5 foods to lose fat, regulate your appetite and improve your metabolism without counting calories | Dr Federica Amati

Dr Rupy: Dr Federica, what is the healthiest way to lose weight and keep it off without counting calories or taking drugs?

Dr Federica: The best way to do it is to actually just eat more whole food. We've become obsessed with calories and counting calories, and a lot of people who struggle with their weight or who try to lose weight quickly just fixate on the calorie counting and forget about what food that those calories are actually bringing you. And from all the physiology we know, everything we understand about appetite hormones and hunger and weight regulation, what's really clear is that the best way to achieve and maintain a healthy weight is to eat the right foods. So a lot of the time it's really helping people to increase whole food intake. Because our food environment right now pushes us more towards convenience foods, drinking our meals or eating calories from foods that aren't whole foods. They're highly processed foods or they are food products, as I like to call them. And so actually just helping people to edge their way back towards eating whole foods is the simplest way. And it's funny because I often when I work with people one on one and especially sort of perimenopausal or women in their forties and they are struggling with weight gain and they are like, please help me, and I say to them, you need to eat more more food. I'm like, you need to eat more. And they're like, I'm sorry. They literally their face, there's a sort of slight twinge across their face which is like, is she okay? And it's really hard to embrace that when our diet culture has propagated this myth that you must eat as little as possible if you want to shrink.

Dr Rupy: Why is it that switching from food-like products to whole foods actually leads to people losing fat?

Dr Federica: So there's lots of mechanisms, right? So some of the work that we've been doing at Zoe with Professor Sarah Berry has been looking at what what parts or what sort of qualities of ultra-processed foods are actually driving the ill health that you see in all the epidemiological studies where, you know, the highest UPF consumption is consistently associated with worse health outcomes across the board from mental health to metabolic health to fertility. So what we wanted to see is like, well, what is it about these foods actually? Because they're so, it's such a big bucket, right? So what is it? And the key themes seem to be energy intake rate. So how quickly can you eat them? You know, if we take a really obvious example of say, eating whole nuts. So say you've got yourself some mixed nuts, almonds, walnuts, you know, all the stuff and you're eating them whole. And then you buy a nut bar, right? Inherently, they might have very similar ingredients actually, but the way that the nut bar has been processed makes it so much easier to eat quickly. So your intake rate of the same calories, fat is very different to if you're eating the whole food. And that's a really basic example. But you see that across all sorts of things. One of my favourite examples is like take a corn on the cob and then take a tortilla chip. Takes some time to eat your corn on the cob and it's going to be pretty satiating, but you can go through a whole packet of tortilla chips pretty quick. So energy intake rate is important. When that relates very closely both to energy density, so how many calories per mouthful do you get in these foods, and it tends to be higher for ultra-processed foods, and also the food matrix. So the structure of the food, how are these nutrients encapsulated in the natural structure of the foods? This applies a lot to plant foods. Interestingly, it also applies to dairy foods. So food structure and dairy foods is different when you're comparing for example, butter to cheese, which have actually pretty much the same saturated fat content, but the way the food matrix encapsulates those saturated fats means that the impact on your health is very different.

Dr Rupy: Let's let's dive into that a little bit because I think that will be quite shocking for a lot of people to think you've got exactly the same dairy product, same amount of saturated fat, but cheese seems to be better for you than other dairy products like I know milk.

Dr Federica: Yeah. And and especially I think butter is a is a good comparison because because it literally in terms of macronutrient is the same, right? And the way that the fats are encapsulated in the cheese because of the fermentation process of the milk means that you don't actually access the saturated fats in the same way when you digest them. On top of that, you have the fermentation products, the amino acid composition of cheese, which is different. So when it reaches your gut, you absorb it differently, but you also interact with your gut microbiome very differently. Butter doesn't really do much for your gut microbiome. So this idea that, you know, back of pack, calories, it doesn't really tell us anything about the food matrix. And it's a really critical part of how our body interacts with, absorbs nutrients from food. And it goes a long way in answering why whole foods have such a powerful effect on healthy weight regulation, on having a really lovely satiating meal and not feeling hungry all the time. So destruction of the food matrix is a major issue when it comes to ultra-processed foods and combining that with the energy density part, this energy intake rate is what we clearly see as a problem even in the RCTs like Kevin Hall's study. You know, when he did that RCT of UPF versus whole foods, one of the major drivers of the weight gain in the group who sort of ate the UPFs was this the speed at which they could consume about 500 extra calories a day, which is a lot. Like that's a lot. Without feeling fuller, right? So that's one aspect. Then the other aspect which is really important is additives. So we do know that additives in ultra-processed foods have varying effects on health. It's the I reckon for me it's like the element of ultra-processed foods that is we're still uncovering. There's a new study published every week on the effect of a specific additive or the effect of what we call the cocktail effect. So actually additives that are thought to be pretty harmless when combined with another five additives seem to have a negative impact. That is something that we're unravelling continuously. So we're working with food additive experts who are continuously updating our database to say actually like, okay, this one's position has changed. This one has changed. This cocktail effect has been identified. So that's really interesting and also a bit scary because it's this xenobiotic effect. So these chemicals that we didn't evolve with that are created as part of the food product and the food industry and we don't really know what they're doing. And we don't know what they're doing together either. So additives is something to keep an eye on, but again, in the same breath, some additives are really helpful, right? If you're fortifying plant milk, that's an additive and it's really good to have that fortification. I mean, in the UK, we have an issue with a lack of fortification for things like folic acid and iodine that cause real public health impact. So we mustn't conflate all additives into one big ugly bucket. Different additives have a different role to play and they can be harmful, harmless or beneficial. So that's something to to bear in mind. And then the last piece is like hyperpalatability, right? So this is a not as exact a science as energy intake rate, but it's a clear signal. Like the science is actually I'd say it's pretty convincing that the way that these foods are processed, they are made to be much more delicious than you would find in a whole food, basically. So this combination of fats, sugars, carbohydrate source, they interact in a way that makes them just irresistible to eat more. So they override our normal satiety signalling when it comes to that what what we call cephalic satiety, so like our head, our taste, how that influences the signals that we send our brain to be like, yeah, we've had enough. The hyperpalatability seems to sort of override that. So once you pop, you just can't stop is like a biological reality. And so when you get those those things combined, you have this this gradient. So what we've called it the Zoe processed food risk scale and it's this like understanding of which foods are processed but actually their likely health impact is neutral. And then which foods are processed in a way where their health impact is likely to be higher risk. So, you know, food processing has this real potential to make things affordable, shelf stable and accessible on one hand, but on the other hand, it there's it has the potential to become make food irresistible, overriding your satiety signals and so extremely profitable. And as much as I have I have spoken to and I know of some amazing food companies that make great products, but it's undeniable that the underlying driver for the food industry in this country and countries like the US is profit. So, you know, there was a Tortoise Media report that came out maybe two years ago now, I guess, that identified that about 70% of food companies in the UK only make UPFs. Only. They don't make they don't make any sort of whole food adjacent or just convenience processing where it makes things more accessible. So, you know, policy has to play a role here. We need the government to be like, hey guys, let's like moderate this food environment so actually we have a variety because at the moment it's it's actually stacked towards profit against public health.

