  disease,  

that's  what  is  important.  

So,  let  me  give  you  some  examples.  

So,  alcoholics.  

You  can  say  alcoholism  is  too  much  alcohol  in  or  to  liKle  alcohol  out.  

Right?  

Now  that's  a  fundamental  law,  the  first  law  of  thermodynamics  of  alcohol.  

You  cannot  create  or  destroy  alcohol,  

so,  if  you  tell  me  that's  wrong,  

then,  you're  saying  that  the  fundamental  laws  of  nature  don't  apply.  

Well,  obviously,  that's  not  true,  

but  that's  the  same  argument  that  people  make  for  calories.  

That's  only  the  proximate  cause,  

that's  not  the  ulCmate  cause  and  treatment  is  fuCle.  

If  you  say  that  "Oh,  you  are  an  alcoholic,  I  have  advice  for  you.  

Drink  less  alcohol."  

You'd  say,  "Well  that's  preKy  bad  advice."  

So,  what's  the  ulCmate  cause  of  alcoholism?  

Well  there  are  lots  of  different  things:  

addicCon,  family  stressors,  an  addicCve  personality.  

All  of  these  things  are  the  ulCmate  cause  of  alcoholics.  

So,  if  you  think  about  that  for  a  second,  

now,  you  can  actually  treat  the  disease,  

because  you  know  what  the  ulCmate  cause  is.  Right?  

So,  the  treatment  is  not  telling  somebody  to  drink  less  alcohol,  

the  treatment  is  support  groups,  like  Alcoholics  Anonymous,  

family  help,  social  work,  friends,  church,  religion.  

All  of  these  things  are  crucially  important  

and  you're  not  breaking  this  alcoholic  first  law  of  thermodynamics,  

because  it's  ridiculous,  that's  only  the  proximate  cause.  

You  can  take  the  same  thing  as  a  plane  crash.  Right?  

What  causes  a  plane  crash?  

Well,  the  proximate  cause  is  there's  too  much  gravity,  or  too  liKle  liZ.  

It's  a  fundamental  law  of  nature.  

So  therefore,  the  treatment  is  to  have  bigger  wings  

or  cut  the  weight  of  your  plane.  

Well,  that's  preKy  ridiculous  as  well,  

but  again,  advice  to  get  bigger  wings  is  you  don't  say,  

"Well,  you  are  ridiculous  

because  you  are  contradicCng  the  fundamental  law  of  gravity."  

That's  only  proximate  cause,  that's  not  what  causes  it,  

that's  what  immediately  precedes  the  plane  crash.  

The  ulCmate  cause  is  things  like  human  error,  

weather  or  mechanical  problems.  

So,  the  government  make  sure  that  people  get  adequate  training,  

they  have  maintenance  and  they  have  proper  weather  forecasCng.  

And  that  makes  sense,  because  that's  the  ulCmate  cause.  

When  you  treat  the  ulCmate  cause,  it's  useful,  

when  you  treat  the  proximate  cause,  it's  useless.  

So,  we  can  actually  apply  this  preKy  easily  to  obesity.  

So,  here's  the  way  we  think  about  obesity.  

Too  much  calories  causes  obesity.  

That's  what  everybody  says,  but  that's  really  just  the  proximate  cause.  

If  you  treat  that,  you're  going  to  say,  "Eat  less  or  move  more."  

But,  what's  the  ulCmate  cause?  

So,  this  is  the  first  law  of  thermodynamics,  

but  it's  also  the  unspoken  accusaCon.  

And  again,  one  of  these  things  that  I  think  is  one  of  the  most  unfair  things  about  obesity,  

is  that  what  we  say,  is  that,  "This  is  the  proximate  cause,  

but  the  ulCmate  cause  is  that  it's  your  fault."  Right?  

That's  the  unspoken  accusaCon,  "You  let  yourself  go.  

"It's  your  fault.  You  shouldn't  be  eaCng  that  bagel.  

It's  all  treatment,  is  willpower.  That's  all  you  need."  

That's  what  they  say,  but  the  model  is  incorrect.  

It's  only  correct  if  this  model  is  correct.  

There's  another  model  of  hormonal  obesity,  

which  treats  obesity  as  a  hormonal  problem.  

So  again,  the  proximate  cause  is  sCll  too  many  calories.  

But  what's  driving  you  to  have  too  many  calories?  

Well,  it's  insulin,  corCsol  as  well,  it's  the  hormones.  

