Let’s Talk About Weight Loss
Dr. Mike Jones sits down to talk with Kate about healthy weight loss principles, barriers to the process, and how to fight scratching the "itch." Learn practical ways to grocery shop and avoid unhealthy hurdles when out-to-eat with friends and family.
Note: This podcast was originally recorded for publication in March 2020, but due to pandemic emergent communications, never aired. Please enjoy this re-broadcast episode in honor of National Nutrition Month 2021!
Speaker 1:
Thanks for joining us for this episode of Centra Scripts, where we talk health and wellness and practical tips for your everyday life. And now here's your host, Kate Kolb.
Kate Kolb:
Well, welcome back to Centra Scripts. We're so excited to have you here today with us. We are discussing Nutrition Month. And I'm actually here with Dr. Mike Jones today. And thank you so much for being with us and agreeing to do this podcast today.
Dr. Mike Jones:
Well, certainly. Thanks for inviting me.
Kate Kolb:
Yeah. And if you don't mind, can you just tell us a little bit about yourself, what your background is and what brought you to Centra?
Dr. Mike Jones:
Sure. Yeah. I've been with Centra about two years now, just over two years. And I trained originally in family medicine at St. Louis University and I've practiced inpatient and outpatient primary care for much of the next maybe 15 years. About 12 years in is about when I began to develop an interest in obesity.
Kate Kolb:
Okay. So why then at that point? What attracted you to this field of study with weight loss and obesity studies and bariatric medicine?
Dr. Mike Jones:
Well, there's a few reasons. One is I have, for most of my adult life, struggled with obesity myself and another is obesity in primary care, pretty much any field of medicine, but I felt it particularly in primary care, seemed to get in the way of treating a lot of other things and seemed to be the root of many other conditions we deal with regularly. And so I think to deal with health in general, especially as rampant as obesity has become, we need to address it. But neither of those two reasons are the biggest reason because we've known that for a long time, probably the biggest and most influential reason was the stumbling upon new information about obesity based on studies that date way back to the early 80s but it really ramped up significantly in the late 90s and since then, a kind of call, a late 90s ... The obesity revolution. We began obtaining evidence that there is much to this problem that really, in some cases, is almost the opposite of what we've assumed for much of modern medical history.
Kate Kolb:
Interesting. Okay. Yeah. Well, I wanted to talk to you today because we have spent the month of March highlighting some aspects and some important things about nutrition, it's National Nutrition Month, and we wanted to take the time to highlight this idea of ... Their 2020 theme is actually Eat Right Bite by Bite, and I feel like that fits into a little bit of what we've heard you talk about in some of your seminars before. And I know you've done a few things around the holidays that you've talked about with healthy eating and how to approach that. And so during this Nutrition Month, just wanted to talk to you a little bit about why do you think to even have a Nutrition Month is important for people?
Dr. Mike Jones:
Well, I think there's certainly a lot that we need to learn differently about how we eat. Frequently I will give this example to patients who I'm having this discussion with, and we'll tell them that most patients, if they're being prescribed a medication, will want to know a little about the medication, what is it? What's it do? What are the risks, the potential side effects? Why do I think and why do you think as the physician that the benefit of this medication outweighs its risks? And I think thoughtful patients that are engaged in their health are wanting to know that kind of thing, and that should be the type of thing that physicians are explaining. However, this same person, when they leave the doctor's visit, after these thoughtful questions, will stop at a fast food place, or a restaurant, or go home and put things in their mouths without any thought to what effect does this actually have on me? What is the risk benefit ratio here? And I never did either. So I'm not blaming, I'm pointing out that I think having a month is great if that helps make us more mindful of the need to realize that the food we put in is chemistry.
Dr. Mike Jones:
We think of medicines as chemicals we're putting in our body that aren't normal or natural, well, a lot of the foods we put in there ... But how many foods do we put in our mouths that we can't even say most of the ingredients on the ... And most don't even know that that's the case because they're not reading the ingredient list. So I think Eat Right Bite by Bite is ... There's probably a lot of good little mottos we could come up with, that would be true. It's not the dietary indiscretions on Thanksgiving or on Christmas or during the picnic for 4th of July or on your birthday that really cause the damage, it's the thousands of small decisions that we make all the time because of how we habitually live relative to our food intake and our nutrition.