Dr Rupy: It's a really important point you're making. And just to caveat this entire conversation, whilst we are going to be talking about whole foods and a move to more fibre, etc, it it is easier said than done, particularly when you're up against a marketing machine. Um that is constantly bombarding you with messages about convenience and price and all the rest of it. And I think in a era where a lot of people are experiencing financial insecurity, it's like the only viable option in a lot of cases. But there are solutions that we're going to talk about in a bit. So just to sort of summarise the ultra-processed food or the processed food issues, energy density per gram, there's the speed of consumption, the food matrix which is disrupted, palatability, which I completely, you know, I'm I'm guilty of popping and not stopping myself. And overriding those satiety signals. I want to pull on the thread of additives a little bit more because I think this is an area of confusion for a lot of people, no matter how educated you are in nutrition, which additives do we know are genuinely, you really want to stay away from them as much as possible versus some that are like, might be bad, might be all right, might be safe. And then what are some sort of rules of thumb that people can utilise when they're looking at a product, turning over the pack and going through, okay, I'm going to put this back versus, you know, this is probably going to be all right.

Dr Federica: Yeah, it's do you know what? It's such a good question and it is really hard to answer because the science is changing so rapidly. So I recently, so recently NutriNet-Santé, which is a group in France that do a lot of research on additives and health outcomes, they published a paper and in one of their cocktail effect analyses, they identified acetic acid as one of the additives that seem to have negative effects when combined with four other others. It's vinegar, right? Yeah. What? I was like, oh my god. So here's the thing, right, it's it's not about fixating on one additive because I think whilst there are some that come up as being probably more harmful more more than not, so like CMC, which is an emulsifier. What we need to try and think about is, okay, we don't know enough about these additives on an individual basis and we definitely don't know enough about them when they interact. And the evidence we have shows that people who consume the most additives in general have this much increased likelihood of cocktail effect. And it's this cocktail effect which for for me is like a red flag. It's it's, you know, we just don't know. Not none of us eat one food at a time. A meal is composed of several foods and your day contains dozens of foods and then your week, I mean, you carry on. So for me it's more about, okay, where when you purchase foods, if there is a really long list of additives on the back, I mean, emulsifiers for me is a group that comes out as being mostly not great. There are some exceptions where some emulsifiers actually seem to have a beneficial effect on the gut microbiome, at least in like initial preclinical or small clinical studies. But overall, emulsifiers for me is like, they seem to be interacting with our gut barrier and our gut microbiome in the way that's not looking positive for most of the outcomes. And certainly, you know, now in the guidelines for people with IBS or IBD, like one of the approaches is to reduce emulsifiers in the diet. So like a clinical guideline. So that's that's a sign. But try to look at your overall consumption of foods that contain additives as a whole and when you do that, just try to reduce that risk of the cocktail effect because we just don't know what's going to come out with these combinations. And this is very similar to how I think about supplements, right? Additives and supplements, these are bioactive compounds. So the more we kind of mess around with them and mix them all together, the more likely that we're going to have interactions that we're not expecting. So just be really like targeted with what you're doing. So if there are certain foods, so I'll give you an example, I drink soy milk, I drink fortified soy milk, right? That fortification is additives, but they're there for like a purpose. They're there for a health benefit. But when I go to purchase other foods, I try to stay away from foods that are prepared for me in a way that then has a lot of additives. Now there are brands now that use less additives, less emulsifiers, less colorants, less sweeteners. You know, it's these kind of what I would call cosmetic additives that so they're not there for fortification, they're not there to add any nutrition to the product. They're there for look, mouth feel or or sweetness. They're the ones that I'm like just reduce the overall quantity where you can. And so what does that look like? It's like, well, if you're buying a sweetened yogurt, just buy the plain yogurt and then sweeten it at home. And I know that's adding an extra step, but it's those small kind of tweaks that means that your overall intake is going to be reduced and we're also moving you away from the industrially processed products to the more kind of whole food adjacent group. So my my overall take is instead of fixating on one type, it's like try to reduce the the cloud, the cocktail effect of the quantity that you're consuming because similar to the UPF studies, it seems to be those who eat the highest quantities of these products or chemicals have what worse outcomes compared to those that just eat less of them.

Dr Rupy: So a like a rule of thumb, and I know that we are brushing this very broadly, is to try and go for those one ingredient foods that you can actually recognise on the fresh food aisles and less on anything in a pack. Now, I know there's lots of caveats with that and there's a lot more nuance because there are some companies doing a really good job of removing emulsifiers, additives, etc. But generally you want to be moving in that direction.

Dr Federica: Yeah, ideally you're moving towards whole food products and then when you're moving to products that are prepared for you, whether they're frozen, tinned, canned, that's all great. You know, convenience is still good. I can't, not everyone has time to like soak their chickpeas last night and stuff. And then when you're buying products like like a plant-based milk, fortification is a different bucket to cosmetic additives. So just try to understand like what are these additives there for? If they're there for shelf stability and to create a product that has added B12, so fortification, that's actually okay. And I'll give you a ascorbic acid. I love it when people are like, ascorbic acid. I'm like, yeah, that's vitamin C. It just gives some shelf stability to your tomato sauce, right? So there are some that are just actually derived from foods normally and aren't to worry about. It's the cosmetic ones that are more like, let's just reduce them. We don't need things to look bright blue. Or like, you know, you don't if you're buying a product that's like low fat, no sugar, so it's got lots of emulsifiers, lots of added sugars like, what is that product and could you just opt for the minimally processed version? And that is typically things like yogurts, desserts. It's things like so I've seen low fat, sugar-free biscuits and I'm just well, I'm not sure what we're achieving with that. It's like there's also this um this we need to take a step back and say, do we need this in our diet? Does this need to be a regular part of our diet? Because whilst a biscuit is great, are you best off just having the biscuit you like when on occasion as opposed to buying the low fat, low sugar biscuit thinking it's a health food and eating that more regularly and then getting this cocktail effect from the biscuit, which we don't know, you know, how that's impacting your health. So it's also about just really reframing what the role of food in our lives and how we approach food as as a tool for good health instead of an enemy that needs to be defeated with like weird modifications to it.

Dr Rupy: I think everyone's looking for cheats and those sort of ways in which they can have their cake and eat it literally. Um and I think we just need to be pragmatic and realistic about um removing ultra-processed foods in your diet and moving towards whole foods as the strategy rather than trying to tweak something that you're already consuming because you like the flavour of those. Okay, so you've got ultra-processed foods here. Um the reason why these can lead to weight gain and removing them will have the converse um

Dr Federica: And I sorry to interrupt you, but it's not actually about focusing on removing is going to be really hard. Okay. So what I recommend and what seems to work well is focusing on what you need to add back in. Because if you're if you're like, oh, I've got to stop eating my, you know, ready meals and I've got to stop eating this and I've got to stop, it's really daunting and you're like, what am I going to eat? So instead it's like, no, focus on what you need to eat more of. There are some whole foods that we know are lacking across our diets. Beautiful analyses that are done by excellent scientists, not me, who who sort of waded through all the global disease burden of disease data and collated these beautiful graphs that tell us which foods are lacking from our plates that are driving disease. And it's one of my favourite um graphs to show my medical students because what you see is that the impact, the biggest impact on death and disease from cardiovascular disease, cancer, type two diabetes is had by what's missing from our plates. So a diet low in whole grains is the number one driver in terms of dietary factors for death and disease in Europe. Isn't that amazing? That's crazy, isn't it? So what I'd love people to do is actually, okay, I'm going to reintroduce whole grains to my diet. Let's forget about all the influences that scared you off your porridge. It's a wonderful, there are great whole grains. Well, that Tim. Yeah, he never went too hard for porridge. No, you know, it's literally like oats are wonderful. Let's just whole grains are so important for human health. I can't overstress it. And we have loads of clinical trial data by the way where we feed oats in for morning, in breakfast, for breakfast in the morning to people with type two diabetes and it improves their glycaemic control. Like it's amazing, right? So like whole grains are number one and I often say like, what's your favourite whole grain? And people are like, I don't know. Because we're so we've lost them in our supermarkets like so we've got to bring them back. I've started seeing now parboiled spelt packets, right? Great. Spelt, quinoa is had a massive glow up and PR though, so it can be quite expensive. Um you know, barley. Barley is one of my favourites.