So,  in  this  case,  if  you  have  a  hormonal  view  of  obesity  

and  the  treatment  is  not  willpower,  

because  all  of  a  sudden  as  a  naCon,  you  know,  

where  50  years  later  we  have  no  willpower,  

and  50  years  before  we  had  lots  of  willpower  -­‐  Like,  that's  ridiculous!  

So,  the  treatment  then,  it's  to  lower  insulin.  

And  then  you  have  to  understand,  

then  you  can  understand  why  it's  going  to  work.  

In  this  hormonal  model  you're  not  breaking  any  laws  of  thermodynamics,  

you're  not  saying  that  you're  creaCng  energy  out  of  nothing.  

And  this  is  one  of  the  things  that  always  leveled  at  these  low-­‐carb  people.  

It's  like  "Well,  what,  you  don't  believe  in  the  law  of  thermodynamics?"  

"No,  we  are  not  saying  that  at  all,  you  idiot.  

"We're  saying  that  there's  a  different  cause,  it's  not  willpower,  it's  insulin...  

That's  what's  causing  you  to  gain  weight."  

So,  they  never  understand  that,  but  calling  names  is  not  the  answer.  

The  other  issue  is  that  again,  they've  fundamentally  misunderstood  the  problem  

and  obesity  weight  gain  is  a  two  compartment  problem.  

What  it  means,  is  that  it's  not  simply  a  maKer  of  the  energy  in  and  the  energy  out,  

it's  not  simply  what  goes  in  and  what  goes  out.  

Because  you  can  think  of  yourself...  I'm  going  to  use  a  different  analogy  today.  

...so,  think  of  yourself  as  the  manager  of  a  coal  burning  power  plant.  

So,  every  day  you  get  2000  cal,  2000  tons  of  coal  

and  you  burn  2000  tons  of  coal.  

But  that's  not  the  only  place  it  can  go,  

you  can  also  store  some  of  it  in  the  storage  shed.  

So,  there's  two  compartments  and  what's  important  is  which  way  you  go,  

it's  not  the  total  amount  of  energy.  

Because  what  happens,  if  you  decrease  the  energy  in,  

so  instead  of  geAng  2000  cal,  2000  tons  of  coal,  

you're  only  geAng  1500  tons  of  coal.  

So,  we  all  assume  that  your  stores  go  down.  

But  that's  only  true,  only  true,  

if  the  amount  you  are  burning  stays  constant.  

And  that  is  simply  not  true.  Okay?  

That's  the  only  way  it  is  true.  

The  other  possibility  is  that,  

as  you  reduce  the  amount  of  coal  that's  coming  in,  

you  reduce  the  amount  of  power  you're  burning  and  you  keep  this  stable.  

Again,  you're  not  breaking  any  laws  of  thermodynamics,  

it's  a  problem  with  parCConing  of  energy.  Right?  

And  this  is  the  problem.  

So  suppose  you  are  in  this  situaCon  

where  you  get  1500  tons  of  coal.  

And  that  for  a  while  you  take  it  out  of  your  stores,  

you  burn  2000  tons  of  coal,  you  are  geAng  in  1500,  

so,  day  aZer  day  you're  burning  more  than  you  take  in.  

Well,  what's  going  to  happen?  

Well,  you're  going  to  run  out  of  stores,  

your  body  is  going  to  totally  shut  down,  you  can't  make  any  power  

and  there  is  blackouts  everywhere.  

Law  says,  "Get  in  here  you  idiot!  What  are  you  doing?"  

That's  crazy,  you  would  never  be  so  stupid  as  to  do  that.  

The  logical  thing  is  to  simply  burn  a  liKle  less  energy.  

Yeah  there  are  a  few  brownouts,  but  there  are  no  blackouts,  there's  no  looCng.  

So,  that's  the  thing,  you  can  do  either,  but  which  one  actually  happens?  

Well  the  thing  is  that  we've  studied  this  for  100  years  

and  we  know  exactly  what  happens.  

So  this  was  back  in  1917.  

They  reduced  the  calories  so,  like  1400  to  2100,  

so  it  doesn't  seem  that  low  compared  to  modern  standards.  

But  what  they  saw  was,  this  was  a  12  young  men  

and  they  reduced  their  calories  about  roughly  30%,  

because  they  wanted  to  know  what  happened.  

And  what  happened  was  that  their  metabolisms  decreased  about  30%.  

