The Essential Role of Moving More and Eating Better with Robert Ross

James Hill:
Welcome to Weight Loss And, where we delve into the world of weight loss. I'm Jim Hill.

Holly Wyatt:
And I'm Holly Wyatt. We're both dedicated to helping you lose weight, keep it off, and live your best life while you're doing it.

James Hill:
Indeed, we now realize successful weight loss combines the science and art of medicine, knowing what to do and why you will do it.

Holly Wyatt:
Yes, the “And” allows us to talk about all the other stuff that makes your journey so much bigger, better, and exciting.

James Hill:
Ready for the “And” factor?

Holly Wyatt:
Let's dive in.

James Hill:
Here we go.

Holly Wyatt:
Today, we're diving into one of the most confusing and I think frustrating might be a better word. Question and weight management. What's the right mix of diet and exercise? Because people hear it all. They hear exercise is everything. I should really focus mostly on exercise. Or they hear exercise doesn't matter at all. Or you can't outrun a bad diet. Just lift weights. Just walk more. Just eat less. Just this. Just that. Just everything. And when people try to figure out what actually works for fat loss or belly fat or metabolic health, I think the messages even get more confusing because it's like, well, what's going to work specifically for that? And what's going to work specifically for me?

James Hill:
Oh, Holly, that's why we have the perfect guest today to help sort out all this.

James Hill:
For more than 30 years, Dr. Bob Ross has been studying this issue. He's a professor in the School of Kinesiology and Health Studies at Queen's University in Ontario, Canada. He's led some of the most important research in the world on how exercise, diet, and body fat interact, especially visceral fat, the fat that drives metabolic disease. He's answered questions like, can exercise alone reduce abdominal fat? How much does diet matter? Do you need both? Why do some people lose weight with exercise and others don't? Is weight loss even the point or is something else more important? His work has shaped clinical guidelines, public health recommendations, and the way we think about obesity. Now, Holly, you know that one of my major pet peeves are nutrition people that do research and ignore exercise and exercise people that do work and ignore diet. Bob does not fall into that trap. He's an exercise guy, but he's always incorporated diet into everything he does. He has really done some amazing studies. When I look at his studies, oftentimes I think, “Gosh, I wish I'd done that study.” So, Bob, we're thrilled to have you today. Welcome to the show.

Robert Ross:
Well, thank you very much, Jim and Holly. I'm honored to be part of your podcast and looking forward to our discussion.

Holly Wyatt:
All right, let's get going. Let's get a little bit, since this is, you are a rare bird, meaning you do study both, and that's very kind of rare in our field.

James Hill:
Which is too bad that that's rare, Holly. I mean, what does that say about our field?

Holly Wyatt:
Yeah, and I normally don't start out with this type of question, but I really am interested, kind of, what first drew you to studying the intersection? Why have you done something that other people haven't done, the intersection between diet, exercise, and obesity, rather than just focusing on one thing?

Robert Ross:
Well, it really started 35 years ago, I guess now, Holly. I didn't think that the narrative at the time that caloric restriction or diet was really the only way to reduce body weight as the primary outcome. Didn't make any sense to me. The narrative at the time was that if you exercise, you will not lose. So we just said, “Well, we'll test it.”

So we put forth the notion that we'll look at that. If someone reduces their caloric intake by 500 calories a day and exercises more at 500 calories a day, is there a difference? Will we really see only changes in obesity with the diet restriction or will exercise increase have some benefits? And as you know, we reported that, in fact, exercise was an excellent means of improving body composition and the risk factors that are associated with obesity. So it really started there. But as Jim was saying, it was very important in our studies to say that the people that were exercising were consuming a balanced, healthful diet, right? That the two were going hand in hand. So you couldn't just exercise and eat whatever you wanted, and you couldn't just diet and not exercise at all. Really, the two came together. And then, of course, the other observation is, well, what if you exercise and did not lose weight? Was that a failure? And of course, our studies, we were very attracted by that question over the years. We still are. We still pursue that. And of course, as you know, we've shown that being physically active while consuming a balanced, healthful diet is associated with a wide range of health benefits. And I really think that message has been lost. I think it's an empowering message.

I think it's a positive message for people, the many who struggle perhaps to lose enormous amounts of body weight. So we promoted both of those messages over the years.