Kate Kolb:
Right. Yeah, that makes sense. So the Eat Right Bite by Bite statement that they're making, how do you think that that can fit into this kind of science of what you are advocating here in your practice?
Dr. Mike Jones:
Well, I think Hippocrates said let food be thy medicine. I'm frequently asked if I prescribe medications to help with weight loss and I have two answers to that. One is no, I don't prescribe medications for weight loss. I prescribe medications to help treat the chronic disease of obesity. But yes, I do. I do prescribe medications. But the single most important medication I prescribe is food.
Kate Kolb:
Interesting.
Dr. Mike Jones:
Just because your car doesn't run, say, on diesel fuel doesn't mean that it doesn't require fuel at all. We've had this mindset for quite some time, especially those of us who've struggled with obesity, that food is the enemy. Food is evil. The less the better. And very few things can be further from the truth. You don't put diesel fuel in your car cause it won't run, you got to put the right fuel. We have to put the right fuel in the right amounts and often at the right times, and that's much of what we focus on now. A lot of the things we use outside of food, like medications, aren't for the purpose of the medication causing us to lose weight. They're more for the purpose of helping us be able to adhere to a new dietary plan, a new dietary routine, and develop new dietary habits, which only happen over time.
Kate Kolb:
Right, right. That makes sense. That's great advice. It actually leads into the next point that I wanted to talk about. I feel like there are a lot of people that have these conversations and these ongoing cycles with their weight or with their relationship with food and that kind of thing, and let's talk a little bit about maybe what are some of the biggest pitfalls for people as they interact with this relationship with food? What would you say to people who maybe don't even understand that there is a relationship with food?
Dr. Mike Jones:
Many of us, particularly in Western societies, although obesity has really become a worldwide pandemic, it's not just a Western issue, but particularly in the West, we have certain assumptions about what food should do for us. First, food is meant to be pleasurable. And while I think that taking pleasure in food, in what we eat, is a gift and it's a great thing, I think we need to first reorient our priorities and realize the first purpose of food is to keep this machine running and hopefully running well. The first purpose or priority of food is not your enjoyment. I'll explain it this way, if I talk about a particularly healthy food with a person, and they say, I don't like that kind of food, they often, especially early on, when they first start seeing me, will make that response very matter of factly as if to say because I don't like it that's enough of an argument. "Nobody should expect me to put anything in my mouth that doesn't bring intense joy".
Dr. Mike Jones:
And this idea that we have to love or even like every bite of food we put in our mouth, I think we need to start trying to get ourselves away from that. I'm not saying we shouldn't enjoy food, but the interesting thing is taste is learned. There was a large longitudinal pediatric study back in the 80s that proved pretty convincingly to us that taste is learned. It's repetitive. And I think we owe it to our bodies to work really hard to cultivate taste for the foods that keep our machine running well.
Kate Kolb:
Right, right. That's a really interesting concept. I can remember having talked to a couple of nutritionists in various seasons of my life, and the one thing that always rang loudly to me that they said was this idea that food is fuel and you have to maintain that mentality in order to have a healthy engagement with it. And so that was something that is always in the back of my mind and it's trying to remind myself that, like you said, food is not the enemy, but it's not only there for our pleasure, but that we need it for our body to run correctly. And so that's an excellent point there as well.
Kate Kolb:
What other pitfalls do you think people might run into as they're trying to think about, "Okay, I need to get healthy in my life. And what does that look like with this idea of how I interact with food?"
Dr. Mike Jones:
Outside of beginning to change how we think about food and its purpose for us, as was just mentioned, there are other barriers. There are other things that get in our way of eating healthier. The home environment. Oftentimes I'll have a patient that struggles with obesity and family members that don't, and they're hindered from making any significant radical changes to the food that's even available in the home. I often recommend they try to really eliminate, at least for a time, while we're beginning this journey to help them with weight and with this relationship with food and with how to appropriately approach your nutrition, that they have factors in their life, in their home working against that frequently. And so that can provide barriers.