Dr Rupy: Pearl barley is I was literally going to say pearl barley is my favourite because it's got that slight chew to it and it's like voluminous and it's yeah, it's really nice.

Dr Federica: It's it's so great for you. Um so there's lots of different options for whole grains. Bring those back in. Yeah. Um and then again, so we're focusing on adding that back in. Add some nuts and seeds back into your diet. Add in um things like fresh like fruits. Again, massively demonised. Fresh whole fruits are I still see some crazy stuff online about how the fructose in the fruit is going to kill you and eating fresh whole fruit is one of the best ways you to that you can reduce your risk of having a heart attack or having heart disease. Like fresh whole fruit is so good for you. Have that back in your diet two or three times a day. People are like, really? I'm like, yeah, really. Like berries in the morning, an apple with your lunch and then maybe a fruit salad with your dinner. Whatever way you like to have it. Um so there are some key food groups that we know are lacking from our plates. And if we can just help people to reintroduce those, legumes being the other one which now thankfully are having a bit of a revival because of some cool brands that are making them really cool again. But you know, your lentils, your beans and yeah, baked beans are fine if that's the way you like to eat them and that's your starting point, like let's get that in. Um so if you focus on that, the UPFs tend to fall off the plate because we only have a limited amount, like we have a certain amount of food we'll eat every day. And so what I find with with patients but also with people just more generally is if we're focusing on adding things back in, the foods that aren't serving us so well fall off the plate and it's a much more achievable, it's a positive nutrition mindset about adding things back in, more achievable, more joyful and and is less fear-based because the issue with the like reducing UPF narrative is also that you can drive anxiety where you then start to really worry about is this UPF? Should I take it out? I'll never forget one woman messaged me on Instagram, she was really what she'd gone really worried about shopping in the supermarket and she was like, can I buy butter? Is that UPF? So it you're like, okay, this has gone way too far. So let's just focus on what we need to eat more of. Be aware of UPFs. Knowledge is power. Being aware of how they're marketed, the role they're playing. Once you see that, you can't really unsee it. And so those two things together, like the awareness piece, the slight rage at the marketing machine, and then the what foods do I need to add to my plate together push you towards a more whole food diet.

Dr Rupy: I love it. So adding more whole foods to your diet, one very clear way of improving one's weight without having to count calories. Obviously, when you increase whole foods, you're going to be increasing fibre. What is it about fibre that is so critical and impactful for fat loss?

Dr Federica: Yeah, oh my gosh, I love fibre. So fibre has like multiple roles to play. So the first thing is what you touched on at the beginning, which is about the volume of food. So high volume foods, kale, cauliflower, broccoli, they often have a great fibrous food matrix. The importance of high volume, high fibre foods is that when you eat them and they hit your stomach, they create volume in your stomach. They stretch your stomach. And we have stretch receptors in our stomach, which are the the second actually stop for satiety regulation. So the first is like what happens in your brain when you see food and smell food and you taste it. And we'll touch maybe on this later, but the importance of preparing your own food and actually handling it and spending time with it instead of just eating out of a packet is why that it impacts that first step. The second step is the stretch receptor in the stomach. So when we stretch our stomach, it sends nervous signals back to the brain to be like, hey, we've got some food in here, we're going to start dealing with it. And it starts to dampen your hunger signalling and your satiety signalling starts going up. So fibre is really important for that. Then as your stomach empties, that gastric emptying is actually slowed by high fibre meals. So it takes a bit longer to go into your small intestine, which means the the nutrients and the food and the nutrients within the food take a bit longer to just pass in, which A, increases nutrient absorption, so it gives your small intestine more time to absorb some of the nutrients in. And B, it means that you have that stretch receptor activation lasting longer because the stomach isn't just emptying straight away. So if you're drinking your lunch, you can imagine that's not happening. Right? Okay, then it goes through the small intestine, lots of nice interaction with the small intestinal wall, takes some nutrients in. And then the fibre reaches the colon, right? So in the proximal colon, you then have this really lovely group of cells and they are like the enteric cells that produce hormones like GLP-1 and they are waiting. They're like, what's happening? What's coming? Again, the fibre then transports fats. So especially with foods like nuts and seeds, you then have this beautiful presentation of fatty acids to the enter-enteric cells be like, hey, here's some. And they're like, yeah, I'm going to release some GLP-1. So that's that's straight after the small intestine. And then as you go through the colon, there are specialised cells throughout that are designed to interact with both the nutrients being presented to them and to the metabolites of the gut microbes that break that fibre down. So maybe just as a quick recap, we don't have the genes that code for the enzymes that break fibre down. So humans cannot break fibre down. But we have trillions of microbes that do. And those trillions of microbes love fibre. Now, the ones that love fibre are the helpful guys. There are also a bunch of microbes that can adapt to digesting things like carnitine from red meat or saturated fatty acids. They're not so helpful. Like their metabolites are not very good for maintaining our gut health. So we want to feed the good guys lots of fibre because they'll break that fibre down and they'll poo. That poo is the metabolites and they either go to feed other microbes, so there's like secondary feeding. And then those metabolites themselves like short chain fatty acids feed the enteric cells. And they sort of say, hey, look, we've broken down some cool fibre which has given us vitamins, neurotransmitters, it's given us short chain fatty acids. Send more satiety signals back to the brain to say that we're still working with this food. So from the moment you eat, see, smell, eat, taste, through to the stomach, number two, small intestine, number three, colon, number four, you have a four-stage appetite system that is wired to make the most of fibrous foods and to give you satiety signalling from fibrous foods. Why? Like, why have we been built in a way that if you eat a high fibre diet, you're basically full for three hours after that meal? That's because of evolution, right? So we evolved as a species that foraged and ate roots and berries and nuts. And really the majority of our diet was this very tough, very fibrous foods that we had to work quite hard to find. And so our entire physiology is there to support us being able to do that for quite a long time. So like we also extract really useful energy from the fermentation of that fibre, right? And to make sure that we can live and function and reproduce with access mostly to high fibre foods. So when you think about it in that context, right, you realise that fibre has such an important role because we literally evolved to survive with quite a lot of food scarcity, but the majority of that food being very fibre rich. And that is why we have these trillions of gut microbes. We co-evolved with them so that they can provide us with some of the nutrients that we're not getting from not being able to break the fibre down ourselves and make those metabolites. I mean, you know, things like vitamin K and vitamin B12, they're made in the gut for us. How cool, right? So it's like when you start to think about fibre that way, it's got so many actions in the way that it actually physically changes our digestion, the rate, the speed at which food passes through. And then importantly also the rate and efficacy at which it lets us excrete the products we don't want. So if you have a low fibre diet, your gut can get very sluggish at actually excreting the things you don't want, including cholesterol, right? We that's one of the major ways to lower cholesterol. But how how food is how nutrients are presented to our enteric cells that absorb nutrients and respond to nutrients. And and generally like just so physically, biochemically and microbiome all have a role to play with why fibre is so important. And it's often for me, it's often the most satisfying thing is when you help someone adopt a higher fibre diet, not only do they say like how much better their gut feels. Being constipated ain't cool. It doesn't feel good, right? But then they also talk about how much that how much more energy they have, how they just don't need to snack anymore. Like it's liberating when you eat a higher fibre diet, it opens up a new world of how you can feel as a human being. And so for me it's like it's a magical thing to witness when someone makes that change. And I mean my mum, I love my mum. She's a legend and she was she's my best patient, right? So she used to have a really low fibre diet. And then she had a health scare and I was like, right, that's it. You're patient zero for me. Let's go. And she transformed her transformed her diet, like night and day. And she was scared of eating most vegetables and she was like, I would never eat lentils and I can't eat mushrooms. She was one of those like she just couldn't tolerate it. And now when we go and stay with my Italian family, um she'll like make herself like lentil and kale and quinoa for like breakfast. And my aunt is like, what? That's great. And she's just transformed her health. She is in such better health now in her 70s than she was in her 60s. And the pivoting to high fibre was an absolutely fundamental part of that.