James Hill:
You know, Bob, it really bugs me when I hear people ask the question of which is more important for weight loss, diet or exercise. Is that the right question? And how should people think about diet and exercise when they look at managing their weight?

Robert Ross:
To restate, I think it's very clear, Jim, and I know I'm singing to the choir here, that both are fundamentally important. Both have independent contributions to the health benefits associated with managing obesity, and both are integral. You're going to need to do both. And that is very challenging in today's society, isn't it? We basically don't have to move, and we can get along quite nicely, thank you, and eating well is more difficult than eating poorly. So here we have our two behaviors, and I know we'll probably get to this. Why are people struggling knowing this? We've known this for many years. Move more, eat well. That's understood by all your listeners. But we've created an environment that makes that challenging behaviors to follow. That's a stress for most people.

James Hill:
You know, Holly and I do a lot of work on weight loss maintenance, Bob. And we hear that people are out there saying, well, eat less and move more doesn't work. When it comes to weight loss maintenance, what we're saying is move more and eat more. The more you can eat and maintain your weight, the better off. And the way you do that is by being physically active. Food restriction is not a great long-term strategy for weight loss maintenance.

Holly Wyatt:
But it works well for weight loss.

James Hill:
For weight loss.

Holly Wyatt:
That's the key. I think you have to understand. You kind of have to understand both and how to understand what you do when you're losing weight and what you're doing to maintain it. But I got a question because I don't want our listeners to be confused. I know that you studied exercise-induced weight loss and didn't change their diet.

Didn't you do some studies where, like, let's say you can get it, you do 500 calories worth (and that may not have been the exact amount, you know), but you do some amount of exercise and you don't change your diet. Can you get weight loss that way? And how much exercise is required to do it that way? I think that's difficult. And why is it so difficult?

Robert Ross:
Well, guidelines, as you know, would suggest as much as 300 minutes a week of some type of exercise and that is associated with weight loss. I have no doubt that that's true. So if you followed the guidelines today and you did not eat more but consumed a balanced, healthful diet, will you lose weight? The answer is yes. We have numerous studies that show that. The issue is twofold.

One, it's not whether if you adopt physical activity, can you lose weight. The question is, the physical activity that you adopt, will you sustain that physical activity? And that's been the challenge, the long-term sustaining of that behavior change. So if you generate a negative energy balance with exercise, you will lose the weight. But I think your expectation has to be that you will change that slowly. That will not occur at the rate of which it would occur if you just eat less. And I think the narrative today for most adults who have overweight or obesity is they want to lose that body weight very, very quickly. And when they don't or they can't sustain the behaviors that are associated with that rapid weight loss, then, of course, they discontinue the behaviors and then they lose the benefit. So if you're physically active and you do not eat more, yes, you will create a negative balance. Yes, you will lose weight. That's the answer to the question. But when I'm speaking to the general public, Holly, what I like to say is it's unfortunate that the scale, the bathroom scale, has been the sole primary indicator of benefit with regards to efforts to manage obesity. I think that's really done us In the end, more harm than good. It takes our focus off what we should be concerned with. Are we reducing adiposity? Are we maintaining functional lean mass as we engage in these behaviors? Those are the questions I think we should be asking. And I think the really positive news is the answer to both is yes. Many people ask me, well, how should I follow if I don't look at the bathroom scale? How should I know? What's the easiest way to know if my engaging in physical activity and eating well is beneficial? And I say, well, check your belt or check your dress size. Yeah. If your belt is at the third position and you move it to the second, not good.

If your belt's in the third position and you're moving it into the fourth, give yourself a hug. Give yourself a hug. You're doing good things. This is very, very good. And don't be so concerned about what the bathroom scale is saying. That is just about one of the best things you can do in terms of managing obesity. So I think that's a very easy thing to do and a very simple message and one that I think, again, is empowering for people. Because you do reduce that belt size If you engage in physical activity consumed with a balanced diet.

James Hill:
Bob, one of the things that I see in the media out there is, well, exercise is not really effective for weight loss because when you exercise, you just eat more. What do you know about that?