Dr. Mike Jones:
Other things that can provide barriers is it is true that much of the healthier food is more expensive. However, there are still ways to eat the more expensive food, especially if maybe we shouldn't be eating as much. Now, I don't want to misrepresent the case here, there are many, many of my patients that I see, I see at least one or two every day, who that is not their issue. In fact, in many cases I have to have them calorie count because they're not getting enough, and that's actually a relatively common scenario. But certainly the expense of food in some cases get in the way. And we're starting to have more and more products on the market that are coming around healthier, a little cheaper than they used to be because of this need. And I think slowly the market's going to change to help us with that, but in the meantime we have to be creative.
Kate Kolb:
Right. What would you say to the person that just says, "Going to the grocery store could just overwhelms me"? what would you say to them in this process of choosing healthier eating?
Dr. Mike Jones:
That's a really good question. And I'll tell you something that my wife does every week when she goes shopping, partially this is because she doesn't like going into the store if she can help it, but another part of it is it's an easy way to make healthier choices and to avoid those impulse purchases if we use a lot of the stores that have the drive up shopping. You order on an app, you pay on an app, you drive up, they put it in, you come home and you unpack it. It's really a much easier way to stick to your grocery list and to avoid walking past the Cheez-Its and the cracker aisle. I personally would have a hard time staying away from those if they were in the house so I don't have them in the house. So that's one piece of advice I frequently give to patients.
Kate Kolb:
Yeah. That's good. Okay, so we talked a little bit about could some of these barriers ... I like that you call them barriers too because I think there's an element to that word that means that there's something sort of standing in the way, but it's not concrete. There's not a reason that you can't get over it or around it. So I appreciate you using that phrasiology there. But I've had people ask us in the past, "Okay, well I'm on this weight loss journey and it's been just cycles and cycles of up and down and it feels like a hamster wheel," what does an actual practice of healthy weight loss look like or what should it look like when people are either starting this process or have been frustrated by the process over a long time?
Dr. Mike Jones:
Well, I think the word process is maybe an apt word to use. It is a process. We don't, and this comes as a shock to a lot of people, but honestly, we don't fix obesity by losing weight. Obesity is not a weight problem. You may notice that Weight Watchers international recently rebranded to WW. Why? Because they, along with their medical advising team, have also come to the realization that obesity is not in itself a weight problem. The weight is a symptom of obesity. The problem is more under the hood, the brain, interaction with the brain, and the GI tract, and how we utilize energy, this energy balance thing. So I think certainly we want people who are carrying excessive body fat to be rid of that to a significant degree over time. But if that remains the focus, it takes our focus off what the real problem is. And that's these abnormally functioning neuro hormonal metabolic processes that aren't functioning the same from one person to the next. We assume everybody uses energy exactly the same, it's just a mathematical equation, and there is abundant evidence that that's not the case.
Dr. Mike Jones:
And so I think maybe the most important place to start, especially if you've been frustrated by this up and down cycling thing, is first cut yourself a little bit of slack. You might've been doing the last time you tried to lose weight and started losing weight very well, and all of a sudden you stopped losing weight and you assume what I was doing wasn't working. And I would argue that a lot of times if you're being consistent, even if the weight's not coming off, it doesn't mean that the underlying issue is not being well addressed from a physiologic, neuro hormonal, metabolic standpoint just because we can't see it.
Kate Kolb:
So let's talk about two of the sides of the same coin because I think you just mentioned it is a process and this is something that people need to be mindful of, and we talked a little bit about that cycle that goes around, so tips for success in this and what is a success metric? What would you recommend to somebody who says "I need a goal and what does that goal need to look like in terms of this journey starting"?
Dr. Mike Jones:
I remain rather reticent to give goals in terms of body weight for several reasons. One, I just mentioned that obesity is not ultimately a weight problem, it's a symptom. So I want to take the focus a little bit off of weight. Not that weight is not a good metric to use over time, but it is not always a good metric, especially in the short term of measuring successful lifestyle and dietary changes that we're making.