Well,  that's  preKy  smart,  because  if  you  don't,  

you  are  going  to  run  out  of  energy  and  then  you'll  die,  

but  the  body  doesn't  want  to  die.  

And  this  was  shown  in  Ancel  Keys'  famous  study.  

Well,  we  all  talk  about  Ancel  Keys  for  other  reasons,  

but  he  did  this  very  famous  study  on  these  conscienCous  objectors,  

people  who  didn't  want  to  go  to  World  War  II,  he  took  them,  

he  reduced  their  calories  by  about  30,  40%.  

Now,  they  actually  kept  reducing  them  to  keep  making  them  lose  weight.  

And  everybody  always  points  this  out  as  a  reason  why  you  shouldn't  fast,  

but  this  was  not  fasCng,  actually  this  was  a  calorie  restricted  diet.  

So,  these  people  were  eaCng  about  1570  cal  a  day.  

So,  it's  not  fasCng,  it's  not  starvaCon,  

it's  a  calorie  reduced  diet.  

And  what  happened?  

Well,  what  happened  was  that  their  metabolic  rates  decreased  by  about  40%.  

PreKy  logical,  you're  taking  in  less  energy,  you're  burning  less  energy.  

So,  they  measured  all  kinds  of  stuff,  it  is  actually  a  terrific  study.  

Heart  volume  shrank,  stroke  volume  shrank,  heart  rate  slowed,  

the  one  that  everybody  noCced  was  the  body  temperatures  dropped,  

so  they  said,  "It's  the  middle  of  July  and  I'm  puAng  on  blankets."  

There's  also  all  kinds  of  neuropsychiatric  things,  

people  obsessed  about  food  and  some  went  crazy  and  that  kind  of  thing.  

And  it's  actually  funny,  because  these  people  were  eaCng  on  an  average  1570  cal  a  day,  

which  is  not  that  far  off  of  what  most  diets  do.  

But  again,  the  point  is,  that  when  you  reduce  calories  in,  

calories  out  also  reduces.  

And  we've  shown  this  in  more  recent  studies.  

So,  this  is  Dr.  Leibel's  very  famous  study.  

And  what  he  did  was  he  took  paCents  with  a  stable  weight  

and  he  put  them  into  a  metabolic  lab.  

So,  he  did  two  things  -­‐  one,  is  that  he  actually  force-­‐fed  them,  

so  that  they  gained  10%  of  weight,  

then,  he  put  them  back  to  normal,  then  he  made  them  lose  weight  

and  he  measured  their  metabolic  rates  all  through.  

So,  what  did  he  find?  

Well,  if  you  force-­‐feed  these  people  and  they  gain  10%  of  weight,  

they  increase  their  basal  metabolic  rate  by  close  to  500  cal  a  day,  

so  the  body  is  not  just  gaining  weight,  gaining  weight,  gaining  weight.  

So,  everybody  says,  "Yeah,  you  eat  more  calories,  you'll  gain  weight."  

Well,  no,  your  body  is  actually  trying  to  burn  it  all  off,  500  cal  a  day.  

And  what  happens  to  those  very  same  people,  

as  you  bring  them  back  to  their  iniCal  weight?  

Well,  their  basal  metabolic  rate  goes  back  exactly  the  same  

and  as  they  lose  weight,  they  start  burning  less  energy,  

so  they  decrease  their  metabolic  rate  by  about  300  cal.  Right?  

So  again,  it  makes  total  sense.  

If  you're  geAng  a  lot  of  coal  delivered  to  you,  

and  just  keep  shuKling  it  into  the  stores  

and  eventually  there's  no  more  place  to  store,  

so  you  sCck  it  in  your  bosse's  office.  Right?  

What  is  he  going  to  do?  He's  going  to  fire  you.  

He'll  say,  "Why  are  you  so  stupid?"  

Again,  the  body  is  just  not  that  stupid.  

It's  going  to  burn  off  all  this  energy,  because  it  doesn't  want  it.  

And  that's  exactly  what  happens.  

So,  it's  a  two  compartment  problem,  you  have  to  see  which  way  you're  going.  

So  this  is  our  big  hope,  you  lose  weight  and  then  you  hope,  

well,  you  know,  your  metabolism  is  going  to  go  down.  

We  know  that's  going  to  happen.  

But  maybe  if  you  maintain  this  way  for  a  long  Cme,  

your  body  kind  of  gets  used  to  this  new  weight.  