Robert Ross:
We don't have compelling evidence, Jim, to really answer that question. It is true that there is some evidence that some people tend to compensate their exercise, the negative energy balance of exercise, by consuming a little more food. That may be true. I think the jury's still out on that, and there are some of my colleagues who would disagree. The reasons for that compensation are unknown, right? Why some people do and some people don't. There's hormonal, there's some very complex issues at the root of that, Jim. But I think that if we had longer studies that went a lot longer, we'd see that that compensation would be overcome. But that's an intuitive thought by me, Jim. I have no evidence to support that.

James Hill:
Bob, I agree. I don't think we totally know that. But the work of our colleague, John Blundell, has suggested that in most people, there is compensation, but the compensation is not enough to completely avoid the negative energy balance, that you get some compensation, but still the effect of exercise is creating negative energy balance. So, I think the jury's in favor of the fact that you're not going to completely compensate, at least in the long term.

Robert Ross:
No. Another issue with that, Jim, is we are so physically inactive now. That any degree, any degree of overeating, a couple of pieces of toast, and we're compensating for any increase in our activity throughout the day. And that, I think, underscores some of these issues here, that activities of daily living, just moving, have been reduced substantially over the years. And it's really contributing subtly, isn't it? It's a very subtle, and I think some of your work, Jim, has shown that very nicely, that just subtle increases of 100 calories or two in a day or over two or three days, but over years, and all of a sudden that the weight scale goes in the wrong direction and the belt position goes in the wrong direction. So it's most people, when they think of physical activity, I think Jim and Holly, they think about that structured, planned activity that you get special shoes and you go to a special place and you do special things. No doubt. If you're doing that, fantastic.

Holly Wyatt:
Yeah.

Robert Ross:
But I think if you look back four or five decades, very few of us did that.

James Hill:
Right.

Holly Wyatt:
We didn't need to.

Robert Ross:
It was just the activity of daily life.

Holly Wyatt:
Yeah.

Robert Ross:
Right? You came home from school, you threw your school bag into the house, and you went out and played. Why? It's not because you were so smart. It's because there was nothing else to do.

James Hill:
Now you sit and play video games.

Robert Ross:
Right. So now, what would I have done, Jim or Holly, what would you have done if you would have had 32 stations on the TV to watch or four TVs in the house and five video games and everything else.

James Hill:
I would have been inside too.

Robert Ross:
Yeah. So I think the point to your listeners is that it's those simple movement activities, 24 hour energy expenditure has been reduced substantially over the years, right? Because we don't need to move as much now to get through life quite well. And I think that's the part of the complex nature of the obesity problem that we know. I think now we know it's not just laziness on the part of people. It's not that people aren't aware. It's that we don't make what Kelly Brownell instructed me over three decades ago. The healthy choice is no longer the easy choice.

Holly Wyatt:
Yes, I agree with that. And I think people are starting to understand that that message. We've been working on that for so long. And I think people are starting to get it, understand how the environment, I think the key is we're not going to change. We're not necessarily going to take our environment and go back. Maybe we can make some changes to it, but we're not going back to where we didn't have TV or we didn't have, you know, so, you know, that's what we want. So it's kind of what do we do now based on the situation we're in? And I'm not saying we couldn't work on some environmental changes. I fully believe in that, but we're not going to go back. So we got to then think about what we're going to do now to translate what we know works, this getting more physical activity. And it brings me to a little bit different question, but one I really want to talk about because it's something we haven't talked about on the show yet is intensity. You know, we always say moving period is better than not moving. So I get that message, right? If you're not moving, to move is, that's a step up. But does intensity of the activity matter when it comes to how much weight you lose or where you lose the weight? Is there something about intensity that we might be wanting to start to entertain, realizing that volume or the amount doing something is first? But let's say you're doing that. Then does intensity come in or not?

Robert Ross:
Again, Holly, I think it depends on what you're trying to achieve. If a negative energy balance, if loss of body fat is the goal, if reduction of the belt size is the goal, then the evidence from randomized trials would suggest no. No, that it really comes down to caloric expenditure, and that's the primary driving force. So what would intensity do for someone? It might decrease the time required to achieve that caloric expenditure. So to make it simple, if I want to burn 300 calories, if I do it at a higher intensity, it will take me less time than the lower intensity. That is just laws of thermodynamics. That's true. Where I think it matters is, let's say, the goal of the person who presents with overweight or obesity Is to manage, perhaps, blood sugar or to improve fitness, cardiorespiratory fitness, the ability to do aerobic-type activities, then I think the jury's in, I think intensity does matter.

