How Weight Loss Can Improve Energy with Carolynn Francavilla, MD - #133

How Weight Loss Can Improve Energy with Carolynn Francavilla, MD - #133

00:00

Hey everybody, welcome back to the EnergyMD Podcast, where we help you resolve your Long Covid and Chronic Fatigue so that you can get back to living your best life. So really excited about today's episode, because we're gonna be talking about all things related to weight and weight loss, and the relationship between weight loss and energy. And we're gonna be doing it with my new friend, Dr. Francavilla.

00:32

So this is Carolynn Francavilla. She's a doctor. Let's learn a little bit about her. So she's an MD board certified in family medicine and a diplomat of the American Board of Obesity Medicine. She owns and operates Green Mountain Partners for Health and Colorado Weight Care in Denver, Colorado. Dr. Francavilla is a nationally recognized obesity expert lecturing to clinicians on the topic obesity as well as teaching through her own platform, help

01:01

She also hosts the Dr. Francavilla Show, a podcast about weight and health, which we're gonna learn more about. She is a founder of GLP Strong Fitness Program and serves on the Obesity Medicine Association Board of Trustees and was awarded the Dr. Vernon B. Astler Award for dedicated service and support in 2017. Dr. Francavilla is an assistant professor at Rocky Vista University and volunteer faculty at the University of Colorado School of Medicine.

01:30

Dr. Francavilla, thanks so much for joining me today. Thank you so much for having me. I'm really excited to have our conversation because this intersection between weight and energy is something I see on a regular basis in my clinic. And I think we're both gonna learn a little bit and hopefully give your listeners some ideas of how they can feel better. Yeah, it's hard when people are tired and they wanna lose weight and sometimes they don't have the energy to exercise. So looking at

01:59

what else is available is really awesome. So let's look at what you call comprehensive weight care so we can kind of get a sense of the landscape. Yeah, so I think a lot of people have a preconceived notion of what the advice is going to be when it comes to weight. And one thing I really like to emphasize is that it's a comprehensive approach if it's done right. So the first thing I always do is try to figure out underlying or root

02:26

causes, why does someone struggle with their weight? And so for your listeners, it may be very related to their fatigue or the other medical conditions they have that are related to their fatigue. So trying to figure out why someone's struggling. Do they have hypothyroidism, for example? Do they have insulin resistance or pre-diabetes that's making it hard to lose weight? And then there's one universal thing that makes it hard for pretty much all of us to lose weight, which is...

02:55

When we start to lose weight, when we cut calories, eat less food, our metabolic rate actually goes down and so we burn less calories and then our hunger hormones go up. And so that's why the weight loss process can be so frustrating for people. They think that maybe they don't have willpower to keep going, but it's really their physiology that's keeping them from losing weight by decreasing their metabolic rate and by increasing hunger and decreasing fullness. And actually that decrease in metabolic rate

03:24

and lead to fatigue. Some people actually have literally have less energy when they are trying to lose weight when they're cutting calories, when they're eating less. So probably something that will come up a couple of times in our talk, but sometimes people really do have decreased energy when they're losing weight. And then from there, looking at nutrition program that makes sense for each individual person, there's really no best way to eat. And so one of the things I like to emphasize, trying to figure out what is gonna work.

03:53

for the individual, what helps support their weight. I mean, what's also doable, right? We all have limited bandwidth with what we can actually achieve. So making the highest impact nutrition changes that are gonna help you as opposed to doing what worked for your friend or what you saw on TV, really what makes the most sense for your life and that's sustainable for you. Crash diets, like don't work long-term. So if you're gonna make a nutrition change, it should be something you can keep doing long-term.

04:23

Something I think we'll talk about a little bit more as well. Movement is not how most people lose weight. And we have lots of studies that show you don't really lose weight from exercise. You have to do so much exercise to lose weight that it's not realistic. It is how we maintain weight. And so certainly many people will experience weight gain when their activity level goes down. And if people do lose weight and want to keep it off,

04:48

increasing movement long term is very helpful to maintain that weight loss. So it's a very important long-term strategy, but if someone isn't able to start with exercise, it's not the most important. And then medications, medications can really help support people who lifestyle a lot when it's not enough for. And like I said before,

05:07

When you start to lose weight, metabolic rate goes down, hunger goes up, and it gets hard to sustain and have a significant weight loss. And so for those people, surgery or medication may be the solution. And then behavior change, which can mean lots of different things. That can be anything from logging food to changing your relationship with food and how you think about food, but all the different habits and behaviors and thought process we can work on. So that is what comprehensive weight care or comprehensive obesity care I think should look like.

05:38

Brilliant. So it seems like we're talking about the behavioral change, medications or surgery, nutrition, exercise. Was that four or was there one? And then did we talk about behavior change? Yes. So underlying causes, nutrition, exercise, medication, and behavior change are sort of the five components. Gotcha. Okay. And the underlying causes, you talked about thyroid and insulin resistance and pre-diabetes.