Dr. Mike Jones:
So often what I have people begin to focus on early on is really the need to rewire the brain. If you have a person, let's say, who their entire life, they've been taught to eat very clean and healthy and they always have, and maybe they exercise routinely and they feel horribly when they do not exercise regularly, and this has just been ingrained in their life, and then they have a tragic event happen in their life. Tragic events often are difficult events or stress are often when we fall back into some kind of default. Well, what is this person's default? Do they all of a sudden start eating way too much of fast food and buying cookies and cakes and candies and pies and eating that stuff? That's not in their default. But one of the things that often is another barrier for my patients is life happens. We have to retrain the brain and hopefully adjust or modify or improve this default such that when life happens, where they land, is not quite so unhealthy.
Dr. Mike Jones:
People often ask, "Well, you have to help keep me from falling off the wagon," and I tell them, "No, you're going to fall off the wagon. But what path is your wagon on?"
Kate Kolb:
Oh, that's really good.
Dr. Mike Jones:
When you fall off the wagon, where do you land? If you land in really horrible health decisions and nutrition decisions, that tells you where your default still is. We have not done enough brain changing. And I see this all the time. I see people fall off the wagon first, two or three months of treatment and a year later they come in ashamed of themselves, you go, "Oh, what's wrong?" "I fell off the wagon again." And I'll look and okay, and they're eating bananas now where they're trying to cut out sugar. And that's okay, you did fall off the wagon, but look where you landed. If we get massive amounts of weight off of people, and at the end of that process, their default isn't changed, we have failed them. Because 85% of people who lose a clinically significant amount of weight and will gain it all back or more in two years or less. We have to treat it like a chronic disease.
Kate Kolb:
Right. Yeah. That's great. And I think a piece of that, and you touched on this just a little bit a few minutes ago too, but what would be your ultimate encouragement, and I think you just spoke on it a little bit with the path and the wagon, but for somebody who is just really fighting discouragement over what their relationship with food looks like or maybe what this longterm trajectory of what they think they have or haven't hit in terms of goals, and not just talking about a number on a scale, but just how they feel about life in general. What would you say to the person that just feels like this is just really hard and how do I get over that?
Dr. Mike Jones:
Right. Well, how I began addressing that is ... And just this morning we had a group class here that I do with my new patients to begin giving them a foundation for how to think about obesity differently. And I find that that is critical for people to ... Those who have been most successful is to understand better. And what I've worked really hard to do is to try to help these folks understand that there's actually a reason why they have difficulty making the choices they often want to make .a person that's not suicidal, doesn't intentionally stand in front of a train, yet why do people that know putting this repeatedly in my mouth is not good for me? I'm persuaded. I'm convinced. Most people aren't out here, anybody, going around saying, "Oh, I think the adverse health effects of these foods that you guys say are bad for us. That's overblown."
Dr. Mike Jones:
I think most people pretty much believe that, "Hey, there's foods that aren't really good for us", especially repeatedly. What in us drives us to do that? Is it really lack of willpower, lack of motivation, lack of discipline? You know what, I know a lot of thin people with lack of willpower, motivation, and that is not the underlying problem. It gets to this concept that I teach patients that I call the itch. An itch, is a metaphorical itch, is how your brain keeps you alive. "Hey, you're thirsty. Go get a drink. Hey, you're getting cold. Build a fire. Hey, you're getting hot. Go inside [inaudible 00:21:09]. Seek shelter. Find some shade." Well, for various reasons, which of course we don't have time to go into here, there are things going on in the part of the brain that regulates energy consumption, the search for fuel and the utilization of that fuel that give us itches that are hard not to scratch.
Dr. Mike Jones:
And what I often use with patients is, have you ever tried to tell somebody, poison ivy, not to scratch?
Kate Kolb:
Yeah, that's nearly impossible.