So for example If you were in my same example 300 calories and it took you half an hour at a higher intensity and 45 minutes at a lower intensity. And that was really important to you because time was a premium for you in your day then good for you. Do that. The body weight, the belt will probably be the same in both those people. However, what we know now from good evidence in the literature is that your ability to improve fitness, which is a very powerful predictor of morbidity and mortality, even in people with overweight or obesity, or to improve your ability to manage blood sugar or to attenuate insulin resistance, intensity does matter. So when we're speaking in our outreach programs to individuals, the questions about intensity, we address that the same way we would do any other form of physical activity. Is it a form of physical activity that you can sustain for a prolonged period?

The answer to that is really so much more important than anything else that we've discussed. So if they say, well, yeah, I can work at a higher intensity for six weeks. Well, unfortunately, you can't put the benefits of that in the bank. You're going to have to sustain that, right? Maybe choosing different modalities. Maybe you're working lower intensity one day than higher intensity. So really, the question can be answered the way we just have. But upstream of that to all of our outreach people is look long-term, what is the type of behavior that you're going to adopt that you can sustain? And I think that that's fundamental. And in the end, it might be some higher intensity, some lower intensity. But I think it depends on the goal of the person that you're working with.

Holly Wyatt:
Right. Because for me, the amount of time is critically important. And to be able to burn more calories in less time is going to be something that is going to be important for my individual plan looking at long-term. And that's where I think really individualizing this and recognizing what's doing what and what makes sense for you really becomes important instead of getting these goals that we put out there and we think they should fit everybody. And in my experience with working with lots of these people, that just isn't the case.

James Hill:
Bob, you've been a proponent of maximizing cardiorespiratory fitness, and it fits so well with what Holly and I talk about. We, in our book, and to help people keep weight off after they stop the meds, everybody focuses on diet, but we have a whole section on metabolism. And your metabolism, when you get overweight and sedentary, it's what we call sluggish. It's not working very well. And a low cardiorespiratory fitness, I think, is a marker of that. So if you increase your cardiorespiratory fitness, you may not see that at rest, but what you see it is out in the real world when you start eating and everything else. And what it does is to really optimize your metabolism. Does that fit with what your work had shown?

Robert Ross:
Well, it certainly does. I think it's the one trait that we have. So for the uninitiated, when we talk about cardiorespiratory fitness, we're talking about adaptations centrally in your heart, right? Your ability for your heart to do what your heart's intended to do. And then when it pumps blood to the rest of the body, the rest of the body, the muscles and everything become a lot more efficient at taking that oxygen and allowing you to do work. So slowly but surely, walking up the stairs, walking, jogging, walking the dog is becoming easier and you're not sure why. It's because that fitness has improved and it's one of the few traits that can tell us about those cardiovascular adaptations In response to physical activity. And it is such a powerful predictor of risk. And as you know, Jim, our good friend, my best friend in science, Stephen Blair, was a proponent of that and really did some seminal work and showing that even if you had overweight or obesity, if you had a very modest improvement in fitness, you had the same health risk as someone who might not have overweight, who has very poor fitness. And this is such a powerful message. So yes, central and peripheral metabolism is changing as a function of physical activity, and it's giving its attenuating risk, and that has absolutely nothing to do with the bathroom scale or your belt, as I like to say, the position in your belt. So a very powerful predictor. And I agree with your and Holly's message that that's a something that we want all your listeners to understand.

James Hill:
Let's look at visceral fat, Bob. I know you've looked at visceral fat. We've done several episodes talking about why visceral fat may be a better marker for metabolic disease and other kinds of fat. What do we know about exercise and visceral fat?

Robert Ross:
Well, we know that exercise is associated with marked reductions in all body fat, both your subcutaneous that you pinch and the visceral, that intra-abdominal fat that you can't see. It's quite remarkable, right, the magnitude of the reduction in that depot in response to very little exercise or very little reduction in caloric intake. It seems to be a very very responsive adipose tissue depot to exercise. So that's the good news and I think that the only way your listeners, again, are going to know. Well, that's really good news, how do I know? Check your belt. Again, if that belt is tightening, you can be absolutely certain. You don't know the degree to which the visceral fat is being reduced, but we have never seen in a population the waist circumference reducing and visceral fat increasing. I have not seen that in 35 years of studying bad depot.