06:08

Interesting. And the exercise one is a really interesting one, which is actually really good news for people who are in my world because they're tired and it's hard for them to exercise. Oftentimes we're talking about their Goldilocks dose of movement, which might just be getting up and walking around the house once, depending on how tired they are. So in terms of priorities, which one would you say is like the biggest needle mover when it comes to losing weight?

06:35

Nutrition really is the biggest thing that has a huge impact in terms of weight loss. But if people are not able to make a sustainable nutrition change on their own, then adding a tool to it like medication or surgery really is what is going to allow the nutrition change to pay off. Those tools don't mean people don't have to pay attention to what they're eating. They really allow people to.

07:02

eat smaller portions and eat healthier foods and feel satisfied. So they really help support a lot of those healthy changes that we want for ourselves and that we want for our patients. So if nutrition alone isn't working, if people are not able to lose weight with really doing the right things, then I think there's no shame, no harm. And we should be encouraging people to consider medications that can help support them with those changes.

07:32

So I know that it's individualized, but in terms of nutrition, are there some general guidelines to follow? Yeah, so I think the biggest thing, I was just on a summit, which you were so nice to be a guest on with me, and the most consistent message I heard from experts on weight and health from so many different disciplines and that I agree with as well, is caution around ultra-processed foods.

07:59

So ultra processed foods are these foods in our environment that are completely industrial made. Things like, not to get blacklisted by anyone, but like Doritos or Oreos or Goldfish crackers. This type of food that you or I couldn't replicate in our home no matter how hard we try because they're made out of these ingredients that are like barely food. So those are these like ultra processed foods and they often have.

08:25

a lot of other chemicals in them as well that are very hard on our body, but they are designed to be ultra palatal, meaning really, really tasty. And they're designed that we keep eating them and eat more of them. So it's very hard to lose weight when you're eating those ultra processed foods because they disrupt our signals. That's, you know, if anyone's ever had like goldfish crackers, it's like easy to eat the whole package of them, right? And they were designed to be that way. It's really hard to eat a whole head of broccoli by yourself.

08:55

right, especially raw. And so that is like a stark contrast. Doesn't mean you shouldn't eat anything but broccoli, but these foods that are natural in our environment, you know, a chicken breast, broccoli, blueberries, are less processed foods like yogurt or oatmeal that are not as highly processed are easier to eat in moderate quantities than are ultra processed foods. And then probably some of the chemicals and additives in those ultra processed foods.

09:24

are further disrupting our relationship with food. So I think the biggest thing I encourage as a first step is cutting out ultra-processed foods as much as is reasonable. There's a role for some of them, right? A protein bar is something I'll have some of my patients eat. That's an ultra-processed food, but we're eating it in an intentional way. And then trying to increase produce. Produce, especially our vegetables, are going to be beneficial in terms of health.

09:51

but they're low in calories. So you can eat a lot of broccoli or zucchini or celery or spinach without it having a huge impact in terms of calories and you're getting health benefit from it. So trying to decrease ultra processed foods, increasing whole foods. And then I think if there is one food that I would suggest most people really consider cutting back or cutting out, it'd be sweet beverages. Those really don't have any health benefit.

10:18

And those are particularly hard on our body and very easy to overeat. So watch the sweet beverages, limit ultra processed food and try to eat more whole foods is the sort of pattern of eating that I think is the most common sense for the average person. Yeah, it seems like sometimes it's what you remove from your diet and not necessarily kind of like what you're adding back in. And so then in that vein, what do you think about gluten?

10:50

Yeah, so I think we have to listen to our bodies a little bit. So that's what I encourage for my patients. You know, I don't know, 15 years ago, when I first started hearing people talk about gluten, I was like, what is this? This is crazy. You know, like, is this really impacting people? And then the more I heard it from friends, family, colleagues and my patients, I was like, there has to be something to this, right? If this many people feel better cutting this out. And so.

11:18

I really think that's something we have to experiment with for ourselves in many cases to see how we feel. We may go off on a huge tangent here. But sometimes I also wonder if for everyone it's truly the gluten that's the problem, or if it's some of the additives that go along with it, pesticides that may be on that wheat, or other things that are in breads and pastries that are additives to make them raised that are not traditionally eaten foods like yeast, but chemicals.

11:46

So I think there may be sensitivities to some of those things in that for some people, gluten is like the proxy for like other junk in the food that is causing inflammation or issues. You know, I always think if people are inflamed, if people are not feeling well, people are having digestive issues, that there's no harm in cutting out a food for a while and seeing if they feel better. And so something I will sometimes talk about with my patients is, you know, trying off gluten.

12:13

Dairy, I think for some people, is really inflammatory. That is when I noticed a huge impact for myself. You know, and so I encourage people to eat dairy on a regular basis, but if they have certain symptoms, I'm like, well, what if you tried off of it for a month and see how you felt? So that's kind of my approach to some of those foods is like, certainly cutting out gluten is not a way to lose weight, but for many people, they may feel better.

