Controlling hunger – part 1

Have you eaten a loaf of garlic bread, a bowl of pasta, and a dish of pistachio gelato and still felt hungry? Have you come home from dinner and then ate a bag of popcorn in secret to satiate you before bed? You’re not alone.

I hear these stories from people every day, and I’ve had some of my own. Your mind is telling you that you are full because you must undo the top notch on your belt, but your stomach is still complaining that it’s empty.

Some people continue to eat, sometimes all day long, until mere moments before they go to bed. They feel helpless and out of control, binging on foods they know they should be avoiding.

Then everybody knows people who are the complete opposite. Those people eat half a sandwich or a small salad at lunchtime and then declare themselves completely stuffed. And they’re not trying to be modest. They actually are completely full. They won’t eat more because it’s uncomfortable for them to do so. These people are often quite thin.

Many of our IDM Program clients have undergone bariatric surgery. Their appetites were so far out of control that they felt they needed invasive, expensive surgery to regulate their unruly bodies.

And despite all the promises of bariatric surgery to allow patients to lose weight and improve health, it fails almost invariably.

The stories are eerily similar. Initially, they lose some weight, but after several months the weight creeps back on. But worse, they feel that their appetite is just as out of control as it has ever been. “How can this be?” they ask despairingly. “I’ve had my stomach physically stapled to make it smaller!”

They misunderstand the problem with hunger. It’s not about the size of your stomach. Hunger does not occur because your stomach is too big. And if that is not the problem, then surgically cutting it smaller is not going to help.

Likewise, hunger is not about your willpower or self-control. You cannot will yourself not to be hungry. You cannot ‘decide’ to be less hungry. You are hungry or you are not.

What controls hunger

Your appetite is hormonally driven. That is what we need to fix. Not surgically rewiring our intestines. Not counting calories. If you don’t regulate your appetite on a hormonal level, you’ll never regain control no matter how small your stomach is.

We are hormonally driven to eat (we get hungry) or to not eat (we get full). If people are given dietary advice that makes them hungrier, then they’ll eat more. That’s not their fault, that’s normal.

What advice has been the cornerstone of dietary therapy for weight loss for the last 50 years? Cut a few calories each and every day by eating low-fat foods, because fat is very calorically dense. We are also told to eat six or seven times per day, or ‘graze’ rather than eating three main meals per day as all our ancestors used to do.

Sounds pretty reasonable. Here’s why it doesn’t work at all.

There are certain hormones that make us full. These are called satiety hormones, and they are really very powerful. People often imagine that we eat just because food is in front of us, like some mindless eating machine. That’s far from the truth.

Imagine that you have just eaten a huge 20-ounce steak. It was so delicious, you even ate a few extra slices, but now you’re completely stuffed. The mere thought of eating more nauseates you. If somebody set down another 12-ounce steak and offered to give you everything for free, could you do it? Hardly.

Our body releases powerful satiety hormones to tell us when to stop eating. And once these kick in, it’s extremely difficult to eat more. This is why there have always been restaurants that will offer you a free meal if you can eat a 40-ounce steak in one sitting. They aren’t giving away very many free meals.

The main satiety hormones are peptide YY, which responds primarily to protein and cholecystokinin, which responds primarily to dietary fat. The stomach also contains stretch receptors. If the stomach is stretched beyond its capacity, it will signal satiety and tell us to stop eating.

So how does the low-fat, calorie-reduced diet eating six or seven times per day stack up? By cutting out the fat, we don’t activate the satiety hormone cholecystokinin. Because protein is often eaten along with fat (like a steak, or an egg) then you are not activating the satiety signal peptide YY. This makes us hungry.

So, a few hours after we eat, we get hungry again. So instead of waiting until the next meal, we eat a snack. Because snacks need to be easily accessible, it tends to be carbohydrate-based, like a cracker or a cookie.

It’s fairly simple to prove to yourself. Think about eating steak and eggs for breakfast, which is high in dietary fat and protein. Do you imagine that you would get hungry at 10:30?

Now imagine that you ate two slices of low-fat white toast with low-fat strawberry jam and a big glass of orange juice. There’s virtually no fat or protein in this breakfast of champions, but you know as well as I that we are ravenous by 10:30, which sends us out on a mission to find a low-fat muffin to tide us over until 12:00.