James Hill:
When you compare diet versus physical activity on visceral fat, is it amount of weight loss or does exercise give an advantage over diet alone?

Robert Ross:
Well, exercise with or without weight loss is associated with marked reductions in abdominal obesity. That makes perfect sense, right? That's a very important observation. So, the waist circumference or your belt buckle is improving. Why? Because you're reducing both total and visceral fat. People will say, well, why then is the scale not telling me why? It's inconsistent with that. And that's because you're gaining subtle gains in skeletal muscle mass. So it's a win-win, right? You have an increase in the functional tissues. You have an improvement in fitness. You have an improvement, your ability to manage blood sugar, and all of this has occurred In the absence of any change in the bathroom scale. So exercise with or without weight loss is going to be associated with changes. Now, to be clear, exercise-induced weight loss is going to be associated with a greater reduction.

Holly Wyatt:
Right.

Robert Ross:
So that's good. But what we want to say is that's good. But if you're exercising without weight loss, that's not bad.

Robert Ross:
There's also benefits to that as well. It's win-win. And again, I think that's a very important message for all your listeners.

Holly Wyatt:
So I think when people get kind of confused is how much, so in that case, you're saying you're losing some visceral fat, you're losing some fat from your abdomen, but you're putting on some muscle or lean tissue somewhere. So the scale is a wash. What's the volume of that or how much are we talking about? Are we talking about 10 pounds or are we talking about two?

Robert Ross:
Well, in our studies, of course, you're not losing any.

Holly Wyatt:
Right but I'm saying the amount of the swap of fat for lean tissue that you're seeing that then makes the scale. You're saying there's some fat being lost in the visceral and there's something being gained other places that's not fat and muscle or some type of lean tissue gain so the scale stays the same. I want people to kind of have in their head how much is that. Are we talking small amounts? Are we talking a bigger amount? Because I think sometimes people get confused. Oh, I've put on 10 pounds of muscle.

Robert Ross:
Yeah. No. You're not going to see that for sure. It's very subtle, right? So exercise without weight loss, we'll see a 15 to 20% reduction in visceral adipose tissue. We'll probably see around a two centimeter reduction in waist circumference, right?

Holly Wyatt:
Okay, two centimeters. That's good. That helps them, I think, understand this a little bit.

James Hill:
But still, it's a big impact on health, that two centimeter. You don't need to lose 10 pounds of visceral fat. A small change in visceral fat is very important.

Robert Ross:
And that's why if I may, Jim, say and we've written on this and had editorials, I've never understood the concept of 5% being clinically meaningful weight loss. I think that distracts the listener from what's really important. When you engage in these behaviors, the two of them simultaneously, there is immediate benefit. You exercise one time. You improve your ability to manage blood sugar. So I think that if you lose 5 or 10% no one's ever said certainly you or I or Holly have never said that's a bad thing. But that's very difficult for a lot of people. So maybe the first step is prevent weight gain. Engage in these behaviors and gain the benefits of the behaviors because they are occurring. They are. It's absolute. Very positive.

Holly Wyatt:
This kind of leads to one of the questions I had thought about in terms of non-responders. So the question I wanted to ask you was, why do some people respond strongly to exercise while others seem to be non-responders? Well, one of the reasons maybe is what is a responder? Are you looking at weight? Are you looking at some of these other markers? But definitely in your studies, do you see people who don't respond as strongly? And have you been able to kind of untangle why that might be?