12:37

And if you don't feel any different and it's hard to eat gluten-free, then maybe don't invest too much of your energy. But since you asked the question, I want to hear your thoughts now. What are your feelings, our thoughts on gluten? Well, I've found that, you know, somebody is metabolically stable. So if their thyroid is dialed in and they're not too out of balance, that they can go gluten-free. And I've found that they will lose about 10% of their body weight.

13:06

you know, maybe three pounds a month until they get back to their high school weight, if they were healthy in high school. So just from removing gluten. Now, oftentimes they're also doing it's never just in isolation. So they're off of sugar and alcohol generally, and they're eating more vegetables. So it might be a combination. But when I've had some people just go off gluten, oftentimes it can be dramatic, because oftentimes the weight that they have is water weight. And I think it also depends what your.

13:32

replacing it with. So if you're taking out gluten, but you're replacing it with a lot of other ultra processed, you know, baked goods. So you're just doing a bunch of, you know, gluten free cereal and gluten free bars and gluten free muffins. I think that you're going to have a different effect for a lot of people than if you remove gluten, but you're also now increasing your whole grains, your vegetables, your other whole foods, then

13:58

then that may be part of the impact for people there as well. Yeah. And I think what you said also about the additional additives, pesticides, et cetera, is really true. You know, when you go to other countries, you know, Europe, you know, we just, we went to Iceland and I've been to India before all those places. I was able to eat the gluten. Now I didn't go crazy with the gluten. And we just had a client who came back from Finland where she's like, she couldn't, she actually couldn't eat the gluten in Finland.

14:28

she started our program, now she can eat some of it, but it's like the, but you can't eat any here, you know, so there is this disparity between kind of like what we're doing to our wheat. And sometimes it's the hybridization, you know, it's the dwarf wheat, etc. And sometimes it's also the additional additives. So that's always interesting when people travel and they when they try things and they're like, you know what, I didn't react the same.

14:52

I hear the same thing from my patients often when they'll go to Europe and they're like, I wanted to see how I felt eating the bread or the pastries there or it was worth trying. And they're like, and I felt fine. And it's kind of scary a little bit to me, right? But our food is less regulated here in the US and we do have a lot more of that ultra processed food, the stuff that truly is industrialized food. It's not really real food.

15:22

And we'll see how things happen with Europe, because I do believe that, unfortunately, they just kind of open the doors to genetically modification. So, and, you know, Monsanto. So we'll see how things go, but hopefully it'll continue to be that way. But I also, you know, I think it's, whenever we talk about something, it's important to say, if that, you know, some people may have results from that, but if cutting out gluten.

15:47

doesn't lead to weight loss. Like it's not your fault you didn't do it wrong. Like you may just need more aggressive nutrition changes or you may need a support of some other tools to help with weight loss because cutting out any one food group, whether it's meat or dairy or gluten or whatever one thing is certainly not a guarantee that your weight is gonna change. So let's say that somebody has done a really nice job with their nutrition.

16:16

They've modified their diet, removed these things that we've kind of talked about today and you've addressed their root cause stuff. So their thyroid has been optimized and they're still having a hard time losing weight or let's actually maybe let's go to the root cause stuff a little bit more. So what I guess what in the root causes you talked about thyroid, you talked about diabetes, insulin resistance, let's go to hormones. So the thyroid, sex hormones, adrenals.

16:45

How do they play a role? So there's lots of hormones at play. And that can be everything from our sex hormones, which decline for lots of reasons, including aging. Insulin is the biggest hormone that I think about in my practice, because that insulin resistance is something I've seen about 90% of my patients who struggle, meaning that when they eat glucose, when they have sugar, they're

17:10

insulin is going up more than it should and that leads to metabolic issues with regulating weight, with burning fat, often with appetite. And so those elevated insulin levels are the hormone that I worry about the most to be honest. Elevated cortisol, you talked about adrenals, that definitely plays a part.

17:30

I find that there's two big drivers of that, other than if it's like Cushing's disease, which we always have on our differential, but usually it's not at that extreme edge, right? It's a more subtle elevation in cortisol. And so the sleep apnea, if sleep apnea has not been treated, that can drive up cortisol, that affects weight, that affects appetite. And then stress, and stress can be lots of things that could be physiologic. So whatever process is.

17:58

causing the chronic fatigue like long COVID or any other thing is a stressor to our body, right? But it could be the modern world we live in that is incredibly stressful as well, or a history of trauma. And so that can be a little bit of a harder thing for me to be the person to manage as the physician. I think identifying it, pointing it out, working on stress reduction is something that can be helpful to reduce cortisol.

18:24

And then poor sleep also, you know, even other than sleep apnea, not getting enough sleep is gonna affect cortisol. And there's actually great studies out there that even a little bit less sleep per night makes us hungrier and affects the pattern of what we eat. And so if you're not getting good sleep, you may be trying to do all the right nutrition stuff, but you're hungrier eating the wrong foods. So those are some of the big ways that at least in my clinical setting, I think about and talk about some of the hormonal effects.

