- Weight Loss – Is it as simple as reducing calories in and increasing calories out? No, that is a Myth.
- Before discussing what goes wrong, shall we discuss what is normal? Understanding normal digestion and energy metabolism
- So, what does go wrong in the case of obesity/excess weight? Why do we say that Obesity is more of a hormonal issue?
- What is the correct way to manage excess weight/obesity? What is the correct dietary approach for obesity?
Suppose we were to ask you, “Do you know how to reduce weight?” we’re sure that everyone would immediately say, “Obviously! Reduce calories in by reducing food intake, increase calories out by exercising more and bingo! body weight will reduce.” And then, if we probe into why we are not doing this, the answer could be a lack of will power and self-control, coupled with binge-eating and lacking exercise. Have you ever wondered why, otherwise successful people, who have achieved so much in life would fail to do this simple thing? If one really lacked willpower and self-control, most things in life cannot be achieved.
Imagine you are in the backseat of a taxi, and the driver suddenly hits the break to avoid something. You would definitely jerk forward and probably hit the seat in front. This is not because of a lack of willpower, but because of the underlying physics. What if there are such underlying reasons for why some people overeat and why some people tend to be inactive?
Let us go a bit deeper
However hard it is to accept, this concept of calorie reduction is not entirely true. It has been repeated and reproduced so many times and seems so simple and intuitive that this myth of obesity as a caloric disorder has become deeply established. This simple equation
Calories In – Calories Out = Body Fat
Is built on a lot of assumptions and current research on obesity has shown most of them to be false assumptions. Let us attempt to understand some of the erroneous assumptions.
1. Errors in our understanding of “Calorie in”:
The inherent assumption of “calories in” is that all calories are exactly the same. This can mean that the calories coming from sugar and calories coming from, say olive oil or spinach are the same, which we intuitively know cannot be true. The first important thing to understand is our body does not have any receptor for calories, it understands only carbohydrates, proteins, fat, fiber, and other micronutrients. And the way the body metabolises each of these constituents is very different and uses different pathways and different parts of the body play very different roles in this energy metabolism. For e.g., carbohydrates are broken down into chains of glucose and the hormone insulin plays a crucial role in its metabolism, whereas dietary fat is broken down into fatty acid- a process that has very little or no connection to insulin. The two different foods evoke vastly different metabolic and hormonal responses. A detailed understanding of normal digestion mechanisms will help us appreciate this better.
This idea that all calories are the same, allowed businesses to sell a lot of sugary and unhealthy products, sometimes even directly marketing them as ‘low calorie’ or diet products. Since there are so many vested interests out there, it is very important that we take the time and educate ourselves to manage our health better.
2. Errors in our understanding of ‘Calories Out’
When we talk of “calories out” or energy expenditure we assume that the amount of exercise we do will have a huge impact on energy expenditure. Make no mistake – exercises have various beneficial impacts on the body. But assuming exercise to be a significant component of energy expenditure is where we go wrong. To understand this better we need to understand the body’s ‘Total Energy Expenditure (TEE)’
Total energy expenditure = Basal metabolic rate + Thermogenic effect of food + Non-exercise activity thermogenesis + Excess post-exercise oxygen consumption + Exercise.
Basal Metabolic rate (BMR): The energy required for metabolic housekeeping tasks such as breathing, maintaining body temperature, keeping the heart pumping, maintaining the vital organs, brain function, liver function, kidney function, etc. This depends on many factors including genetics, gender, age, height, weight, body temperature, external temperature, diet and organ function.
Thermogenic effect of food (TEF): The energy used in digestion and absorption of food energy. For e.g. food rich in refined carbohydrates is easily absorbed and takes less energy to metabolize. Proteins are harder to process and use more energy.
Non-exercise activity thermogenesis (NEAT): The energy used in activities other than sleeping, eating, or exercise; for instance, in walking, gardening, cooking, cleaning, and shopping.
Excess post-exercise oxygen consumption: The energy used in cellular repair, replenishment of fuel stores, and other recovery activities after exercise.
Because these components are difficult to measure, we make the wrong assumption that these factors are all constant over time. This assumption leads to the crucially flawed conclusion that exercise is the only variable in total energy expenditure. Thus, increasing ‘Calories Out’ becomes equated with ‘Exercise More’.
