Thread by @DoctorTro

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 and can be conditioned

Think of Pavlov & commercials - these aren’t going away quickly or ever

Second up is appetite triggered by Social cues to eat

our social lives, whether they are business meetings, family dinners or birthdays

Unless you are going monk mode - this cue to eat is also not going away & requires attention 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

Brains reward:
Carbs & fat > carbs alone > fat alone

Fourth up is hunger induced by glycemia changes…

Have you ever eaten pizza and 2-3 hours later find yourself eating cold pizza and it tastes better? Maybe the same with Chinese food?

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 don’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

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 didn't 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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