Dr Rupy: Yeah, it sounds like such an unlock for so many people. And if someone's listening to this and thinking, look, Dr Federica, you've convinced me, I'm going to up my fibre. A, should we be aiming for more than 30 grams? And if so, how much? And B, like what are some of those key foods that are lacking in a typical person's diet that could actually move the needle considerably for fibre?

Dr Federica: Yeah. Okay, so really important point to start with is that the majority, vast majority of UK adults are not getting anywhere near 30 grams. So the statistic that came out from last year's survey, 96% of Britons don't achieve 30 grams a day. But crucially, most people are getting around 15 to 18 grams a day. So the start, we've got to think about the starting point because if you go from 15 to 30 overnight, it ain't going to be pretty. So start, think about where you are and increase gradually. So start by adding 5 grams a day. Now that might be through a supplement or it might be by introducing foods like lentils, but quite a small amount so that you can get used to it. So typically with patients of mine who have very low fibre intakes, I I have a dual approach. I'll say to them, take the supplement and then start with these foods and then let's see and then we'll remove one, add the other. You have to do it gradually. Now the reason you have to do it gradually is because if your gut microbes are not haven't been fed, so if you think of your gut microbes like a zoo and you haven't fed them for ages, right? They're really tired, they're dwindling, they might be dead. And then you chuck loads of food at them, it's just going to sit there, right? You have to start feeding them slowly again so they can repopulate and multiply and then handle the lentil. If you just chuck a load of lentil down, you're going to get constipated, you're going to get flatulent. No one likes that. So gradual increases. If you have a sensitive gut, I think what I hear a lot is people who really stress about not getting enough fibre who have sensitive guts, there are ways that you can introduce fibres and focus on specific foods that are gentler for for those kinds of guts. So if that's you, like it's worth speaking to a nutritionist or a dietitian who can help guide you. A low FODMAP diet is a short-term intervention, it's not a long-term dietary approach. So important to point that out. But there are ways that you can do it even if you have a sensitive gut. And so start slow, know where you are. Remember that things like coffee and dark chocolate contain fibre, which is always joyful. And then once you get to 30 grams a day, and you can track it by using a a log logging app. I mean, of course, Zoe, we have a photo logging app that helps you track fibre and plant intake. But there are others and you could do it manually if you wanted to if you had the time. Um and then once you get to that, actually the studies that look at dose response for fibre, 50 grams, you're still seeing improvements. And there's one study that had 90 grams a day and you still saw improvements. So I don't we don't know or I I certainly haven't seen data to suggest an upper ceiling for it, which is crazy. But what we have done, what Tim's research shows is that 30 plants a week seems to be a really good point, inflection point for improvements for gut microbiome composition. And that starts to sort of flatten around 45 plants a week. So whether you're looking at grams per day or plants per week, both of them are delivering on a fairly similar effect in terms of like introducing diversity to the gut, feeding the gut microbiome. Um but I think the foods to focus on because this is where a lot of people get a bit stuck. They're like, well, if I'm eating an apple, some cucumber, some pepper, some salad every day, like surely I'm I'm getting close. And maybe I have some broccoli for dinner. It's like, well, no, because actually some plants don't have that much fibre in them. It doesn't mean they're not good for you, important to point this out, but it just means that you'd have to eat a large volume of them to get a decent serving. So the five food groups that really contain a really nice punch of fibre and it's funny because they're also the base of the Mediterranean diet. And they're also the five food groups that are lacking from our plates and driving disease are whole grains, nuts and seeds, legumes, so that's the entire like the pulses and legumes family, fresh whole fruit, specifically things like berries, pears, kiwis that are higher in fibre. And then brassicas. So like your broccoli, your cauliflower, your your broccoli sprouts if you're like really going for it. If we can increase them every day, so if we try to get some of those five every day, you'll be getting your way to 30 and 30 grams of fibre in no time. You know, like half a cup of lentils is 18 grams of fibre. Yeah, it's a lot, hey. Yeah, yeah, yeah. So it's like once you get those foods in your diet and you're used to adding them all the time. So whether you have mixed nuts and mixed seeds, I just have them on my kitchen counter and I just add them to everything or just grab a handful and snack on them. The nuts, not the seeds. It's quite hard to snack on. Um you know, they it's just once you start adding them in, it's you don't have to think about it so much anymore. Because you're automatically saying, oh, okay, well, I'm just going to grab that mixed bean tin and I'm just going to chuck it into my pasta dish. I mean, I'm from Rome, so pasta and beans is like my comfort, that is my food. Totally. Yeah, yeah. Um and then it's and whole grains I find are the ones that need the most prompting. We need to remember they're there. Remember they're a really important part of our diet. For some people it is just experimenting with porridge and then doing mixed porridge. It doesn't have to just be oats. You can have an oat, barley and quinoa porridge. So um yeah, it's like just once we get those food groups in, then we're really it's easy to get to 30 grams a day or beyond. And as I said, the the studies and the data we have, more than 30 is good. 30 is kind of the the starting point, isn't it? Yeah, yeah.

Dr Rupy: I mean, like it's interesting, we develop, you know, recipes every month, we do about 20 or 30 now. And we have sort of developed hacks or strategies around introducing fibre at every opportunity for all meals, whether it's breakfast, lunch or dinner. And I think ensuring that you're getting that core fibre source every meal is really important. And the simplest ways to do that are some of the ones that you've mentioned here. Really experimenting with the diversity of grains. Pearl barley is one of them, freekeh is up there, quinoa, pseudo grain, but you know, everything's adding. And then the lentil and bean strategy, we're trying to get, I mean, we literally just did a salad yesterday and it's a chicken salad, which is generally quite low in fibre, but when you start introducing like a whole grain into that and then puy lentils, you've increased it to like, you know, half of what the recommended amount is per day in just one meal. And so it's, you know, and it's satiating because of all the mechanisms that we've just talked about in terms of stretching the stomach and the hormones as well that are secreted from the from the digestive tract. Um so it's yeah, it's it's incredible what you can do by just adding a few key ingredients to your meals that bump up the fibre.

Dr Federica: And once you have them ready to go, you just it's you just add them in, you don't have to think about it. And the parboiling for me is an unlock. So people who really don't like to cook or don't know how to cook, having parboiled lentils and parboiled spelt, I haven't seen parboiled barley yet. I'd love that.

Dr Rupy: I haven't, I've seen it in a mixed grain. So there's like a product where they have a mixture of like four different grains. I think it's Merchant Gourmet. No affiliation with them, but it's pearl barley, it's like rice, it's something else and it's like, oh great.

Dr Federica: So you know, having that there, if that's going to help you to achieve this, amazing. And when you combine whole grains with pulses, magic happens in terms of the amino acid profiles, right? So all plants contain all the essential amino acids, but the profiles are different according to the food group. And when you combine pulses with whole grains, you get that balancing out of the amino acid group. Stunning work. And it's why so many traditional diets combine them. Like, you know, across the world wherever you go, it's like, oh, whole grain and pulse because it delivers on this brilliant amino acid profile, protein, protein quality, right? Which is where my heart is at now. It's like, how do we help people achieve the best protein quality in their diet? And that is one of the ways where it's just so health promoting. It's brilliant.