Dr. Mike Jones:
It doesn't work. I remember being taught in med school, "Yeah, look, don't waste your time badgering patients about scratching." What do we do about it? We help reduce the itch. That really is a lot of what I do. So if you're discouraged by your repeated attempts, do not be afraid to go to your primary care doctor, your specialist, whoever you see and bring up this issue with your dietary habits with your obesity. And obesity starts long before most people would say, "Oh, I have obesity." But bring it up and they may have some suggestions. And if they don't, they now have tools, folks such as myself and Dr. Ali in our department here, who are really dedicated to trying to help people with this. And a lot of my job is helping people reduce the itch, because if the itch itches bad enough, you're going to scratch it no matter how much willpower you have.
Kate Kolb:
Yeah, that makes a lot of sense.
Dr. Mike Jones:
So that's part of getting under the hood I talked about earlier, reducing the itch. If you have a small itch on your arm, you can say, "Eh, I'm just going to ignore it," but if that itch is cranked up high, you're going to dig at your arm. It's very similar with our drive or motivation to eat. That person that scratches their poison ivy, we don't cast dispersions at them and say, well it's a character flaw. You're scratching an itch because it's natural to scratch an itch, especially when an itch is really bad. So my target with using medication, with using the counseling we have here with our bariatric counselor, with seeing the dietitian, our whole multidisciplinary approach is to, sure, educate people, but knowing is not the same as doing. We've got to give them the tools to try to be able to implement these things.
Kate Kolb:
Yeah, that's great. I really, really love that. And I think that when people start to engage in it that way, like you were talking about earlier, it's a change of the mindset and it's retraining the brain to interact with these things on a different level than we've experienced before. And it's something that will project that healthy mindset forward.
Kate Kolb:
So I want to circle back around, just here at the end of this, to something that we were talking about at the very beginning when you said we tend to think of food as well it's supposed to bring me joy and all of this. And I want to just caveat over to the side for a little bit here on what do you do, because we get this question a lot. Okay, so I'm doing this really great nutrition plan and I feel like I have a pretty good relationship with my food choices and what that looks like in my life, but I do it well in my own circle of influence and then it all goes out the window when I go out to eat or to a special function or something like that. What do you tell to the person that just feels anxiety in that moment of can I still enjoy these types of things and feel like I'm a part of it without it being just an overwhelming experience?
Dr. Mike Jones:
Yeah. Yeah. And of course that comes up a lot and I always tell patients we have to learn how to treat this disease in the context of real life. We can't generally, in most circumstances, take people and put them in a bubble, extract them from their life and do this. So longterm, the answer to that is, change our default so that even when we do go out, our default's relatively healthy. We're scratching our itch, but it's a healthier itch. So that's longterm.
Dr. Mike Jones:
Short term, what do we do? Well, short term, I strongly advocate avoiding eating out. However, there are some tips, some techniques I think that can be helpful if you are going to eat out. One, I tell people to eat before you eat out.
Kate Kolb:
Really? Okay.
Dr. Mike Jones:
And it doesn't have to be massive, but it should be healthy of course. Eat before you eat out. Going to eat out is more for the fun than the nutrition, so why not get most of your nutrition, or at least good nutrition before you go? If our hunger is satisfied, we often don't really care what satisfied it, except while we're actually enjoying it.
Dr. Mike Jones:
I'm a foodie myself. I love to eat. So some of it is getting creative. So eat and then before you leave, look up the menu online, get a piece of paper, write down what you're going to order. You will make a different decision having recently eaten than you would have if you were hungry. Or first of all, it's like going to the grocery store hungry.
Kate Kolb:
I was just thinking that.
Dr. Mike Jones:
When you go to a restaurant, you're basically going to a grocery store. They just prepare it for you. The menu is not a list of things that are available to eat, it's an advertisement. And everything looks really good and it makes your mouth water, and it's harder for us to not make impulse purchases at the restaurant looking at their menu. The online menus aren't quite as appetizing. You get on there, you look and see what you want, you write it down. If they hand you a menu, tell them to keep it. When the server comes around to take your order, you can read it to him or hand it to him. And then often in those cases, since the portion sizes are so ridiculously large, probably at least three to four times more food than any person actually needs at one sitting, ask them to bring a container when they deliver your food-
Kate Kolb:
Just at the beginning of the meal.
