There are 5 types of hunger that ideally should be taught to all patients with obesity
Without cultivating an awareness of appetite, hunger and cravings, a patient with obesity will not know what they are fighting against
So Let’s start!
We are going to start with some easy ones…
The Cephalic phase response aka food cues - this is hunger stimulated when in presence of food.
These signals are deeply ingrained
Think of Pavlov- these aren’t going away
Second up is appetite triggered by Social cues to eat
our social lives, wether they be business meetings, family dinner or birthdays
Unless you are going monk mode - this cue to eat is also not going away & requires attention to manage
Sometimes easy steps like eating before you go or bringing a dessert that works for you can make the social drive to eat easier. When you aren’t hungry or you have a way out on your terms, these triggers are easier to manage
Third up is the fat+carb combination. The brain rewards carb+fat combinations. It does rewards added fats alone like putting oil on a salad or like adding butter & sour cream to a baked potato.
But our reward systems are truly paired to carbs alone or carb+fat combinations
For example, you’ll eat plain pasta. You won’t eat a bowl of melted cheese but you’ll LOVE Mac and cheese.
You’ll eat baked potato, you won’t drink oil, but you’ll love chips or fries
Have you ever eaten pizza and 2-3 hours later find yourself eating cold pizza and it tastes better? Maybe the same with Chinese?
This is likely post prandial glycemic dipping … follow me on this one.
We know that even 20mg/dL downshift in blood sugar can stimulate the reward centers of the brain.
Think of a diabetic patient that just dosed too much insulin & their blood sugar goes low… what do they say?
They say “give me chocolate, ice cream, cookies, candy or soda… “
what drives this? Likely those reward centers are getting stimulated… I’ve never heard a hypoglycemic patient ask for diet vegan broccoli 😝
When that post-prandial glycemic downshifts occur the brain reward centers are activated, the brain is saying “get me awesome”
That’s why cold pizza tastes better 3 hours later even though you just ate and feel gross!
You could have had an anvil in your stomach but if your brain sees lowering sugar in the setting of high insulin, the brain is getting activated to get awesome food. These downshifts in sugar have been shown to lead to increased intake & hunger
This is also possibly why gastric bypass pts gain weight …the brain signals doesn’t care much about your stomach surgery 🤔
Nonetheless we know from @davidludwigmd by keeping carbs low you decrease hunger & increase “metabolism” by 200-300kcal/day
5th is one of the most important - stress induced hyperphagia
We have seen stress lead to massive changes in blood sugar on CGM without food intake…
We have also seen that stress is one of the leading causes of weight regain in our practice
Coincidence? Possibly
Stress causes a number of physiologic changes, heart rate, blood pressure, blood sugar, blood flow changes in the brain. It’s not typically during acute stress that humans seek to eat more. It’s after
After a tough day…
“I put the kids to sleep”
“I was watching TV”
When patients are in that subacute stress phase, their blood sugars are coming down, but pragmatically speaking stress is a comfort deficiency
With a brain with blood flow shunted away from the frontal lobe, with glycemic shifting & lack of comfort -its is a disaster for eating
Patients needs to be educated on the fact that stress is literally a willpower deficiency through involuntary blood flow & hormonal changes and if they don’t have defenses in place to defend their lifestyle, they will likely regress to what’s easy and available
And what is easy and available is the obesogenic food environment & thus weight gain
@KevinH_PhD showed that processed foods lead to eating 600kcal more per day versus unprocessed.
The last type of hunger patients need to be educated on is the dessert effect aka sensory specific satiety
This explains why when grandma leaves everything on the thanksgiving table, why despite being ridiculously full people find themselves picking food they didnt eat at dinner
And why despite being full when grandma puts out dessert everyone is able to eat that amazing pie.
This is also a deeply ingrained signal and transcends any diet. Variety and different food taste/texture profiles will make you eat more whether you are vegan or Keto
Okay. That’s all for today. I hope you found this helpful!
I realize that when many see this graph below they become paralyzed because it says a lot, yet doesn’t say much at all…
Like Einstein said, if you can’t explain it to a 6 year old…
You know the rest
😜😜😜😜😜😜
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I saw a recent patient who came to me for weight loss & diabetes remission… he lost a significant amount of weight & his sugars improved but his lipids did not improve, an ensuing CAC showed a score of ~10, the patient was in his 3rd decade… I recommended a statin
I rarely prescribe statins in primary prevention but a confluence of factors leads me to believe this patients underlying dyslipidemia including high TG, low HDL & high LDL will not improve with lifestyle alone
Why do I bring this up?
🗣I believe the pharmaceutical industry is profit driven & wants the widest possible base to sell to
🗣I don’t trust medical organizations & verify guidelines myself including primary data
I’d like to formally invite @drjkahn and @gorskon to discuss the physician’s role in vaccine uptake on our podcast @LCMDPodcast which is consistently top 10 in medicine for iTunes
I’d be happy to have either guest but preferably both!
🚨Retweet if this sounds fun🚨
We record Fridays in front of a live audience at 10am EST
So @gorskon is on a mission to weed out anti-vaxx sentiment.
Great.
But what about the countless doctors were RECOMMENDING vaccination BEFORE an EUA approval and BEFORE ever seeing FDA briefing docs or a label & then recommended to children BEFORE testing in their age group?
Everyone is after the anti-vaxx people
I think we should be going after THESE lemming parrots of doctors.
The doctors who would mandate EUA vaccination by law, the ones who believe everyone should get an EUA vaccine without outcomes studies
I’m worried about our profession’s ability to think.
Doctors believed they understood the vaccine, and yet we discovered myocarditis & VTE afterwards
Being cautious is quite reasonable for some
While still many others can’t afford to wait & should get vaxxd
Literally we had to eat mayonnaise and pita sandwiches b/c my parents were out working.
To ensure we had food, my family literally bought fast food sandwiches when on sale & froze them so we could eat if they couldn’t cook dinner.
I know my parents did their best for me. They worked tirelessly and they have done the amazing service of being an amazing example of sheer tenacity & hard-work
But this was the food environment that kept me trapped for years to come
Why am I so passionate about convincing armchair scientists that glycemia is mediated by carb intake & not weight loss?
There are HUGE implications for every patient w/diabetes on insulin, pre-surgical patients, & those embarking on lifestyle change who want quick biofeedback
The fact that SO MANY medical organizations are wrong speaks to serious problems with our ability to understand and interpret science on a SYSTEMIC level
The fact that low carb diets were only recently added to the ADA supposed healthy eating patterns is a testament to this
While I take great pride in questioning authority, thinking independently & challenging status quo, my motivation here is to JUST correct what is wrong
B/c of this I have been forced to publish research which I have little desire to actually do & in the face of great criticism