Dr Rupy: So we've talked about whole foods as it relates to fat loss, fibre as it relates to fat loss. You mentioned amino acid profiles. How important is protein and getting core protein in your diet when someone is trying to lose weight?

Dr Federica: Yeah, so I think protein is is of course essential for good health. It plays so many critical roles, right? Not only in muscle maintenance, bone mineral density maintenance, but also like our entire immune system relies on protein. If you're someone who struggles with chronic inflammation, your protein needs are going to be higher because you're constantly using protein. There's lots of different things to consider with protein. I think where the issue with protein is that most of us are getting enough. So like the average UK adult gets around 1.2 to 1.3 grams per kilogram of protein per day for their body weight per day. And so it's less about are we getting enough of it and it's more about where are we getting it from? So it's this quality idea. Now with weight loss specifically though, hopefully after this conversation you won't be restricting your food too much. But if you are restricting your food or if you're taking medications which means your appetite is suppressed, then getting enough protein becomes paramount because if you're drastically reducing your caloric intake, then and you're not getting that protein amount, then you do run the risk of losing muscle mass. And muscle is essential for metabolic health. And your bones are pretty important too. Like you don't want to age with lower bone mineral density because that then puts you at higher risk of breaks. So the there's like a nuanced conversation with protein where if you're somebody who's looking to achieve healthy weight loss and you want to retain your muscle mass but lose fat, because that when we talk about weight loss, that's what we're talking about. Like nobody wants to lose muscle mass and bone.

Dr Rupy: That's why I'm specifically like saying fat loss.

Dr Federica: I enjoy it. It is it's about fat loss. And and maybe we'll touch on this, but like, you know, fat is an organ and it's a very live endocrine metabolic organ. And so it's it is really about eating in a way that helps us to get rid of the fat, excess fat that we don't need to store right now, but maintain the other tissues that we want. So when we get to like this reduced appetite, reduced food intake, then we actually need to focus on those higher protein foods because we need to get them in before you stop eating. Otherwise, we don't have a store for protein and your body will just use your muscles. And losing muscle is actually fairly easy. Regaining that lost muscle is actually quite hard. So we need to balance the this is what where nutrient density comes in really. And I think for me, protein is part of nutrient density. Now, also, we are exceptionally good at absorbing protein, especially before the age of 65. Our body, our systems really primed to like be efficient at this because it's so important. So I think it's also important to remember that as long as you're eating enough of the foods that are a good quality protein source, your body's going to do a good job of absorbing and using it. So what I what I see a lot is especially in the younger people is this obsession with protein where protein is above all else. So the reason why I am careful with how I speak about protein and I I want to reinforce the fact that unless you're appetite is suppressed or unless you're drastically restricting your food, you probably don't need to worry about it is because once people start fixating on protein, everything else falls off and it just becomes I want to make sure I'm getting enough protein. Also, I think it's important to point out, this is very important. If you want to maintain your muscle or grow your muscle, the biggest lever is resistance training. Like so there's, do you know Professor Stuart Phillips?

Dr Rupy: Yeah, yeah.

Dr Federica: I adore him, right? And his he's probably the leading expert on protein at the moment in the world, right? And his all of his research, he's like, if you're the resistance training is the cake. The protein is the cherry on the cake. So if all you're doing is eating protein and you're not doing any resistance training or lifting weights, you're not doing anything to preserve or grow your muscle mass, basically, right? So that's really important. And also we need to remove this sort of weird um fiction that there are protein anabolic windows that you have to get 20 grams for breakfast, 30 grams for lunch. We have like our our window for protein is about 36 hours. So as long as you're getting your protein throughout the day, you're going to be good. And as I said, unless you're restricting, you're probably already getting enough of it. So let's focus on the quality. Legumes, nuts and seeds, whole grains, tofu, soy products, tempeh, fantastic for protein. And then when we think about animal derived proteins, um I've I've created like a protein pyramid for my teaching where we talk about sort of, you know, next level up is fermented dairy. So you have the yogurt, you have things like cheeses, hard cheeses, fermented cheeses, and oily fish. They're really, oily fish three times a week, really good for you. And within that you can include some shellfish as well, which has some omega-3s and has some really great micronutrient profiles. Then there's eggs and chicken, like less frequently. I mean, I can't believe how popular eggs have become. Like I actually one of my research projects was on how eggs can help to reverse malnutrition in children in Nepal. Like I'm all for eggs, right? They're great. But no one needs six eggs a day. No one does. Um so eggs and chicken like a couple of times a week, you're good. And then right at the top you've got red meat. And I think, you know, we could talk about red meat and it's not necessary for human health. It doesn't you don't have to eat it. But if you do want to, there are different types that are maybe going to be a little bit better for you or a little bit better for the environment, but it really shouldn't be like a central part of our diet week to week. Um and that's just according to the data and I'm sure there's people out there who feel that it's great for them and they want to eat it eat it more often. So I you know, as a reminder, this is just this is population advice. Um but certainly for the data we currently have, like a diet that's very high in red meat does increase your risk of type two diabetes, cardiovascular disease and endometriosis in girls, which I think is an important one that is often missed. Um so that's my sort of protein pyramid. So let's focus on the combination of plant proteins that we spoke about.

Dr Rupy: Yeah, yeah. I just to reiterate, I think you know, amino acid profile, you can absolutely get from plants, particularly from diversity. Big fans of soy and tofu and tempeh here, these fermented um uh bean or legume based products because tempeh is a fermentation process, so you can tempeh anything. Um and you know, the density of protein that's available as well is really comparable to that of chicken. So you don't need to have any of those animal based products. It's great to get some variety in there. I think day-to-day people would struggle in in some cases just relying on soy and and tofu. But getting a good mix, I think is great. And I agree, I think there's a real focus and mismarketing around protein to the point where if you look at the protein number on a packaged item, you immediately think that it's healthy.

Dr Federica: Oh yeah.

Dr Rupy: When it's not got any fibre in and it doesn't have any of the extra nutrients that we've been talking about, which are really good for fat loss. Um and it's lacking that nutrient density. So I think there needs to be a re-education about what a quality protein is and how you can have high protein, high fibre, high whole food diets as as part of your, you know, your daily strategy.

Dr Federica: It's the protein package, right? So it's this idea of what are you what are you getting with that protein? So when we're thinking about some of the foods we've meant, let's take oily fish. That protein package is delivering omega-3 fatty acids, it's delivering iron, it's delivering protein, good quality protein, and micronutrients like iodine, zinc, right? So that protein package is great. Then you go to like a high protein ice cream. And I'm like, guys, like it's just health washing. And you know, it's not it's it's there's data, like people will pay 20 to 60% more money for the same product with a high protein claim on the pack. And in terms of behaviour research, people will take a high protein claim on front of pack as a sign of healthfulness of the product. This is something I am very passionate about. If there's a product that has a front of pack claim that is either high in protein, only 99 calories, any of those like fancy, they're usually colourful in a wheel or whatever. Those are marketing tools. They're not health promotion tools. And so people I think sometimes get them conflated with things like the traffic light system, which is supposed to help with healthier food choices, but problems there, but whatever. Um you know, people think that the front of pack marketing claims are guides for their health. No, no, no. They're guides for profit. Ignore them. And like, you know, if you buy a floret of broccoli in the supermarket, there is no like high in micronutrients, low in calories.

Dr Rupy: There should be though.

Dr Federica: Well, but no, but I'm like, actually no, that's how we can distinguish them. Maybe they should, but you know, there's not enough of a profit margin for them to bother.