Dr. Mike Jones:
And cut it in half at least. Because if it's there, you'll do what I do, or at least a lot of people will, and that's pick at it and there's nothing left to take home if I'm not careful, especially if I'm out with friends and we're socializing. We're there longer. Put it aside, it's easier to not mess with it.
Dr. Mike Jones:
And then another thing is really trying to be mindful and conscious of the types of foods that that maybe you've learned about and then what to eat and whatnot.
Dr. Mike Jones:
Coming back to in the early part of treatment for obesity, and particularly with my patients, we haven't changed the default at all yet. We're in the process where we got to get under the hood, help reduce that itch because it itches and if you have an opportunity, you're going to scratch. So let's minimize the itch best we can. Let's also minimize access to the scratching the itch. And then making it fairly infrequent for a time, once we get somebody down to a maintenance healthy body fat percentage, one of the first questions I ask when we hit maintenance and I say, "Okay, we're shifting gears now", is what do you miss the most? And is there a way we can test drive that again and see? Is there a reasonable way we can reincorporate that into your lifestyle? And there's ways I monitor that over time, but let's worry about what the rest of life has to look like when we get there because that really is a lot ... I used to put a lot of effort into trying to come up with a maintenance plan for somebody, and I never need them or rarely need them because we get there, their default has changed. So I said okay, how do you want to change it now and, "Why would I change anything?"
Kate Kolb:
Which is great because that means the reframing has happened.
Dr. Mike Jones:
That's right. That's exactly right. So now, this sounds simple talking about it like this, it certainly isn't. It's certainly a process. It's certainly something that if you fall off ... One of the things I really drive hard at also for patients is if we have you on a plan and you're expecting certain things from yourself, and you feel like you really messed up, those folks are much more likely to not come to their next visit because they feel as though, "Well, I didn't do anything we had talked about doing. It's a waste of a visit," and I would argue the opposite. I would argue that's when you need to be here because my job is to help reduce the itch. If you can't avoid it, why can't you avoid it and what can we try to help do about that? We wouldn't say that about any other condition. "Okay. I'm diabetic and well, I haven't really been making the right choices and my sugars are through the roof, so it's a wasted visit to go in and see Dr. Koby for my diabetes. Now you'd be like, "Well, okay, I know I haven't been doing exactly what I should do, my sugars are in the 400. I really need to get in there." That's the mindset I want my patients to adopt. We're here to help, not point fingers, not chastise. We get it.
Kate Kolb:
Yeah. And I think that's great. I think that's a needed element to this is just allowing that shame cycle to come off of people and allowing ... I've got very good friends in my life, and we remind each other all the time, shame off you. Just shame off you instead of on you because I think we've put that shame on ourselves so easily and readily, and so that's just a really good reminder.
Kate Kolb:
Well, we are going to actually just wrap up this episode, but I'm going to give you a chance for the last words here, anything else that you would just put out there that you would want to share about this kind of nutrition journey or any of this for them to hear?
Dr. Mike Jones:
Well, yeah. I guess just recapping a little bit. A lot of times we say, and I've said this to myself and most of my patients at one point or another I've said this, I know what to do. I just need to do it. And I like to rephrase that a little bit. Well, first I think a lot of people think they know what to do it, and it turns out everybody apparently is a nutrition and obesity expert. But a lot of people really don't know and they don't know what they don't know, but some of us have a reasonable idea. So I think reeducating is certainly important and I don't want to minimize the necessity of diligence, intent, using some willpower, even though obesity was not caused by poor willpower. Like I said, we're trying to get under the hood and allow changes to happen, but you can't make changes happen if no change ever happens. You got to reduce some of that burden and help carry it for them, then they can focus a little bit on making those permanent changes. So it's not a either or. It's not a I got to have a lot of willpower to do this or I need some pill or product or a program that does it all for me. It's both and. We have to have both.
Kate Kolb:
Yeah. Well, thank you again so much for just being willing to have this conversation with us today. This has been great information. And we just look forward to being able to dive a little bit more into this on the blog and some supporting areas there at centrascripts.com. And once again, just thank you for tuning in. We appreciate you guys as listeners and look forward to talking to you next time.