18:55

And what do you recommend for duration of sleep and what time people should be going to bed? Ooh, that's a good question. I might get in trouble with myself with my recommendation. I don't know that there's like a time, you know, because like some of us have slightly different lifestyles of when, so, you know, certainly going to bed at three in the morning every night is probably not ideal, but I don't know, I'm interested to see if you have any data that says like going to bed at 9 p.m. is better than 1130, but.

19:21

Um, you know, we think most adults need seven and a half to eight hours of sleep. Um, some people need more, you know, people can self identify that they need nine or 10 hours of sleep. People who have themselves convinced that they're doing fine on six and a half hours a night are probably almost always wrong. Um, you know, like most people really need more than that. So, you know, the, I think most of our data supports that people need seven and a half hours of sleep is probably a minimum.

19:50

People have different levels of quality of sleep as well. And so if you're getting disrupted by pain throughout the night, by sleep apnea, by a partner with sleep apnea, by a pet or a child, then you may need more time in bed to get enough sleep. And then of course, trying to minimize those disruptions because the quality of sleep is also important, not just the amount of time. What do you recommend for sleep?

20:14

I generally recommend earlier is better, at least for my population. The studies that are most recently on my mind are actually the ones where I was arm wrestling with my 16-year-old about what time to go to sleep. And so most of the research on going to sleep after 11 for a teenager indicates worse symptoms, worse production the following day, more cognitive difficulties, more fatigue.

20:44

And I kind of feel like it's a little bit closer to 10 for adults, at least the people that I work with. And sometimes their sleep circadian rhythms are so dysregulated that they are having more energy into the evenings than they do first thing in the morning. So they're like, but 10 o'clock is when I'm ready to go and I'm feeling good and I'm getting stuff done. It's like, yeah, and that's.

21:07

That's the adrenals, that's the thyroid, that's a number of these things that need to be. Right, right, that's your body going into fight or flight mode, that's the cortisol going up and it's not real, it's not the good type of energy. You want to wake up feeling refreshed, not get those energy spikes, you know, when you should be going to sleep. Yeah. So let's talk about menopause. So, you know, women who don't have weight issues at all until they hit menopause and then all of a sudden they start to put on weight. How do you navigate that?

21:46

of attention right now are actually treating menopause a lot more in medicine, which I think is really beneficial. But there's probably two, there's a couple main drivers of why weight gain can occur in menopause. The first is hormonal. So as estrogen goes down, body composition does change and women will tend to gain more adipose or fat tissue around their belly and have a decrease in lean mass or muscle mass that goes with it.

22:13

you know, everyone's response is different. So that could be a couple pounds different for some women, right? And that may be OK for them. But that can sometimes be dramatic, where women will have 15, 30 pound difference in their weight that they can attribute to when they went through menopause, sometimes even more insulin resistance.

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often can intensify in this time period. So someone who really didn't have much insulin resistance before with that menopause transition often experiences more insulin resistance, probably also partly because their lean mass is going down. And so it may be more important to watch the quality of carbohydrates that you are eating in this time period, eating more complex carbohydrates and making sure to get enough protein sources and healthy fats.

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in this time period and maybe the first time in your life that you've had to actually pay attention to carbohydrates, especially simple carbohydrates, sugary foods, or ultra-processed carbohydrates. And then a lot of women have symptoms during menopause, like disrupted sleep, right? And so then they wake up feeling fatigued and now it's harder to make healthy food throughout the day. It's harder to exercise, harder to go on the walk that maybe they were doing before because...

23:28

they don't have that restful sleep and they're having more fatigue and they're having more brain fog. And so doing some of the self care that might be helpful also becomes harder. So those are some of the reasons that women can often start to struggle with weight often for their first time in their life during menopause or someone who had struggled suddenly has this intensifying struggle with maintaining or gaining weight even. So it sounds like that's pretty common in your patient population where

23:57

It's a new problem for them.

23:59

Absolutely. Yeah. There's different triggers of patterns of why people will gain weight. One of the patterns we see is a change in activity level that happens with a transition to real adulthood. So someone who played sports in high school or college, all of a sudden they get a desk job and they become much more sedentary and gain weight. After childbirth, some women struggle to get back to a normal weight. Menopause is another one of those time periods.

24:29

stress, trauma, struggling with a chronic illness, right? It's just hard to manage it all. So there definitely are patterns of why people struggle. And I think that's part of that workup of underlying causes that I mentioned in the beginning too, like what changed, right? If you were maintaining your weight or you had a little bit of weight gain, but it had felt okay to you, what changed?

24:54

when your weight suddenly became a problem. Now for some people it's been a problem since childhood. They've just slowly been gaining, but a lot of times we can kind of identify what that trigger was and that helps us figure out what the best plan to move forward is. So you've mentioned insulin resistance a couple of times. Can you describe it in lay terms for our audience? Yes, okay. So insulin is a hormone that we all make unless we have type one diabetes. It's made in our pancreas.