Dr Rupy: There isn't. And I think uh in defence of some foods and some packaged foods that are probably utilising some of those tactics that have been uh misappropriated by foods that are trying to masquerade themselves as health foods. I think some of the newer sort of brands out there are actually using that labelling technique, but when you look at the back of pack, they're actually really, really good or they're doing the best thing. And I think there's going to be like

Dr Federica: There's like a there's there is attention now because I saw a lentil, a packet of lentils recently that finally said high in fibre. I was like, hallelujah.

Dr Rupy: Totally. Yeah. And you've got loads of brands like, you know, M&S and and and other own brand labels that actually have done a good job of increasing nutrient density, increasing fibre. But then also using the same sort of like, you know, rings and you know, this is high fibre, high protein, all the rest of it. So it it's a murky world and this is where I think we need to help people distinguish what is a healthful product versus a less healthful product and have that health reflex of looking at the back of the pack and recognising labels.

Dr Federica: But also look at it. Add it to its core. Is it a junk food? Is it a biscuit, a chocolate bar? Is it some sort of cake, ice cream? If it is, then the front of pack claim is just trying to give you the illusion. I mean, there's so many ice cream brands that do that now where it's like and you're just and it's just just have the nice ice cream. Like just just get the one. So because it's just it is an illusion. It's not helping. So there is that you're right, it's about empowering people to take a step back and be like, okay, this is confusing my decision making. We know there's data it confuses us. So just take a step back and be like, what is this product? What role does it have in my life to improve my health or help me achieve my fat loss goals, help me achieve a healthier weight overall. Like what is it going to play a role in that or am I just being misled by this pack claim? And then don't give them that power. Take it back. Put your money back in your pocket.

Dr Rupy: Yeah, like a high protein cereal is still cereal, a high protein ice cream is still ice cream. So so don't be misled. Okay, so we've talked about the sort of food first approach without calorie counting to uh help people with fat loss, making sure that you're getting good quality whole foods, a full complex of uh proteins from good quality sources, fibre. Anything else that we've missed?

Dr Federica: I think healthy fats have to are really important for this. So fats do play a really great role in satiety and also in health. Like we need we do need healthy fats in our diet. You feel pretty rubbish if you don't. So uh and I we are moving out of this low fat era that was pervasive in like 80s, 90s, early 90s. So remembering that fat is not all equal, healthy fats from it is mostly from plants. So things like avocados, nuts and seeds, extra virgin olive oil, olives themselves, and then oily fish, they play a really important role in our health overall, in making sure we absorb micronutrients that are fat soluble. So if you don't have the fats in your diet, it's actually hard to absorb enough micronutrients. And also in ensuring that we can create the adequate amount of hormones and that we can create like the oils we need for our skin, for example. It's amazing um how many people that have a low fat diet don't realise that their low fat diet is actually exacerbating their skin conditions. It's really interesting to me. So we do also have a pretty big problem in the UK with uh a deficiency in omega-3 fatty acids. So the estimates range uh from sort of maybe 50, 60% of the population to as high as 80% of us, it depends on which analysis you look at, may not be getting enough omega-3 fatty acids. And they are essential fatty acids. We can't make them ourselves. Our liver is really cool, it can make lots of things, but the essential things, essential amino acids, essential fatty acids, we can't make. And so there is this like real hopefully a a push and a drive to encourage people to get more omega-3 fatty acids. Now, there's a big concern around sustainability of fish. So I it's worth saying there's really good algal supplements and there are fish brands and companies that do source their fish responsibly. You don't need lots of it, two to three portions a week. Um and you know, the fats, the omega-3 fats, the ALAs that are available in nuts and seeds, they're also great. They just the conversion of ALA to DHA and EPA is just not that efficient. So that's why you kind of need to have either both the oily fish and the nuts and seeds or the algal supplement and the nuts and seeds. So that's something really worth pointing out. And there's some really cool research that has come out of a group of scientists at Queen Mary's that have found that specific long chain fatty acids directly interact with the enteric cells that produce GLP-1 and PYY. And if you feed those, preferentially feed those cells with a combination of long chain fatty acids, it increases endogenous, your own production of GLP-1. It's so cool. So fatty acids, healthy fats need to be part of the picture. Um and which is also really important because of their anti-inflammatory effects. So omega-3 fatty acids in the liver love each other. And we, you know, we haven't really talked about the mechanisms of fat loss, but chronic inflammation really dampens our body's ability to lose fat, to let go of fat from fat cells. So and also for our fat cells to switch between white and brown. So we need to help reduce generalized inflammation. And by the way, what we just talked about, fibre, high quality protein, whole food diet helps with that already. But I have to say like omega-3 fatty acids play a a special role for that as well. So worth worth looking at that.

Dr Rupy: Definitely. And and in terms of other quick, well not quick wins, but other wins for people who perhaps don't have the capacity to change their diet entirely. Meal timing. What role does meal timing play for fat loss?

Dr Federica: Yeah. So I'm going to wrap two things up together. Meal timing is important, but not in the way people think. So I think a lot of people think they have to fast for like 18 hours and then only eat six hours. Actually, a lot of the research we've done, but also other people's research shows that eating, shifting your eating window to earlier in the day is helpful for fat loss. So if you're somebody, now this I have to sort of um say this, if you're someone who really hates breakfast and doesn't want to eat breakfast, please don't force yourself, right? But if you're experimenting or you like breakfast, for example, shifting your eating window earlier to finish eating earlier and eating window of 10 to 12 hours, so nothing crazy. We don't want four-hour eating windows, six-hour, it's really hard to maintain and it's very anti-social, which, you know, social health and uh reducing anxiety and stress is an important part of fat loss, really important. So if you can shift your eating window to a bit earlier and have a really nutritious breakfast, oh my gosh, those are two magical unlocks for fat loss. A lot of people skip breakfast hoping it would help them lose weight and lose fat and their metabolism. No, no, no. It's actually the opposite. So especially in the first half of our lives, we are much more insulin sensitive in the morning. Our circadian clocks wake up and one of the first things that, you know, once your cortisol's gone up and you've got out of bed, your blood pressure is high enough not to faint, it's great. And insulin's being released. We are most insulin sensitive in the morning. So eating a nutritious meal in the morning, and morning is like loose, pre-midday, right? Depends when you wake up. So we have to we do have to tailor this advice to people's individual lifestyles, but if you think about your 24-hour clock and when you wake up and go to bed, the first half of your day is the best time to have a really nutritious meal. You're going to absorb the nutrients better, you're going to get that protein into your muscle better, you're going to because also insulin is not just about sugars, okay? It's an unlock for nutrient absorption into tissues and you're going to store those sugars, store them away more efficiently. So try to shift your eating window earlier. Certainly from the analysis we've done on eating window, pre 9:00 p.m. dinner is kind of ideal for most people. So if you can finish eating by then, great. And then have your breakfast when it makes sense for you and your lifestyle and what you're doing. Try to keep that eating window 10 to 12 hours. So it might be 9 to 9 or it might be, in my case, you've got young kids, we eat early. You know, I'm sort of having breakfast by 8:00 and I'm finishing my dinner by 6:00, 6:30. Um and really begin with breakfast. Overhauling your entire diet is quite daunting. So break it down. Start with your breakfast, make that your win of the day. Most of us, 20% of our caloric intake comes from breakfast. So it's quite a big chunk of your diet. Get that right. You know, experiment with your whole grains and adding in healthy fats, nuts and seeds, like get get that sorted, get that really well. And then once you have that in place, you're probably going to have more energy, you're going to be more satiated in the day, you're going to find it easier to think more consciously about your decisions on lunch and snacking because you're not starving, right? Um and you've already started your day with some really good nutrient density. Because I guess one of the big concerns with um you know, the kind of inflection point we're at now where we have access to these drugs that lower our appetite and we have this food environment which is full of not very nutrient dense foods, is that we we have this kind of underlying micronutrient deficiency for a lot of things in in our population. The fibre deficiency is like the massive red flag because it shows us that we're not eating the nutrient dense plant foods that contain a lot of these micronutrients. And then when you start to look at the layers, it's like, oh, you know, 40% of menstruating women under the age of 26 are iron deficient. That's a bad thing. Oh, and like between 60 and 80% of us are omega-3 deficient. Then you look at folate and it's a disaster because we don't fortify with folic acid in this country yet, although it's supposed to be happening soon. Then you look at iodine because again, we don't fortify our table salt. And it's like, so public health interventions have been a bit lacking and we have a diet that's not supporting these micronutrients. So we have this uh we we have to be really mindful that if we're trying to lose fat, whether with drugs or not, we need to make sure that our micronutrient intake from nutrient dense foods is actually supporting our health as well. But we don't need to panic and go to boots and buy all the supplements. Because these micronutrients are in our food if we eat nutrient dense foods. And then I'm not anti-supplementation. If you have a deficiency or if you follow a vegan diet, please take B12. Like there are certain things. But but we are we there is this real double burden of malnutrition, as we say. It's like you have people, a majority of the population, adult population is overweight, but at the same time, quite a large majority of the population is lacking in key nutrients. So we're overfed and undernourished. Um but if we go down the route of increasing our nutrient dense whole foods, we tackle both.