That's  our  big  hope.  

Unfortunately,  it's  not  really  true.  

So  if  you  look  at  long-­‐term  studies,  

so  up  to  a  year,  where  they've  maintained  the  weight  loss,  

what  you  see  is  that  the  metabolic  rate  drops  by  about  400  cal  a  day.  

So,  it  never  got  beKer.  

So,  it  maintains  itself  indefinitely.  

So  it  looks  like  this  is  what  happens  when  you  try  to  reduce  calories  

and  that's  why  caloric  reducCon  really  doesn't  work.  

The  other  issue,  the  other  hormonal  change  that  we  get,  

when  you  start  to  reduce  calories,  

is  that  you  change  your  hormones,  

your  saCety  hormones  and  your  hunger  hormones.  

So  again,  this  was  published  in  2011,  so,  about  five  years  ago,  

and  this  was  a  study  where  they  took  people  and  they  made  them  lose  weight,  

and  they  maintained  it  over  a  long  period  of  Cme.  

And  then  they  measured  their  hormones  and  said,  

"AZer  one  year,  let's  look  at  what's  happening.  

So  again,  the  hope  is  that  as  you  get  used  to  this  new  weight,  

that  your  body  will  just  kind  of  seKle  down  and  be  normal  at  this  weight."  

But  it  doesn't.  

So  ghrelin  is  the  so-­‐called  hunger  hormone,  it's  a  hormone  that  makes  you  hungry.  

So  even  one  year  aZer,  your  ghrelin  is  much  higher  than  it  was  before.  

PepCde  YY  is  the  saCety  hormone,  it  makes  you  full.  

So,  if  it's  lower,  it  means  you're  more  hungry.  

And  again,  even  aZer  a  year,  your  saCety  hormone  is  lower  than  normal.  

So,  the  boKom  line  is  that  you're  a  lot  hungrier,  

because  you've  lost  the  weight  and  you  haven't  adjusted,  

all  you've  done  is  reduced  calories,  you  haven't  fixed  the  actual  problem  of  insulin.  

So  you're  hungrier.  

And  again,  this  always  strikes  me  as  one  of  the  most  unfair  things  in  medicine.  

Because  you're  hungrier,  like  you  are  eaCng  more,  you  want  to  eat  more  

but  it's  not  because  you're  some  gluKonous  slob,  

it's  because  your  hormones  are  making  you  hungry  

and  you're  burning  less  energy.  

So,  as  you  regain  that  weight,  everybody  thinks,  

"Oh,  you  went  off  your  diet  because  you  have  no  will  power."  

And  again,  one  of  the  most  unfair  things  in  medicine,  

because  we  know  it's  all  about  your  metabolism  which  went  down  

and  your  hunger  hormones  which  went  up.  

But  they  all  stem  from  a  complete  misunderstanding  of  obesity.  

So,  it's  not  a  lack  of  willpower,  

you're  not  some  gluKon,  it's...  

No,  it's  your  hormones  that  are  making  hungry.  

and  you're  not  some  slob,  because  you're  not  exercising,  

you're  like,  burning  like,  500  cal  a  day  less.  

Not  because  you  don't  want  to  and  because  you  are  not  exercising,  

it's  your  hormones,  it's  your  basal  metabolism  has  gone  down.  

Now,  we  know  this  happens.  Right?  

So  again,  if  you  look  at  this  caloric  reducCon  as  primary  model,  

which  we  use  all  the  Cme.  

Too  many  calories  it's  your  personal  choice,  it's  not  actually  true.  

It's  all  due  to  these  metabolic  adaptaCons,  

because  of  the  reduced  energy  expenditure  and  the  increased  hunger.  

We  know  this  happens  because  this  humongous  trial  of  the  Women's  Health  IniCaCve,  

which  is  50,000  women.  

So,  here  they  start  off  baseline,  1788  cal  a  day,  

at  follow  up  seven  years  later,  it's  1445.  

You  lost  361  cal  every  day,  day  aZer  day.  

And  they  gave  them  more  fruits  and  vegetables  and  fiber,  

if  you  look  at  energy,  what  they  did  of  course,  

was  they  did  about  a  50%  carbohydrate  diet,  

so  they  went  up  from  44.5  to  52.7.  

And  if  you  look  at  fat,  fat  went  from  38.8  to  29.8.  

Great,  terrific!  