25:23

And insulin is a hormone that helps us store sugar. So, you know, when we eat a meal, we need to store some of that sugar to use for later. When we have insulin resistance, our body isn't responding very well to the insulin. So I describe insulin as going up to a cell, acting like a key to let a sugar molecule in. And when you have insulin resistance, your cells aren't listening to the insulin.

25:52

And when you're young and healthy, your body just says, that's fine, I'll just make more insulin and I'm gonna bombard the cell until it responds and lets glucose in. The problem with that elevated insulin is it goes on to cause different hormonal disruptions and when it comes to weight, it makes people keep weight on. It makes it harder to burn fat when you have elevated insulin levels.

26:17

It can affect your appetite. And then long-term, what can happen is your body can't keep up at a certain point and then your blood sugar starts to rise because you can't make enough insulin, then you get more metabolic disruption. And at a certain point, you can't keep up at all. And that's when your blood sugar gets high enough that you now have type two diabetes because your blood sugar's rising and you can't keep making that extra insulin to keep up with it.

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So that's kind of generally the process. And I see some degree of insulin resistance in about 90% of people who come for help with their weight. And so can you reverse insulin resistance with diet alone? Almost always. It kind of depends how long you've had it. So if you have had insulin resistance for many decades, it's possible that your pancreas is kind of worn out and can't.

27:13

reverse, that's usually someone who's progressed enough with type 2 diabetes that they've already been started on injectable insulin and have been on it probably for at least a decade. But most people who haven't gotten to that point, they can reverse insulin resistance. And so

27:29

Ways we can do that with lifestyle are by decreasing the amount of simple carbohydrates in the diet. So certainly our ultra processed foods, our sweet drinks, our sugars, our sweets, our candies, desserts, but things like, you know, white bread, white rice, potato, those sorts of things drive up our blood sugar and we have to make more insulin to respond to it. So if we

27:53

give our body less sugar or less glucose, less carbohydrates that it has to deal with, that can help reverse this process. And then resistance training and exercise in general is another way that we can reverse that. So when we exercise, we're using up that sugar. And our muscle cells actually don't need insulin in order to use sugar. So...

28:17

Exercise can be incredibly important and it doesn't have to be crazy amounts of exercise. So we can see that like a 10 minute low impact light walk, a little bit after a meal can help with that absorption of glucose and decrease insulin. So this does not mean training for a marathon or joining a CrossFit gym, walking can help with insulin resistance.

28:43

And then for people who lifestyle alone isn't enough or maybe they don't have the energy to do those things, there are medications that can be helpful. The most widely used one is metformin and that can help the cells listen to insulin better. And then our newer medications, our injectable medications like.

29:04

You know, well, they don't necessarily help with insulin resistance, but they will lower the blood sugar if we use things like, you know, as Zempik, Wigobi, those types of medications as well. But yeah, insulin resistance can absolutely be reversed with nutrition and movement. And it's actually one of my favorite things to do. And how does somebody know if they have insulin resistance? Yeah. So if you've ever been told you have diabetes, type 2 diabetes, you have insulin resistance. If you have

29:33

free diabetes or high blood sugar on any of your blood tests, you have insulin resistance. But people who haven't reached that point, there is blood tests that can be done. You can do a fasting insulin level at the same time as a sugar. There's a calculation you can do called a HOMA IR. Basically you want your insulin to be on the lower side when you're fasting, probably lower than 10.

29:58

Um, but if you have a blood sugar, that's more than a hundred when you're fasting or you have an insulin that that's more than, you know, 10, that's a sign on blood work. Other signs, if you have a darkening on the skin, on the back of your neck, that's something called acanthosis nigericans. You can also get in your axilla, your armpits. Um, so if you have a darkening, kind of a purpley, almost looks like it's dirty in that area or a lot of skin tags in those areas, those can be a sign of insulin resistance. If you've been diagnosed with high triglycerides on blood work.

30:27

that's often a sign of insulin resistance. If you have been diagnosed with polycystic ovarian disease, that can be a sign of insulin resistance. So those are a lot of the things we're looking for when we're saying, do you have insulin resistance? And you mentioned fasting, intermittent fasting is kind of, it's interesting in our community with long COVID as well as chronic fatigue because it can be very supportive.

30:56

with autophagy and whatnot, but it also can be stressful on the body. So I'm curious, have you found a utility for fasting and intermittent fasting in your population? You know, if fasting works for someone, I certainly support it. The vast majority of people who come to me have a...

31:17

kind of a poor relationship with food. A lot of them try to restrict when they're eating and then find themselves overeating. And so for some of those people, fasting can exacerbate that, that can make it worse. So I do have some people who I think are good candidates for fasting, but for people that it hasn't worked for, I guess I don't try to push that too much if we've already proven it's not a fit. There are, I...