Dr Rupy: Yeah, yeah. I love what you were talking about earlier when we were talking about whole foods in that to lose weight or lose fat specifically, it's really about eating more of the nutrient dense stuff. So the nuts and seeds, the dried fruit as well as fresh fruit, the greens, the, you know, the whole sources of fibre and protein that we've been talking about and healthy fats. It's yeah, it's super important. Um and more people need to recognise that as a solution, which is kind of counterintuitive as a means to actually improve their their weight. Um I want to switch gears now into perhaps some of our listeners thinking, Dr Fed, I've done all these things that you've told me to do. I've eaten my whole foods, I've got lots of fibre in my diet, I eat healthy fats. I'm still overweight. I'm being offered a weight loss drug. What do I need to know before, during and hopefully after I stop said drug?

Dr Federica: Yes, really important question. Thank you for asking. So 95% of the millions of people who access GLP-1s in the UK do so through private prescription. This is an important point because if you access it through the NHS, you have a full tertiary service. You get psychological support, you get nutritionist or dietitian support, and you get exercise support. So those 5% of patients who are accessing the drug through the NHS are within a real lifestyle medicine structure. Okay. These these drugs offer an adjunct to the lifestyle changes we've discussed. So they are really powerful medicines that have are really transforming metabolic health care, right? But in all the guidelines, in all the clinical trials, they are delivered alongside a full nutrition, exercise and psychological support intervention. The reason I wrote the book, The Appetite Reset, my new book, is because of that 95% of people who are accessing these drugs without any of that infrastructure for success. Even more worrying are those who are accessing like TikTok compounded versions which aren't even safety checked. Okay, so please don't do that. It's like not the same thing. It's really dangerous. Um now, why is it important to think about this before as well as during and after? So it's not just about changing your diet once you've started the drug, okay? What's really clear from the evidence and the what we understand from the physiology and we've discussed with the gut and the gut microbiome role, is that patients or people who prepare their gut, prepare their liver and prepare their pancreas for these drugs have much better outcomes. So the pre-treatment is really critical. If you're thinking about taking these drugs, a bit like back in the day when bariatric surgery was the only option, right? You wouldn't you're not allowed to get bariatric surgery without prehab because it just wouldn't work. You can't do that. And of course, surgery is very different. It's invasive and there's a physical recovery to it. But think about it in the same way. So if we if we are taking a drug like a GLP-1 or the dual agonists, soon to be triple agonists, when these drugs are acting in a system in your body, if the system in your body, specifically the gut, liver, pancreas axis, right, which then feeds back to the brain because really it's all about brain signalling, that's the crux of it when for the food behaviour anyway. If that system is broken or is damaged or is really struggling, the drug's not going to be as efficient. Like simple as that. So if you you want to give yourself the best chance that you're going to have the desired outcome of the drug, right, at the lowest effective dose. Because that's the goal. The goal is to make your effective dose as low as possible. It reduces the side effect risk and we think, so according to like the clinical trials published so far, it helps to uh maintain treatment, sort of how people stick to treatment. So prehab for your gut, your liver and your pancreas, the advice is the same for all three. They're basically symbiotic. They work together. So if you're feeding your gut well, your liver is going to be happy, your pancreas is happy, everyone's happy. And when the drugs intervene, when the drugs are added to that picture, they're added to an a system that works. So the analogy I use in my book is because my husband, he loves cars. I always think about cars. Is if you have like a race car, like a, you know, a Ferrari or something, and you're like, that's the drug, like it's all ready to go, it's shiny, it's new. And your road is like potholed and unpaved. It doesn't matter how good your car is. It's going to be a tough ride. It's a good analogy this. Thank you. I'm enjoying this. So thank you for that. So the smoothing of the road ahead comes from you preparing yourself, your body. Now, also, it's very good to get these dietary habits in place before you start the treatment because when you start treatment and you may suffer side effects and it may impact your your mood as well, you already have the framework in place. You don't want to be reaching out for the framework and setting it up when you're not feeling great. So do that beforehand. It can increase the chance of the uh drug having the desired effect. It decreases that risk we spoke of of having micronutrient deficiencies worsen. So if you're someone who has been offered these drugs and your diet is quite poor at the moment and you're maybe already micronutrient deficient, we really don't want you to take a drug that then lowers your food intake further and puts you at real risk of micronutrient deficiencies that have health consequences, right? So we need to level the playing field before we reduce your appetite to make sure that nutrient density is already part of your playbook and that we've corrected any micronutrient deficiencies that were there. During treatment, so the people who do then choose, um I think the number one thing to remember during treatment is that overwhelmingly the side effects are gastrointestinal. So it's your gut that's going to give you issues, whether it's constipation, nausea, vomiting, pain, like gastrointestinal issues are the biggest issue, heartburn. And guess what? The best way to treat them is with your diet. So the best way to reduce gastrointestinal side effects is to modulate the diet. And a lot of people don't know that. So they're like, maybe I should take some reflux meds and acids over here. And I'm not saying sometimes pharmacotherapy is good. But actually the best way is to reduce all of them is to look at your diet and your hydration. We haven't really touched on hydration here, but it's funny because people worry about water. They're like, am I drinking enough water? And you see them walking around with these huge cups. It really isn't a problem for the majority of the population. But in GLP-1 receptor agonist medication, actually hydration is something to think about on top. Make sure you're getting enough water. Um because your thirst response is dampened too. So you've got

Dr Rupy: I I don't think people realise that.

Dr Federica: No, no, they don't. So hydration is one of the main pillars for during treatment, okay? So making sure you're getting enough water uh or green tea or whatever, like whatever your fluid of choice, as long as it's not a sugar sweetened beverage because then really what are we doing? But hydration is important. So during treatment, your diet is your best tool to reduce your gastrointestinal side effects, which are the main ones. And also your diet then becomes incredibly important at achieving what you're trying to achieve, which is this change in body comp. We're not trying to lose our muscle and our bone and our fat. We're really trying to preferentially lose fat mass, retain muscle mass and retain bone mineral density and and bone strength. And it is doable. So there's a lot of fearmongering online. I have to say, I I saw last week it was like, Ozempic dissolves your bones. And you know, a few months ago it was like, Ozempic kills your muscle. It doesn't. The thing with these drugs is that they they are medical malnutrition, right? They cause the same effects as a famine but with drugs, which sounds terrible if it's mismanaged. Like that is a real risk is that if it is mismanaged, that's what we're doing here, right? So any kind of starvation, malnutrition will result in a loss in fat mass, muscle mass and bone mass. That's what happens. Your body is doing what it can to to get what it needs. Now, what's really cool is during treatment with these drugs, if you have this real 360 approach and you understand the importance of pulling the levers that means that you lose the fat but you retain your muscle and your bone, you do it. Now, again, resistance training is the biggest lever. If you're not resistance training and you're eating adequate protein, you will still lose muscle mass. So unfortunately, if you don't like resistance training, this is going to be hard because it's it's three times a week, three to four times a week resistance training, structured resistance training to retain muscle mass.