Robert Ross:
Yeah, two points. Yes, we have seen inter-individual variability. And there's not a researcher in their data that if they look at the individual data, they will see variability. There's no question. One of the reasons that's not very imaginative or sexy is because we don't measure certain traits all that well, right? And subtle differences between people are not really differences at all, right? But I think the other point that you mentioned, Holly, is even more important. We have never, if we look at a list of cardiometabolic risk factors and body composition measured by MRI (so we look at that very, very carefully), never is a strong word, but rare have we not seen beneficial responses cardiometabolically or body composition-wise for all of our people. There might be some variability and quite frankly, we don't measure some of those things very well. Right? I mean you take your body weight at 8am or you take it at 8pm and you can have a very different number on that scale. So it becomes difficult when you try to compare an individual response. That's a science in itself. But what I think the listeners should understand or it's important, I think, is that if you take the list, your metabolic risk factors, your cholesterols, your triglycerides, your sugars, your blood pressure, your body composition, your visceral fat, rarely do we see people not responding in several of those risk factors in response to physical activity combined with a balanced healthful diet.

James Hill:
So, Bob, the big thing in the obesity field right now are these new effective weight loss medications, the GLP-1-based meds. And what they do, they seem to work by having people being very comfortable eating less. They don't seem to do much on the expenditure or the exercise side. What's your thought about that? Any concerns over the fact that these are working on just food intake? Is it important for these people to worry about physical activity? What are your thoughts there?

Robert Ross:
I think, Jim, and I emphasize I'm not an MD. I'm not a medical doctor. I think that we need all the help we can get in the field right now. Because obesity prevalence, as you know, is increasing unabated worldwide. It's a crisis situation. So if an individual is struggling to be physically active or to consume a reasonable caloric intake and the GLPs work for that person, then good for them. I think that the evidence, my understanding is the evidence to date is showing, however, that there is concerning loss in functional tissues, skeletal muscle mass, and lean tissues. And certainly, without any physical activity, there's no improvement in the risk factors that are directly attributed to that behavior. So it's not that it's to me if someone was was prescribed a GLP-1 and they were experiencing weight loss, good for them. I think that's good but I would strongly advise there to engage in physical activity because right now we don't have an answer for the loss of lean mass and functional tissues that come, that seem to be associated with prolonged taking of the GLP medication. So certainly you're eating less and you're comfortable doing so, and there's understandable mechanisms that explain that. But if you're not engaged in physical activity with that group, two things. One, you might see a loss in the tissues that you want to maintain, and unless you stay on that GLP for the rest of your life. Right? You have not adopted, you have not sort of developed any of the behaviors that you're going to be required to maintain that weight loss.

James Hill:
Yeah, we talk about if you stop the GLP-1 meds and you're sedentary, you don't have a hope. You're going to regain the weight. The best thing you can do is while you're on the GLP-1s, increase your physical activity, increase your metabolic fitness, and that gives you a better chance of when the appetite comes back after you stop the meds.

Robert Ross:
Absolutely, I agree. Spot on. I think the GLP-1s too, from what I'm reading, Jim, are really widening the gap between the vulnerable and the non-vulnerable populations. I mean, the very populations that are at the most need, right? That struggle.

James Hill:
Yeah.

Robert Ross:
Right? To buy that healthful diet and to engage, to have the disposable income, to join the health clubs, etc.

James Hill:
And we still know that despite sort of the companies thinking of people taking these for life, people aren't buying into that at least yet. They're going on them losing weight and they're going off them, which is why we can't ignore lifestyle. The reality is when you stop the meds, you're very likely to regain the weight unless you have a plan. And increased physical activity has to be part of that plan. So I think the future is figuring out how medications and lifestyle are combined at the right time and the right places.

Robert Ross:
Absolutely. I couldn't agree more. And we can get on another related topic, but that's when the allied health professionals, the kinesiologists, the dieticians should be working in lockstep with the medical community so that we can provide the guidance and the follow-up and the behavioral cues for people to adopt and sustain these behaviors. So I agree 100%. It's good that we have a pharmacological strategy that might be associated with some reductions, and I'm hoping adiposity, not just body weight. But if those behaviors aren't changed, as you say, then we are in for long-term disappointment.

James Hill:
That's what we worry. It's going to be people losing weight and regaining it. And we've seen that movie play over and over and over, and it's not a good one.

Holly Wyatt:
I want to go back to one thing, though. And I can't believe I'm going to ask this question, but this is what I get to do. This got me thinking. Because I think Jim and I agree with most of what you're saying and the exercise in this improvement in cardiometabolic parameters and cardiovascular health. But let's talk about some data we have. People go on the GLP-1s. They do not necessarily, they don't have to, and many of them don't necessarily increase their physical activity. And they have measured cardiovascular outcomes, and they have seen mass improvement in those cardiovascular outcomes.