31:46

favor a little bit more like fast mimicking. So ProLons are product that's out there where you're actually eating specially formulated food that gets you into a fasted state without the restriction and kind of stress of not eating at all. So I think tools like that, but I think fasting just has to be for the right person where it makes sense. So some of my patients who

32:12

you know, it's it's still sort of effortless for them to, you know, eat a late breakfast, eat an early dinner. They're able to eat balanced meals and do that. I think that can be helpful that people who are sort of like white knuckling it all day long. And then when they eat, they're eating the wrong things or their appetite is so strong that they are having a hard time making healthy choices. Then I tend to steer those people a little bit away from.

32:41

from fasting. And I think the principle of fasting, right, is if we're eating all the time, our insulin is up all the time, right? That's one of them. There's also the autophagy portion. And so that has other health benefits. On the weight side, we're often trying to drive that insulin level down. And so I use that as a talking point too, of like when we eat matters, what we eat matters. So if you're grazing all day, then you're constantly spiking your insulin up. If you have...

33:07

discrete balanced meals throughout the day, then you have a little bit more of a normal insulin pattern and that's probably beneficial too. So when people are excited about like the science behind fasting, it's like, well, how do we apply that in a way that works for you right now? Maybe we don't need to get aggressive and do a 16 or like 24 or 72 hour fast, right? But maybe we can use the principles, which is like, let's not be constantly exposing our body to sugar that it has to deal with. So it sounds like three squares.

33:37

I tend to favor three square meals, but if people need meals in between, I'm also not completely against that. But I generally have people eat three times a day.

33:50

What are you? I don't know, you're kind of smiling along, I don't know. No, I agree. I think it really has to be individualized. I think that, I mean, I like the idea of intermittent fasting. I do it myself, but I also know that it's a good thing that I don't have choices in my house that would lead me to make some bad choices because I know that I get sometimes into a bit of a pickle where it's like, wow, I'm really hungry right now and I could make a bad choice. Yeah.

34:19

And I think it's knowing that, you know that about yourself or having someone who can coach through, does this make sense for you? I personally eat like five times a day. And I personally don't do well with regular fasting, it triggers me to overeat. And so for me, I see that in some of my patients having those same experiences. So I think it really has to be the right fit.

34:44

Um, like anything, right? Like if you cut out gluten and you feel fantastic, you should continue to not eat gluten. And I don't need a test to tell you that you should not eat any more gluten. Right. Um, if intermittent fasting works well for you, like, great. Like you, if you feel good, that's a completely reasonable approach to nutrition. Yeah. I'm glad you brought up that bit about gluten because I think a lot of people are really counting on laboratory tests these days, you know, for, um, telling them.

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to do a lot of different things and I'm finding that every test really is imperfect and so really the human experience oftentimes is the best test. Absolutely, like I mean again I don't need a test to tell me I have certain symptoms when I eat dairy. Like you know I've lived in my body for like 40 years now and when it tells me something I'm going to listen to it and I try to respect my patients when they tell me something even if it's something that doesn't make sense right. I don't have to have science for everything if that is your lived experience like

35:41

That's how your body's responding. Let's honor that. Right. Yeah, I'm glad you said that, because way too often I see people who've had medical trauma, essentially doctors who are invalidating an experience that somebody's having, or they have fatigue and the person's like, well, there's nothing wrong with you because I can't find it on a laboratory test, right? So completely deserving, not seeing the person. So I so appreciate that you said that. Yeah, absolutely. It's so hard to have.

36:09

disease that's not well understood, right? I'm sure that's why your patients love or your clients love working with you, right? Because just to be listened to and validated is so powerful. So let's come back to menopause. So we were talking a little bit about exercise and I know that exercise is different in menopause. How is it different from pre-menopause? What do you see?

36:34

You know, people like to get into the nitty gritty of exercise. And I honestly think we overdo like who should do what? Like the trends on this change. I will say one big thing that I think people in general, as we age men and women actually should be focusing more on is resistance training. We're losing muscle mass as we age. And so to fight that, we need to make sure we're eating protein to.

36:59

to build muscle and we need to move our muscles more. We need to do resistance training. Resistance training can be things like yoga or Pilates. It can be body strength training, doing squats, modified squats, pushups against a wall. And it can involve using weights, but it doesn't have to involve using weight. So if that's intimidating or not within what someone's interested in, bands and resistance training are also fine.

37:29

With aging, we do need to emphasize that resistance training. And then functional movements are something I think also gets overlooked. So there's a lot of talk about muscle mass and lean mass right now and the importance of that with aging, which is all true. But if your muscle isn't functional, I don't care how much you have either. And so, I come from the CrossFit world a little bit, but we talk a lot about functional movement there. And functional movement is things like a squat.

37:57

OK, a squat is literally the movement you're doing to get in and out of your chair. And so if anyone's watching me on video, like literally, I just got in and out of my chair. That was a squat. I want to be able to do that the rest of my life. We talk about a deadlift movement. A deadlift movement is literally picking something off the floor, right? So it doesn't have to be a piece of heavy weight. That may be a grocery bag or your keys or your purse, right? So we want to be able to do functional movements like that. We want to be able to push things up over our head. I always think of putting in a suitcase.