To put in perspective, Basal metabolic rate for a lightly active average male is roughly 2500 calories per day. Walking at a moderate pace (2 miles per hour) for forty-five minutes every day would burn roughly 104 calories. To put it simply, that will not even consume 5 percent of the total energy expenditure.
3. Errors in our understanding of the relationship between calories-in and calories-out
We assume that the calorie-in and calorie-out are completely independent. But research has clearly established that the caloric intake and expenditure are intimately dependent variables. Decreasing ‘Calories In’ triggers a decrease in ‘Calories Out.’ A 30 percent reduction in caloric intake results in almost a 30 percent decrease in caloric expenditure. The end result is, therefore, minimal weight loss.
To understand this, imagine that because of the coronavirus our income went down. We don’t keep spending like before. We cut down on what we think is not critical and spend only on essentials. That’s precisely what the body does too. When we reduce the food intake to reduce calories, the body reduces its energy expenditure by lowering the basal metabolic rate.
In addition, when you are in a diet to reduce calories, there are other compensatory mechanisms that kick-in. For e.g., during a diet, people typically tend to reduce their movements and non-essential activities which results in a direct reduction in NEAT. Since food consumed is less, TEF also comes down.
4. Error in assuming that we have complete control over calories in
Even though eating is a deliberate act that we do, most of the time it is clearly in response to various hormonal triggers inside our body. We consciously decide to eat and stop eating in response to hunger signals and satiety (fullness) signals triggered by different hormones. For e.g. hunger is triggered by the hormone Ghrelin and satiety is signalled by the hormone Peptide YY.
For example, the smell of frying food makes you hungry at lunchtime. However, if you have just finished a large buffet, that same smell may make you slightly queasy. The smells are the same. The decision to eat or not is primarily hormonal.
We hope that this establishes the idea that weight gain and obesity is more of a hormonal problem and not a simple calorific disorder.
So then what exactly is the reason? To be able to appreciate that first, we need to understand how our normal digestion and energy metabolism happens.
Like most functions in the human body, digestion and metabolism are mediated by the interplay of multiple hormones. Let us understand this process.
All foods are composed of a combination of three major components, called macronutrients:
Each of these macronutrients is composed of smaller functional units. Carbohydrates are chains of glucose and other sugars. Proteins are chains of amino acids. Fats are chains of fatty acids. There are also smaller, microscopic amounts of vitamins (A, B, C, D, E, K, etc.) and minerals (iron, copper, selenium, etc.), known as micronutrients.
Food first enters the stomach, where it mixes with stomach acids and slowly gets released into the small intestine. Nutrients are extracted throughout the journey through the small and large intestines. Proteins are broken down into amino acids which are essential for building and repairing the body’s tissues. Fats are broken down into fatty acids which are directly absorbed by the body for energy and storage. Carbohydrates, which are chains of sugars, are broken into smaller sugars, the primary source of energy. Dietary fibers are not broken down; they move through without being absorbed. All cells in the body can use blood sugar (glucose). Certain foods, particularly refined carbohydrates, raise blood sugar more than other foods.
The rise in blood sugar stimulates the release of the hormone Insulin. Hormones are messengers in the body, and they communicate by binding to the receptor cells on the surface of target cells, much like a key fits in a lock.
Insulin is a key regulator of energy metabolism and is one of the fundamental hormones that promote fat accumulation and storage. Insulin facilitates the uptake of glucose into cells for energy.
After taking a meal, carbohydrates in our diet ensure that there is more glucose than what will be needed immediately. Insulin helps move this flood of glucose out of the bloodstream into storage, for later use. It is first stored as glycogen in the liver—a process called glycogenesis. The body can convert glucose to glycogen and back again quite easily. But the liver only has limited storage space for glycogen. Once this space is full, excess carbohydrates will be turned into fat—a process called de-novo lipogenesis.
Few hours after a meal, blood sugars and insulin levels start to drop. Less glucose is available for use by the muscles, the brain, and other organs. The liver then starts to break down glycogen into glucose to release it into the general circulation for energy—the glycogen-storage process in reverse. This happens most nights. Let us call this the fasting period. If the fasting period prolongs, the limited glycogen store depletes and now the body can make new glucose from its fat stores—a process called gluconeogenesis (the making of new sugar). Fat is burned to release energy, which is then sent out to the body.