Low-­‐calorie,  low-­‐fat  diet.  Great,  love  it!  

Well,  it  didn't  worked.  Right?  

These  people  who  should  have  lost  36  pounds  every  single  year,  

didn't  even  lose  a  single  pound,  like  in  10  years  almost,  

not  a  single  pound.  

They  should  have  lost  like,  you  know,  210  pounds  of  fat  

and  they  lost  nothing,  nothing.  

It's  not  even...  this  is  1  kg,  

so  you're  probably  talking  about  like  a  quarter  of  a  pound.  

You  know,  the  weight  of  a  good  bowel  movement  or  something  like  that.  

Yeah,  it  doesn't  work.  

So  we've  known  it  for  so  long  

and  yet  we  keep  telling  people  over  and  over  and  over,  

"Reduce  your  calories,  reduce  your  calories,  exercise  more."  

We  know  it  doesn't  work.  I  could  have  told  you  that.  

And  this  again,  is  the  cruel  hoax,  because  we  put  the  blame  on  people,  

when  the  blame  should  be  on  ourselves,  on  the  advice  that  we  give,  

which  is  so  poor.  

So,  you  eat  less  calories,  you  lose  weight,  

your  body  senses  that  you  lose  weight,  

so  you  decrease  your  metabolism  and  increase  your  hunger.  

Then  you  regain  that  weight.  

But  since  you  have  a  lot  of  willpower,  you  double  down.  

You  are  going  to  eat  even  less  calories  and  we've  all  done  this.  

So,  you  lose  a  liKle  bit  more  weight,  

but  the  problem  is  your  body  adjusts  again,  reduces  its  metabolism  

and  increases  your  hunger,  and  you  start  to  regain  the  weight.  

And  it  keeps  going  on  and  on  and  on,  unCl  you  can't  take  it  anymore.  

Because  you  feel  lousy  and  the  weight  is  sCll  coming  back,  

that's  the  cruel  hoax.  Right?  

And  then  to  top  it  off,  everybody  thinks,  

"Oh  yeah,  that  guy.  He  couldn't  sCck  to  his  diet."  

The  most  unfair,  like  the  most  cruel  thing  we  do  to  people.  

And  the  ulCmate  proof  is  not  in  some  kind  of  big  study,  

the  ulCmate  proof  is  in  all  of  us.  

I  can  show  you  all  this,  but  like,  honestly,  

who  hasn't  done  these  sort  of  diets?  

My  guess  is  like  90%  of  the  enCre  populaCon  of  North  America  

has  been  on  some  kind  of  diet  like  this,  

at  some  point  in  their  life  and  it  didn't  work.  

That's  just  the  truth.  

And  this  is  the  problem.  

The  problem  is  that  you  need  to  know  which  way  you're  going.  

And  the  problem  is  insulin,  

because  that's  what  tells  the  body  which  way  to  go.  

Insulin  tells  the  body  to  store  fat,  that's  what  its  normal  job  is.  

When  you  eat,  insulin  goes  up  and  you  start  to  store  fat.  

You're  not  breaking  any  laws  of  thermodynamics.  

So  what  we  see  is  that  if  you  look  at  it  from  the  hormonal  obesity  point  of  view,  

if  you  try  to  really  understand  the  eCology  of  obesity,  

what  you  see  is  that  it's  sCll  too  many  calories  in  the  end.  

That's  the  proximate  cause,  that's  not  the  ulCmate  cause,  

the  ulCmate  causes  is  the  insulin.  

And  if  that  is  the  ulCmate  cause,  forget  about  this  eat  less,  move  more,  

that's  not  going  to  be  successful  

any  more  than  drink  less  alcohol  is  more  successful.  

The  ulCmate  treatment  is  to  lower  insulin.  

Now,  that  you  understand,  now  you  can  design  raConal  treatments.  

So,  what's  the  evidence  that  insulin  actually  makes  you  fat?  

Well,  there's  all  kinds  of  associaCon  studies,  

but  the  problem  with  the  associaCon  studies  is  that  they  don't  tell  you  anything.  

What  you  need  are  our  causaCon  studies.  

And  to  do  that,  you  have  to  give  people  stuff  like  insulin.  

So,  this  is  the  DCCT  trial.  So,  this  is  type  1  diabeCcs.  

And  what  they  did  is  they  had  a  group  

which  had  a  lot  of  insulin  and  low  blood  sugars,  

and  another  group  which  had  not  that  much  insulin  and  higher  blood  sugars.  