38:26

above me on an airplane, that is something I wanna be able to do for the rest of my life. I wanna be able to push myself off the ground if I fall. And so functional movements are really important as we age as well. But also for people who maybe haven't been able to move in a while, it's not just about looks or how much you can deadlift or something like that. It's really about function. Can we do these important functional movements as we age? That's wonderful advice.

38:57

So we've talked about the root causes, we've talked about nutrition, we've talked about exercise. So let's go to, did we talk about behavioral change? Oh, I think that's been woven throughout but some of that's figuring out things that work for you.

39:13

You know, like if something's really restrictive and that triggers you to overeat, like that's not a good fit for you. Stop fighting the reality. If you're hungry every day in the afternoon, even though your plan is to stick to three meals a day, but you're hungry and then you overeat at dinner every day, let's have a healthy balanced snack in the afternoon so you don't overeat later in the day. So behavior is so much, it's the sleep, it's the stress, but it's also just like recognizing what your body's capable of. And I think

39:41

sometimes just being kind to yourself. And so I think that's a message probably for your listeners is being kind to yourself, doing what you're capable of. And so you may not be able to make all your food from scratch. That's unrealistic even for people who have plenty of energy. But what can you do to get a more balanced diet that is healthy within your bandwidth? Even if that's ordering food out.

40:09

What restaurants have more vegetables? What restaurants, maybe that are more of a local restaurant that use less processed ingredients? Where can you get food? Is there frozen food that's frozen but not processed? So what are those easy buttons that allow you to be successful? And that's some of the behavior change too, because there's no perfect diet. And we have to give ourselves some kindness and operate in the reality. And we're in. And if you don't have energy, it's really hard to.

40:38

you know, maybe take care of yourself in the exact way you would like to. I like to ask myself, how can I make this more simple or how can I make this easy? Right. I recently wanted to become a better cook because I'm not. And so I realized that I was really my challenge was not having recipes and because I do like to have recipes, you know, I like to follow a process.

41:06

And so what I did is I started using Chat-Chip E.T. and I would walk around my kitchen and say, I have this and this and this and this, tell me what I can make. And then I got an instant pot. And then now I tell it, I want it to be paleo and gluten-free, dairy-free, sugar-free, and I want you to give me a recipe that's in this instant pot. And I want it to be twice as many vegetables as there is meat. And these are the things that I have in my kitchen. So...

41:34

I can do that. And then it gives me a recipe and then something comes out tasting relatively good. So that was what I needed to do in order to get better at this particular thing. I love it. Yeah, it's finding like what works, right? Like, is it that instant pot? Is it, you know, I have people who like the meal delivery kits to, you know, some of it's just the thinking about it. Right. Like, it's not always a lot of people are willing or able to eat healthy foods. Right. But like.

42:02

you're busy, you're tired at the end of a workday, caring for kids, all the things we have to do in our life. And you're like, I don't even know what to make, right? I like can't even think about what to make. And so, you know, is that meal prepping? Is that planning ahead? I love your idea of like having chat GPT come up with a plan for you. Is it a meal delivery kit where the healthy ingredients are all there, the recipe's there, you just have to make it. And sometimes what we have to do changes at different points in our life. If something is no longer working for us, then...

42:31

How do we change and again, make it easy? It shouldn't feel hard. It doesn't have to feel hard. I love that. So we've got a couple of minutes left. I wanna go into medications and surgery. Yeah. So surgery is not my area of expertise, but I will just say I support my patients when they're preparing for it. And often, you know, it takes me years of convincing them that that may ultimately be what they need. If they really...

42:56

need a significant weight loss to feel better. If we're talking, you need 20% plus weight loss to really have an impact on your health, you may need to consider surgery, especially if none of the other things have worked for you. Medication, same thing. So always reasonable to start with a healthy diet, trying to increase movement, decreasing stress, decreasing inflammation, helping sleep. But...

43:21

A lot of the people who come to see me have tried those things and they're doing them. You know, I have people who've been gluten free and they eat a paleo diet and, you know, they can count calories in their sleep and they work out an hour a day and they're still struggling. And when we layer medications on, you know, they aren't thinking about food all the time. So they don't have to have that snack anymore. They're able to decrease their portion size.

43:44

They're able to skip the cheeseburger when they're with a friend or eat half of a cheeseburger when they go out. And so it really allows them to make those lifestyle changes in a more impactful way. So I don't certainly start everyone on a medication, but if what someone is doing hasn't worked, there is a physiologic reason why. And so a medication can be hugely life-changing for people who, you know,

44:14

weight would improve their health, but they just haven't been able to do it with lifestyle. And if that's you, you're not alone. Only maybe five to 10% of people have long-term success with lifestyle alone. So where do you start with medications? You know, patient specific, right? So we have older affordable medications like Fentermine, which is a stimulant, so it can help with energy. It's not something that everyone's a candidate for, but it's generic, it's cheap, it's affordable.