Robert Ross:
You mean fitness?

Holly Wyatt:
No, I don't mean fitness, but I mean measures of cardiovascular health have improved with those drugs enough that they even, you know, some of the indications are even going in that direction. So what's going on there? Because it's not through physical activity that the heart, the cardiovascular system is improving. So, and I can't, like I said, I can't believe I'm bringing this up, but I think it's kind of what's going on?

Robert Ross:
Well, that comes as no surprise, Holly. I mean, if we assume that the reduction in body weight in response to GLP over a course of time is associated with reductions in body fat, then you are going to get improvements in your ability to manage blood lipids and blood sugar.

Holly Wyatt:
Yeah.

Robert Ross:
But that's not the question I would ask. I would ask if you did a randomized trial, and you put someone on just the GLP, and then the GLP and physical activity, would you then see a synergy, right? That not only had acute effects that will be different, better than the GLP alone, but you've instilled behaviors that can be maintained post-medication. So it doesn't come as a surprise to me, Holly. We're not shocked that there would be an improvement in metabolic syndrome components in response to weight loss, be it diet-induced, exercise-induced, or drug-induced.

Holly Wyatt:
Yeah. I don't mean shocked, of course. But what I wanted to point out to the listeners, and if I was on a GLP-1 that I would be wanting to say is, okay, I have been on this drug, and yes, it's reduced my weight, and through that, it's improved my heart. And yes, I fully believe that you can do more and you want to do more. And the whole book we've written is about that kind of idea, especially if you're going to go off. But there is something about the medications that it's not just about weight. It has improved cardiovascular outcomes. And we have data to show that. And I don't think we can ignore that and not make the listeners kind of feel like, oh my gosh, I've not done anything for my metabolic status by being on these GLP-1s, because that's not true.

Robert Ross:
I don't disagree. I think the evidence is clear. That's true, and it comes as no surprise. I might use a slightly different word, Holly, and not say cardiovascular, but say cardiometabolic, and not to be nuanced, but when I think cardiovascular, I do think central. Heart. And I do think peripherally in terms of blood flow and the mechanics that are associated with improving fitness. The only way we'll see that with weight loss by diet or by medication is if you express the improvement in fitness by kilogram body weight. So not to get technical now but over many years dietitians say, well, if I lose weight, I improve my cardiorespiratory fitness. Well, you do if you express it relatively to body weight. That's true. And it might be easier getting up the stairs. But you haven't changed. Right? The structure. You haven't changed stroke volume. All the fancy things that we measure in the heart or the ability to consume oxygen. You just weigh less. So I don't know right now that we have any evidence at all with GLP. I don't know what the mechanism would be that you would improve cardiac output or that you improve a peripheral AV difference, the two components of fitness.

Holly Wyatt:
We have just things like stroke and blood pressure and cholesterol and things like that. And that's what I'm talking about when I say cardiovascular. I'm not really talking about that. So, anyway, I just wanted to bring that up because I think that's important for people who are on the drugs. And I always want them to start physical activity for so many reasons. But I don't want them to think that they haven't done something good for their health by being on the drugs.

Robert Ross:
No, of course not. And we started by saying that, Holly, that look, if people are struggling with changing behaviors the way that you and I would like them to be, then that's great that we have that. I say the same for hypertension. If you don't engage in those behaviors and you have elevated blood. Well, thank God we have a pharmacological strategies to reduce that risk factor. So that's a given.

James Hill:
Okay, Holly, we're approaching the end here. Why don't you go through some rapid fire with Bob and see how flexible he is to giving these answers quickly?

Holly Wyatt:
Okay. All right. Some quick answers. One myth about exercise you wish would disappear forever.

Robert Ross:
That exercise is not an effective way to manage obesity and related health risk.

Holly Wyatt:
All right. The most underrated form of movement for people with obesity.

Robert Ross:
I'll say resistance exercise, and I'll use that in the context of aging. So that's the most rapidly growing demographic is aging. And with aging, you have two problems. The waistline is expanding and the muscle is decreasing. So, we have this sarcopenic obesity. And I think resistance exercise should be a fundamental strategy, certainly in all age groups, but certainly in that age group.