Now, instead of eating three larger meals, we are eating six or seven smaller meals. This means that we are not activating the stomach stretch receptors to tell us that we are full and should stop eating.

While cutting our stomachs to a smaller size with bariatric surgery may seem like an option, the nerves that supply the stomach are often cut during this time, so they cannot provide those all-important satiety signals.

The standard dietary advice to lose weight was doing everything exactly wrong. It could hardly have been worse if they were trying. But it wasn’t a problem with the number of calories. The problem was that the diet we were told to eat for the last 50 years did nothing to control hunger. The problem is not with the people, the problem is the advice nutritional authorities are giving to the people.

The problem is amplified if we are eating, as most people are, processed and refined carbohydrates. Your blood sugar levels skyrocket telling your pancreas to produce a surge of insulin. The job of insulin is to tell your body to store food energy as sugar (glycogen in the liver) or body fat. That huge spike in insulin immediately diverts most of the incoming food energy (calories) into storage forms (body fat).

This leaves relatively little food energy for metabolism. Your muscles, liver, and brain are still crying out for glucose for energy. So you get hungry despite the fact that you’ve just eaten.

It’s the domino effect from hell if you’re looking to maintain or lose weight. Because these processed foods have removed all or most of the fiber, it does not take up much space and does not activate the stomach’s stretch receptors. Because they are low fat, they’re removed most of the protein and fat.

So, there’s no activation of the satiety signals, at a time when most of the ingested calories of food energy have been deposited in the body fat. No wonder we get hungry! After a huge meal, we can often find ‘room’ for dessert, which is usually highly refined carbohydrates, or we can still drink that sugar-sweetened beverage.

For years you’ve been lied to. You’ve been told that you lack the will power and that your obesity is your fault. That couldn’t be further from the truth. You think your body is broken because your body doesn’t respond the way you’ve been told it is supposed to.

You know you’re following the rules. You’re eating what the authorities tell you to eat. You’re barely eating at all to keep your caloric intake low. You can’t lose weight and you’re hungry all the time. With about 70% of Americans overweight, is it possible that 70% of Americans are broken?

In short, eliminating processed junk foods and refined carbohydrates, reducing or eliminating starchy carbohydrates that rapidly digest to sugar, and enjoying natural fats and proteins can create long-lasting satiety.

Taming the ghrelin growl

How can you further reduce hunger? The answer, counter-intuitively, is periods of intermittent fasting. Skipping a few meals can shrink your appetite.

The hormone ghrelin, also called the ‘hunger hormone’, turns on our appetites, so you want to lower it. People assume that if you’re fasting, your ghrelin level is going to continue to rise, but that isn’t true. And most of you know this by now because you’ve been hungry for years while eating constantly.

Eating all the time does not turn off hunger and lower ghrelin. The answer to turning down ghrelin is the opposite – intermittent fasting.

Many people are frightened to fast for even a short while because they think it will only increase their already out-of-control hunger. We’ve had experience working with thousands of patients adding intermittent fasting to their daily routine.

One of the most consistent comments after they start fasting is how much their appetite has gone down. They always say, “I think my stomach shrank”. They often report feeling full by eating only half the amount of food that they used to. No, their stomach didn’t physically shrink, but their appetites sure did.

Hormones like ghrelin are cyclical, meaning they go up and down throughout the day. Circadian rhythm studies consistently find that ghrelin is typically the lowest first thing in the morning. Patients are often not hungry in the morning but they eat because they’re told it’s “the most important meal of the day”.

Ghrelin also fluctuates throughout the day, which is why we tend to experience hunger in waves, largely corresponding to the pattern of our typical meal times. If you are able to fast through the wave, such as skipping a meal like breakfast or lunch, you’ll find yourself no longer hungry a short while later. Then the next wave of hunger will come around the time of your typical dinner.

In short, hunger is a hormonally mediated state of mind, not a state of the stomach.

In fact, sometimes the feeling of hunger actually can be an emotional need that longs to be filled instead of a food or nutritional need. Paying attention to your hunger signals and examining them — but not necessarily giving in to them — can often let you ride the hunger wave and ignore the ghrelin growl until the next meal time.

Is it hunger or is that pang a need for something else?

—
Megan Ramos