44:44

And so, you know, that is sometimes an option we'll start with. We can combine it with another medication called Topiramate that can make it more effective. We talked about metformin is a medication that can help with insulin resistance. So those are some of our more, you know, affordable older options. And then, you know, people have tried those and they haven't had the success they're looking for. Stepping up to things like Wagovi, which most people know as a Zempic, but when it's used for weight loss, it's called Wagovi.

45:13

That's in a group of medications called GLP-1 receptor agonists, and they work hormonally to decrease hunger, essentially. They have a bunch of other metabolic benefits. They can decrease inflammation. And then the other one is ZetBound, works similarly, actually works on two different hormones, GLP-1 and GIP. And people can expect 15 to 20% weight loss on those medications on average. Certainly, some people have more, but some will have less.

45:43

and really powerful tools that can help people if nothing else has worked. And there's no reason you can't start with the medication, but most people want to see if lifestyle works. If it does work, great, like you found a solution, but if it hasn't been sustainable or it really just hasn't worked, then medications are very helpful. And how expensive are they? Yeah, so the ventramine can be like 10 or 12 bucks a month.

46:10

When we start combining with other meds, again, like 10 to 30 bucks a month, not very expensive. The newer injectable medications are sometimes covered by people's insurance plan, but if they're not, you know, if you're using the actual brand name medication, they're about $500 a month. Okay. And what sort of side effects can people see with those?

46:33

The hormones they work on are GI hormones, so gut hormones. And so almost all the side effects are gut in nature. So nausea is common. That tends to get better with time. Occasionally can even cause vomiting, also gets better with time. Sometimes constipation or diarrhea, and those tend to get better with time. So those are the most common side effects that those medications cause. And it sounds like you see a lot of success with the medications.

47:00

They change people's lives. So about 90% of people on those two, Wigovia and ZetBound, will lose at least 5%. So that's what we consider clinically significant. But on ZetBound, for example, which is our most powerful one, the average weight loss is 20%. So yeah, pretty helpful. And then when you layer on lifestyle change with that, I have patients who...

47:26

you know, definitely exceed that when they're really able to change nutrition and change their ability to exercise. And so, you know, I think for your audience, occasionally people do experience fatigue on these medications. So that can be a side effect, but more often than not, when people lose weight, they improve in their energy. And I've actually had people on these medications, especially people with diabetes who really have low energy to begin with.

47:54

who like their energy shoots up. Like they almost have trouble sleeping because they have so much more energy. They take up new hobbies and then they are able to start moving. One of my patients who's been one of my biggest success stories on Monjaro, which is that bound, but for diabetes, she has lost almost a hundred pounds and.

48:17

she just ran her first half marathon. And this was someone who could, you know, like maybe, you know, walk for 10 minutes when she first started all this. So super exciting to see the impact it can have on people and just the energy and the ease it can bring to life when you lose a hundred pounds, it has a huge impact on your health. And are the medications required ongoing?

48:43

That's what we think so far. You know, these have only been used for weight for a few years now, but it does look like the vast majority of people. If you if you need that to lose weight, you're going to need to continue some medication to lose weight. There's certainly stories of people who who are successful without them or can step down to a more affordable medication. But I think it's.

49:07

important to know if you're planning to start one of those medications, your expectation should be that you're going to need to continue it. And I think that's their expectation for anything. I always say whatever you do to lose weight, you have to keep doing. So if you're exercising four hours a day to lose weight, I hope you have time for the rest of your life to exercise four hours a day because you're going to need to keep doing that. Right. You know, if you're doing a keto diet, which I think can be great, can really help with insulin resistance. But if you can only do that for two months and your plan is to just do it for two months, it's not going to be effective.

49:37

doing it. So any of our interventions when you stop them tend to stop working. Well, this has been amazing. Where can people go to learn more about you and the wonderful? Yeah, so I have a podcast called the Dr. Frankavilla show. It's all about health and weight. So if you want to hear more of these conversations, that's probably the best place to go. If you're trying to get your toe into resistance training and want to do some more strength training, I have a simple two day a week program. It's all pre-recorded on an app.

50:05

Called GLP Strong. So that's a great place to go for strength training. And yeah, those are the two best places to find me. But go to the Dr. Francavilla show and can hear lots more conversations just like this. And you have a summit that's going on right now that people will be able to- Yes, so we have a summit that's going on. This is the second week of October right now. We have an encore coming up later in October as well. So that is-

50:29

Dr. Talks, if you go to Dr. Talks and look up Dr. Talks Medical Weight Loss Summit, and I can send you the link for that, then you can check out, we have 40 discussions on there, just like the one you and I had. Experts from all over the country, all sorts of different focuses in terms of weight and health, just a wealth of information there. Yeah, and we'll drop that link below this as well. Okay, awesome. Thank you so much. Thanks so much for joining me today. This was wonderful.