Insulin is a storage hormone. Ample intake of food leads to insulin release. Insulin then turns on the storage of sugar and fat. When there is no intake of food, insulin levels fall, and the burning of sugar and fat is turned on.
This process happens every day. Normally, this well-designed, balanced system keeps itself in check. We eat, insulin levels rise, and we store energy as glycogen and fat. We fast, insulin levels decrease, and we use our stored energy. As long as our feeding and fasting periods are balanced, this system also remains balanced.
Now let us look at the interplay of other hormones. We just discussed that once glucose is detected in the blood, insulin is secreted. Similarly, sensing food in the stomach, primarily protein and fat, satiety hormones like Peptide YY get released in the body. These satiety hormones play a crucial role to ensure that we don’t overeat. Similarly, when fat storage occurs, the fat cells release a powerful hormone called Leptin which signals the brain to stop eating. On the other side, after sugar levels drop, the body releases the hormone Ghrelin which is a hunger hormone to stimulate us to eat. Thus, we can understand that through various hormones, the body tries to control when to eat and when to stop eating.
In our bodies, nothing happens by accident. Every single physiological process is a tight interplay of various hormone signals. Whether our heart beats faster or slower, whether we urinate a lot or a little- are all tightly controlled by hormones. Whether the calories we eat are burned as energy or stored as body fat is also tightly controlled by hormones. So, the main problem of obesity is not necessarily the amount of calories we eat, but how they are spent. Once we understand obesity as a hormonal problem, then we can start looking at the root cause and start addressing that. Even though many hormones are involved, the key hormone which plays a crucial role turns out to be insulin.
In the previous segment, we understood what normally happens in a healthy body.
Now, we have a chicken and egg story in hand. Which came first?
High levels of the Insulin hormone cause Insulin resistance and, Insulin resistance causes high levels of insulin in the body- a vicious cycle.
What happens first? Why?
Like most things in life, ‘nature and nurture’ seem to play a role in this. Genetics and hereditary reasons do seem to be involved. However, it is important to note that most genetic factors are only a predisposition, which means that if the underlying factors are present then you have a higher chance of becoming obese. While we may not be able to control the genetic factor, preventing or avoiding the underlying factors is very much within our control.
We have discussed the normal digestion process in detail. However, primarily because of lifestyle choices, we eat a lot of carbohydrate-rich food, especially food made of refined carbohydrates like sugar, white rice, maida. In addition, all the grains, legumes and pulses which are typically part of our every meal are also rich in carbohydrates, which spike our blood glucose and warrants excessive insulin secretion. And to complicate matters, we keep eating through the day- from early in the day to late in the night- which means that these high levels of insulin are always present in the body.
As part of its normal functioning, we know that insulin pushes this blood glucose into the cells. However, the capacity of the cells to store glucose is very limited and the excess glucose is stored as glycogen in the liver which has a limited capacity. All the excess glucose in the blood then gets stored as fat, which actually has a very large storage possibility. This fat gets stored primarily in the abdomen region inside and around various organs including the liver and the pancreas, normally referred to as visceral fat or commonly called belly fat. (When excessive fat is stored in the liver it creates an unhealthy condition called fatty liver). This excess fat around organs and inside the cells, makes them less efficient and the cells gradually start becoming resistant to the action of insulin. This condition is what we refer to as insulin resistance. Because of insulin resistance, even though there is excess glucose in the body, cells do not get sufficient glucose. Sensing the need for more glucose for the cells, more insulin is secreted by the pancreas, which increases insulin resistance – a vicious cycle.
As we have seen, insulin is a fat-storing hormone. Nothing happens overnight, but over time, all this fat storage leads to obesity. Given the fact that insulin is a fat-storing hormone, excess insulin gradually leads to obesity. Over time, the pancreas loses its ability to produce insulin, leading to diabetes. The high levels of insulin are what is causing PCOS. Insulin resistance is the root cause.