Now,  the  group  that  had  type  blood  sugar  controls  did  have  less  complicaCon,  

but  that's  not  my  quesCon.  

My  quesCon  is,  does  that  insulin  make  you  fat?  

And  it  does.  

So  at  the  end  of  10  years,  9  years,  

you  can  see  that  the  people  who  got  lots  of  insulin,  

like,  almost  30%  of  them  had  major  weight  problems.  

So,  I'm  not  saying  that  they  shouldn't  get  it,  

I'm  just  saying  that  here's  the  actual  causaCon  study,  

we  gave  the  insulin,  they  got  fat.  

You  can  look  at  the  correlaCon  between  the  total  insulin  dose  

and  how  much  weight  they  gain,  

and  it  turns  out  it's  actually  preKy  Cght.  

As  you  give  more  and  more  insulin,  this  is  more  and  more  insulin,  

you  gain  more  and  more  weight.  

And  again,  as  doctors,  this  you  already  know,  

because  we've  all  prescribed  insulin  and  we  all  know  it  causes  weight  gain.  

In  type  2  diabetes  you  see  exactly  the  same  thing.  

So  this  was  the  UKPDS.  

So,  again,  another  trial  where  they  gave  people  lots  of  drugs  

to  control  the  blood  sugars  

and  another  drug,  another  arm  

which  didn't  get  as  much  drug  and  had  worst  blood  sugars.  

But  again,  that's  not  my  quesCon.  

My  quesCon  is,  does  all  this  insulin  make  you  fat?  

And  once  again  you  see  that  it  is  -­‐  so,  the  intensively  treated  group,  

which  had  a  lot  more  insulin  and  a  lot  more  drugs  that  sCmulate  insulin,  

gained  more  weight.  

So  again,  once  again,  moving  us  out  of  the  correlaCon  side,  

these  are  direct  causal  inference.  

There's  a  fascinaCng  study,  done  in  1993,  

where  they  took  these  type  2  diabeCcs  and  they  started  off  with  no  insulin.  

And  they  said  "Well,  what  I'm  going  to  do  is,  I'm  going  to  just  amp  up  the  insulin.  

Give  them  a  lot  of  insulin.  The  sugars  are  going  to  be  beauCful."  

And  what  they  did  was  that  they  went  from  zero  to...  

at  the  beginning  they  were  not  taking  any  insulin,  

by  six  months  of  taking  100  units  a  day,  their  sugars  are  really  well  controlled.  

But  what  happens  to  their  weight?  

Again,  you  can  see  there's  a  steady  rise,  93,  97,  100,  102.  

So,  we  are  not  talking  again  about  correlaCons,  

we  gave  insulin,  people  gained  weight.  

And  what  was  actually  interesCng  about  this  trial  in  parCcular,  

was  that  they  actually  looked  at  how  many  calories  they  were  eaCng.  

And  the  number  of  calories  that  they  ate  

was  reduced  by  about  300  cal  per  day,  250  -­‐  300.  

So,  even  as  they  lost,  even  as  they  took  less  and  less  calories,  

they  should've  been  losing  weight  according  to  the  calories  theory,  

they  gained  like  20  pounds.  

So  you  are  eaCng  less  calories  and  gaining  20  pounds.  

What's  happening?  Well,  you're  giving  insulin.  

Insulin  is  telling  your  body,  "Store  fat,  store  fat!"  

That's  its  job.  

So,  what's  going  to  happen  is  your  body  will  ramp  down  your  metabolism  

unCl  you  store  the  fat,  because  that's  what  its  job  is.  

So  you  see  the  same  thing  with  memormin.  

Memormin  it's  a  very  interesCng  drug  because  it  doesn't...  

it  blocks  gluconeogenesis  and  doesn't  raise  insulin  to  the  same  extent.  

And  what  you  find  with  that  drug  is  that  you  don't  get  the  same  weight  gain.  

So,  you  see  the  convenConal,  

the  people  who  are  just  on  diet  control  in  the  memormin  group,  

they  don't  differ,  but  the  ones  who  get  sulfonylureas-­‐-­‐  

so,  drugs  that  sCmulate  insulin  make  you  gain  weight.  

So  it's  not  just  injecCng  insulin,  

it's  drugs  that  sCmulate  insulin  do  the  same  thing.  