Dr Rupy: And this this was the regimen that they were using in some of these studies.

Dr Federica: Yeah, and also it's the official guidelines from all of the sort of national medical boards across UK, US, EU, yeah, you know, they're all this is how you do it, right? Three times a week. And it's not like an hour of hardcore CrossFit. It's it's just structured. It can be resistance training, it can be fairly lightweight. It really depends where you're starting. But you have to do it. You have to stimulate the muscle growth. And then the protein comes in. So during treatment, that nutrient density, that prioritizing the protein package foods that contain protein plus other nutrients that we want, like fibre, omega-3s or micronutrients, whatever it is, are critical during the the treatment phase. And then another thing that's really important is to make sure you're working with your doctor or your provider of the medicines to find your lowest effective dose. I think this is becoming much more usual now to just not just up the dose for the sake of upping the dose. When you get to an effective dose that is seeing the change you want, stop there because you're then going to run a lower risk of side effects that really stop and hinder your progress. Now I go into a lot of detail on this in the book, but during treatment, having a very structured meal time approach as well, because you know, the problem is that people are like, finally I'm not hungry. We haven't talked about food noise, but the real unlock with these drugs for people who have been struggling with their weight all their lives and who have, you know, there is of course a genetic component to obesity and the genetic component to obesity is in the brain. And when these drugs suddenly silence the food noise that is happening, people are it's transformative. And so because of diet culture, the the trap is, oh well, I don't think about food, I don't need food, I'm not going to eat it. Finally, I can just go through the day without eating. Which can feel like a win if you have been struggling with that all your life, but actually it's not in terms of metabolic health and long-term health outcomes. So structuring your meal times, making sure you've planned ahead, making sure you know like, okay, I'm going to have breakfast at this time, lunch at this time and dinner at this time and these are the things I need to hit in terms of nutrient profiles, making sure I get this food right is really important at this phase, especially if you're someone who has had this unlock of freedom from thinking about food. The the the risk is that you just don't eat enough at all. So really important that you that that part of the approach during treatment is a very structured approach. It also helps to reduce things like reflux. So if you're making sure that your eating window is earlier in the day and you have plenty of time between your last meal and bedtime, because GLP-1 receptor agonists slow gastric emptying, they slow the actual motility of the gut. If we're eating too close to bedtime, you know, reflux is much more likely to happen, for example. So structured, nutrient dense. And then post treatment, because we know that about half of people, 60% of people that are on the drugs come off. And the reasons for that is a variety. So access, people just can't afford to keep paying for them. Um side effects, they just don't really like the side effects. And we've talked about gastric, but I've worked with people who have terminated them because of the side effects on their mood and their pleasure of life. So there's some signals that anhedonia is part of this. Um so you start to enjoy things less and people actually don't want that. So those are the two main reasons people stop um taking these drugs. And so then the thing is is that when you stop taking these drugs, appetite returns and your homeostatic system, your body's like, whoa, we need to like get this weight back because our weight set point is still over there, especially if you haven't been on them for very long. And now we need to, now the famine is over, we need to replenish, right? So uh two-thirds of patients regain the weight lost. Two-thirds. Yeah. Wow. And then the final third regain some but not all of the weight. Um but then some some of the longer term studies are now indicating that there is like a sizable portion of patients that never regain the full weight, which is good. So um and then those of those who regain the weight, about half of them then go back on the GLP-1s. So whilst these drugs aren't intended as a on off, on off, on off, they sort of are intended as a lifetime prescription for people with obesity um and metabolic conditions like type two diabetes, um and now increasingly complicated cardiovascular disease. The reality of how people take these drugs in the real world is that they do come off them and then they might come back on them later. So in the post-treatment phase, we have to focus back on, okay, let's really amp up our natural satiety signalling. It's not going to replace the the drugs, okay? The drugs are like 100 times as strong. But let's do the best we can to eat high volume, high fibre foods that are going to activate our endogenous satiety signalling as much as possible, keep us satiated and feeling full for longer. And then making sure that we're still really focusing on the resistance training and you know, often with the post-treatment phase, that's where increasing your walking, your like your energy expenditure for daily daily lifestyle, so not the gym, basically. That's where you get a bit of an unlock in maintaining the healthy body composition. Sometimes there is, as I said, like weight regain and fat regain. But I've certainly seen and uh you see success with individuals who can titrate off gradually, ideally that is so much better for maintaining the weight loss and the and the fat loss. So if you can titrate slowly off and then adopt this post GLP-1 sort of nutrition approach which focuses on highly satiating meals, that seems to really help with then maintaining a healthy body composition and not having this yo-yo effect uh between treatments or I mean, I've got a a handful of patients who have successfully titrated off, stayed off for two years now without the need to take the medications again. So it's doable. It's not impossible, but it needs a real structured approach and it needs a commitment to to continue that lifestyle. Um but you know, weight set point can change. It just takes some time. It takes a long time, yeah.

Dr Rupy: I think it's really important because prehab uh I think it is within the sort of vernacular of bariatric surgery like you pointed out. Um but I don't think a lot of people are thinking about preparing themselves for going onto a drug that is comparable in terms of the impact to surgery. How long should that prehab period be for?

Dr Federica: Yeah. Ideally, 60 to 90 days. So like two to three months would be and again, depends where you're coming from. If you're somebody who has a really poor diet, very low fibre, erratic eating schedules, it's going to take a bit longer. If you're somebody who already has a really good diet, actually, um it might need less time and it might be more around the structure of like meal timing and exercise, right? But the prehab is there to get you into the routine that's going to see you succeed through treatment. So how long depends on where you're starting from.

Dr Rupy: In terms of supplements, is there a role for supplements when people are on these meds?

Dr Federica: Yes, I think that targeted supplementation is an is a tool, right? So what I would say is that in some populations like older older adults and in people who have vegan diets or have to restrict their diet for any other reason, a micronutrient supplement can be a really easy way to just have give them a helping hand. Now if you follow a vegan diet anyway, you'll be supplementing with some key nutrients. Um so I think there is a role for supplementation, but it needs to be targeted and a big red flag here is these sort of GLP-1 supplements which are just popping up like mushrooms. Right, okay, yeah, yeah. You know, just there are evidence-based supplements. I have I have in my book I go through like a table of the ones that are evidence-based and you can get from your pharmacy. Um please don't fall for sort of the marketing of special GLP-1 boost supplements like they're unregulated, not tested in the population that they need to be tested for. So targeted micronutrient supplementation that is evidence-based, there is always space for. Um but don't fall for magic potions that are being sold as a miracle.

Dr Rupy: Okay.

Dr Federica: They're not.

Dr Rupy: Yeah, yeah. I think you what you said right at the start of this uh segment around 95% of the medications being uh private is really worrying and I think that's why exactly your book should exist to to help a lot of people that can fall uh prey to the supplement marketing machine as well as the lack of the lifestyle interventions that are super important uh when people are on these medications. Um thank you so much. That was great. You're just you're awesome. I love your books. I love the energy you bring and your pod and everything. So it's been a pleasure having you.

Dr Federica: Thank you for having me. It's been really fun.