Parallelly, excess insulin, and insulin-resistant conditions lead to other malfunctions in the body. We discussed that insulin stores excess blood sugar as fat. As fat storage increases, the body normally releases the Leptin hormone which is the counter hormone that signals the body to stop eating. However, excess fat storage triggers excessive leptin hormone, which also starts to lose its sensitivity over time, leading to a condition called leptin resistance. Leptin resistance means that the body does not sense satiety, resulting in overeating.
In the meantime, because of insulin resistance, cells do not get enough glucose, which triggers more secretion of the hunger hormone Ghrelin. We can now understand the dangerous hormonal disorder. More insulin triggers more ghrelin – so we keep feeling hungry. And more insulin leads to leptin resistance which means less satiety and we end up overeating.
Thus, it is important to understand obesity as a hormonal disorder rather than a calorific disorder.
As we’ve established, the first step to effectively address obesity and excess weight is to understand that it is primarily a hormonal disorder and not a simple calorie in-calorie out problem.
Insulin resistance is the starting point of this hormonal imbalance, which is characterised by the continuous presence of excess insulin in the blood. What causes high insulin?
1.Eating more insulin-secreting food
2.Eating those foods frequently
So naturally, the solution has to be a diet with low insulin-stimulating food and less frequent eating.
The primary macronutrient which triggers insulin is the carbohydrate. While proteins are essential for various bodily functions like cellular repair and growth, the body cannot store excess proteins. So excess proteins are also converted into glucose, triggering insulin secretion. The macronutrient with minimal or no impact on insulin secretion is fat.
So the ideal diet to manage insulin resistance has to be low carb, moderate protein, and high amount of healthy fat. Some of the popularly known diets which follow this methodology are the Paleo/Keto/Atkins diets.
Now to most people, the idea that we should eat more fat may sound dangerous. The emphasis here is on healthy fat and not fat from oil fried food. Healthy vegetarian fat sources include nuts like almonds and walnuts and seeds like watermelon, pumpkin seeds, and foods like paneer, ghee, olive oil, etc. All non-vegetarian foods, as long as they aren’t deep-fried, can be considered as rich in healthy fat. Low carbohydrate content in this diet ensures very less insulin is secreted which gradually improves insulin sensitivity
In our regular food, also called common man food, we typically consume more than 400gms of carbohydrates in a day. In a well-formulated low carbohydrate diet, if this can be brought down to around 40gms per day, which is a 90% reduction, then in a short period, significant weight loss can be achieved. Not only does this help with weight loss, but also diabetic conditions can be reversed and significant relief can be obtained for women with PCOS problem (Poly-cystic Ovary Syndrome) characterised by irregular periods.
The key to success is, without doubt, proper structuring of the diet by taking into account other health conditions like thyroid, uric acid, kidney function, etc.
Reduced glucose consumption leads to reduced insulin secretion and better insulin sensitivity. Reduced insulin will stabilise the amount of testosterone in the blood helping to reduce the PCOS effects associated with a higher amount of male hormones. Less insulin in the blood restores the hormonal balance between FSH and LH and helps in preventing anovulation and formation of cysts.
How does Intermittent Fasting help?
Intermittent fasting is a powerful tool that significantly helps with weight loss and improving insulin sensitivity. In this method, the clients are advised to gradually reduce the eating window to around 8 hrs or less. Since no food is taken in the fasting window of 16 hrs, insulin does not get triggered in the body, and in a short span, this starts improving the insulin sensitivity of the body. Some of you may be thinking, “I have never missed a meal, or I feel very tired if I fast.” That is exactly why the guidance matters. With a high carbohydrate diet, it will be very difficult to fast. But the low carb diet prepares the body wonderfully to be able to do intermittent fasting without any dips in energy levels. Every body is unique and hence need to be monitored and guided.
Intermittent fasting is a powerful therapeutic tool which has been proven to stimulate ‘Autophagy’ – the body’s way of cleaning out damaged cells, in order to regenerate newer, healthier cells. Research on autophagy went onto win nobel prize in 2016. In addition, intermittent fasting allows the body to use energy stored as fat to stimulate weight loss and aids in breaking weight loss plateau.
Our flagship diet consulting program, ‘100 Days Challenge’ effectively combines a customised and well- structured low carbohydrate diet, intermittent fasting, and extended fasting with continuous monitoring and guidance. We have seen our clients lose on an average, about 10 kg in 100 days, and recover very well from PCOS symptoms.