And  again,  as  doctor  this  is  not  a  surprise,  

all  these  drugs,  which  are  called  sulfonylureas  sCmulate  insulin,  

so  it's  not  simply  because  you  are  injecCng  it,  it's  exogenous,  

it's  that  when  you  sCmulate  your  own  pancreas  to  release  it,  you  gain  weight.  

And  the  thing  is  that  the  other,  the  flipside,  

is  that  if  insulin  is  what's  making  you  gain  weight,  

then  if  you're  insulin  goes  down,  you  would  predict  that  you  would  lose  weight  

and  that's  exactly  what  happens.  

So  this  is  a  slide  where  it  shows...  

So,  as  your  insulin  goes  down  and  down  and  down,  what  happens?  

You  can't  gain  weight.  

The  classic  descripCon  of  type  1  diabetes  

is  a  melCng  down  of  flesh  and  limbs  into  urine.  

It's  a  wonderful  descripCon.  

Because  he  just  lose  everything  no  maKer  what  you  eat.  

You  can  give  them  anything,  no  maKer  what  you  give  them  to  eat,  

they  have  no  insulin.  

So,  they  have  no  signal  to  store  fat,  they  lose  all  that  body  fat  and  they  die.  

And  that's  unfortunately  what  happened  unCl  insulin  came  along.  

And  there's  a  disease  called  diet  bulimia,  which  is  an  eaCng  disorder,  

where  type  1  diabeCcs  will  deliberately  under  dose  their  insulin.  

So  their  sugars  go  up  and  you  know,  they  could  die  of  ketoacidosis,  

there  are  these  all  kinds  of  problems.  Right?  

So  why  do  people  do  it?  Because  they  lose  weight.  

They  know  it,  we  know  it.  

When  you  cut  their  insulin,  their  weight  goes  down.  

And  recently,  there's  another  drug  which  has  done  the  same  thing.  

So,  these  are  the  SGLT-­‐2's.  

So,  unCl  recently  there  were  no  other  drugs  really  to  lower  insulin,  

but  this  drug,  which  is  a  new  drug  that's  approved  for  type  2  diabetes,  

actually  shows  that  you  can  lower  insulin  levels.  

It'll  make  you  pee  out  the  sugar  and  your  insulin  levels  go  down.  

So  these  two  groups,  the  DAPA  group,  are  the  two  groups  that  have  this  drug,  

you  can  see  that  their  insulin  goes  down.  

But  what  happens?  

Well,  their  weight  goes.  

What's  fascinaCng  to  me...  So  these  are  the  three  DAPA  groups,  

so  all  of  them  showed  weight  loss.  

...what's  fascinaCng  to  me  really,  when  I  look  at  something  like  this,  

is  that  you  can  follow  these  people  out  longer  to  a  year  or  two  years,  

even  four  years  now  and  that  weight  stays  off.  

And  this  is  fascinaCng,  

because  if  you  look  at  virtually  every  single  diet  study  available,  

people's  weight  goes  back  up  at  around  six  months.  

Goes  down...  We  all  know  this  right?  ...and  goes  back  up.  

It  does...  Why?  Because  you've  lowered  the  insulin.  

So,  calorie  reducCon...  So,  some  people  will  say  

"Well,  it's  because  your  peeing  out  sugar,  you  reduce  calories."  

But  calorie  reduced  diets  don't  do  the  same  thing.  

But  when  you  lower  insulin,  which  is  the  ulCmate  cause  of  obesity,  

that  weight  goes  down  and  stays  down,  which  never  happens  

and  that's  what's  really  fascinaCng  about  it.  

So,  you  can  look  at  a  list  of  medicaCons  for  type  2  diabetes,  

so,  there  are  certain  ones  that  increase  the  effect  of  insulin  or  insulin  itself.  

Insulin  sulfonylureas,  TZD,  which  are  another  class  of  drugs,  

they  don't  raise  insulin,  but  they  raise  the  insulin  effect.  

There  are  drugs  that  don't  really  affect  insulin  levels,  

memormin,  these  DPP  4's.  

And  there  are  drugs  that  decrease  insulin.  

So,  acarbose  to  a  small  degree  and  these  new  SGLT-­‐2  inhibitors.  

And  you  can  look  at  the  weight  effect  as  well  and  it's  idenCcal.  

Stuff  that  raise  insulin  makes  you  gain  weight,  

stuff  that  lowers  insulin  makes  you  lose  weight.  