Holly Wyatt:
Here's a good one. Goes right with that. If someone only has 10 minutes a day, what's the best use of it?

Robert Ross:
Walk.

Holly Wyatt:
Love it. One thing you wish the whole world understood about visceral fat.

Robert Ross:
It's not good.

Holly Wyatt:
I love how you're really just going to hit this quick, really right on. Last one, your take. Cardio, weights, or both? What's the real priority?

Robert Ross:
Both. Again, there are adaptations to both modalities that are unique to each other. If I had to choose one, if someone said, well, I'm 35 years old and I have overweight, obesity. If I had to choose one, I guess I would choose aerobic-type activity because that's going to be associated with the greatest energy expenditure in the short term. But as you and Jim have said many times, we want to do something about that lean mass functional tissues as well. So I would say both.

Holly Wyatt:
So, Jim, you want to hit one listener question?

James Hill:
Let's do one listener question. I lost 40 pounds two years ago through strict dieting and lots of cardio, but I've gained back 25 of those pounds, even though I'm still exercising regularly. I'm so discouraged. Why is it so much harder to keep the weight off than it was to lose it? What does the research say about preventing weight regain?

Robert Ross:
Boy, that's a tough one. I wish I had the short, snappy answer for that. If the person has continued If our listener has continued with the same exercise regimen, physical activity regimen, and when I say physical activity, I mean 24 hours. If that has not changed and the exercise, waistline, the dress size of the belt is increasing, then we have to look to something going on with the diet there. Somehow the person has subtly, over time, increased caloric intake and they may have to refocus.

James Hill:
Yeah, I think the important part is you've got to look at both. If you're doing the exercise, you've got to look at diet. If you're doing the diet and not working, look at exercise.

Robert Ross:
You do.

James Hill:
Okay, Holly, you want to do a vulnerability question?

Holly Wyatt:
Yeah. All right. I've got one. When your research contradicts popular beliefs, or I would say people's hopes, and it's not what they want to hear, basically, how do you navigate delivering the truth to those individuals?

Robert Ross:
We need to be sensitive to the challenges that face an individual who comes to me with overweight or obesity. I think we've moved now past the notion that people are simply lazy.

Holly Wyatt:
For sure.

Robert Ross:
That they haven't adopted behaviors because they just don't care. So I think you have to be sensitive to that and you have to be empathetic to the challenges that they face. The environment today does everything it can to make increasing physical activity in any way difficult. The environment does everything we can to make consuming a balanced, healthful diet more challenging than an unhealthy diet, cheaper. So we have to speak to the person to recognize the challenges. That it's not simple laziness. That it's a complex problem. In the end, is it true that we need to find a way slowly to increase physical activity And to consume a balanced, healthful diet? Yes. But I think if we do so recognizing the challenges and the barriers to the person, at the same time recognize the opportunities to empower that person, to tell them how engaging in these behaviors can reduce health risk without any change in that beam scale, I think that's empowering. I think that people would listen to that and would hopefully, hopefully begin to follow the programs that we might prescribe.

James Hill:
Okay, Holly, a quick sum up. The reason I like this episode is over and over and over, Bob has emphasized it's not just diet, it's not just physical activity. It's the interaction of diet and physical activity. But exercise does so many things. It can contribute to weight loss. It can contribute to a favorable body composition. We talked about the concept of cardiorespiratory fitness. This is something that comes with exercise, maybe helped by intensive exercise. It makes your metabolism work more with you in managing your weight than if you don't have high cardiorespiratory fitness. So we leave you with you have to look at both. Whether you're on the GLP-1 meds where you're not hungry and you're managing your diet, you still have to think about physical activity. If you're exercising, you have to think about what's the optimum diet to match your lifestyle. So Bob, thank you for helping us clear some of this up and we'll be back next time with more on Weight Loss And.

Robert Ross:
Thank you, Jim. Thank you, Holly.

Holly Wyatt:
Bye, everybody.

James Hill:
And that's a wrap for today's episode of Weight Loss And. We hope you enjoy diving into the world of weight loss with us.

Holly Wyatt:
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James Hill:
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Holly Wyatt:
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