So  again,  this  is  strong  evidence  

that  the  hormonal  view  of  obesity  is  much  more  correct,  

because  it's  the  obesity  is  the  insulin  which  leads  to  the  obesity,  

which  leads  to  the  compensaCon  that  we  see.  Right?  

These  are  hormonal  effects.  

You  are  hungry  because  your  body  is  increasing  the  ghrelin,  

you're  decreasing  your  metabolism  and  you're  not  burning  it  off.  

And  this  is  the  whole  thing,  that  sets  you  up.  

It  says  "You  don't  get  fat  because  you're  overeaCng,  

you're  overeaCng  because  you're  geAng  fat."  

Which  sets  you  up  for  the  proper  quesCon.  

What's  making  you  get  fat?  What's  the  ulCmate  cause  of  obesity?  

And  again,  it's  insulin.  

Now,  CorCsol  does  play  a  role,  but  that's  for  another  Cme.  

And  what's  interesCng  really  is  that  we  think  that  we're  really  smart  in  2016,  

but  if  you  go  back  to  William  BanCng,  

he  understood  that  refined  carbohydrates  led  to  obesity.  

So  refined  can  now,  in  2016,  aZer  this  kind  of  50  year  hiatus,  

were  we're  talking  about  calories,  

now  we  realize  that  refined  carbohydrates  increase  the  insulin,  

which  leads  to  the  obesity.  

And  this  guy,  BanCng,  was  in  the  1850s.  Right?  

Like  150  damn  years  ago,  they  knew  this.  

It's  like,  "Oh  my  God,  we're  not  that  smart."  

So,  this  is  the  whole  problem.  

If  you  try  to  treat  it  as  a  caloric  deficiency  

and  you  say  that  it's  a  personal  choice,  you  are  going  to  fail.  

If  you  understand  that  this  is  a  disease  which  is  related  to  insulin,  

then  you  understand  why  you  treat  it  the  way  we  do.  

So,  what  raises  insulin  the  most  from  a  dietary  standpoint?  

Refined  carbohydrates  -­‐  the  sugars,  the  refined  grains.  

What  raises  it  the  least?  

Natural  fats  -­‐  olive  oil,  avocado  buKer.  

So,  Marty  Kendall  who's  done  some  preKy  amazing  work  actually,  

mapped  the  cells.  

So  he's  kind  of  looked  at  any  research  done  on  the  food  insulin  index.  

And  what  he  found  was  that  you  can  actually  predict  what  the  effect  of  insulin  is,  

based  on  the  net  carbs  plus  half  of  protein.  

But  that's  sCll  only  explains  about  54%  of  the  variance  

but  that's  as  good  as  it  gets  now.  

So  again,  the  net  carbs,  which  is  carbohydrates  minus  fiber  

and  half  of  the  protein,  which,  again,  explains  why  we  gave  the  advice  that  we  do:  

low  carbohydrate,  moderate  proteins  and  high  in  natural  fats.  

And  what's  amazing  about,  you  know,  conferences  like  this,  

is  that  this  really  gives  us  a  new  hope,  

because  as  long  as  we  misunderstood  the  cause  of  obesity,  

we  were  doomed,  we  couldn't  succeed,  there  was  no  possible  way.  

You  could  succeed  in  treaCng  obesity,  then  you  get  type  2  diabetes,  

then  you  go  blind,  then  you  go  on  dialysis  and  all  these  problems.  Right?  

But  what  this  new  understanding  is?  

It  gives  us  a  new  hope,  because  now  we  can  say,  

"Wow,  I  know  what's  happening  here,  it's  your  insulin.  

So,  let  me  say,  "What  that  can  I  do  to  lower  your  insulin?"  

We  can  do  this,  we  can  do  that,  there  are  low-­‐carb  diets,  

there's  fiber  for  example,  there's  vinegar,  

there's,  you  know,  intermiKent  fasCng.  

There's  all  these  different  strategies  that  you  can  now  use,  

which  will  be  successful,  and  that  is  the  most  important  thing.  

Is  that,  you  know,  this  is  not  a  condemnaCon  of  what  we've  done,  

this  is  to  tell  you  that  this  is  a  new  dawn.  

As  long  as  you  understand  what  causes  obesity,  we  can  treat  it,  

we  just  need  to  get  the  message  out  there,  

we  need  to  get  people  on  our  side  and  do  it.  

Thank  you  very  much.