**Jim 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.

**Jim 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.

**Jim Hill:** Ready for the “And” factor?

**Holly Wyatt:** Let's dive in.

**Jim Hill:** Here we go. Today's episode, Holly, is truly something special. We're taking a step back in time, over a century back, actually, to see how obesity research began, how it's involved, and why this journey is critical for everyone's future. You might think we've uncovered all there to know about weight loss and obesity, but there are still mysteries, ongoing discoveries, and a surprising history that impacts what we know and don't know about this complex issue.

**Holly Wyatt:** Exactly, Jim. And for this episode, we're joined by none other than Dr. George Bray. And if you are someone who's done any research in obesity, you know that name. Dr. George Bray is a true pioneer in the field of obesity research, and his recent paper, Obesity, A Hundred-Year Perspective, captures the key discoveries, evolving definitions, and groundbreaking ideas that have changed how we think about and approach obesity. From early ideas that linked obesity to overeating to today's understanding that involves genetics, environment, and metabolism, Dr. Bray's work shows us how each step has shaped today's treatment strategies, and more importantly, where we still need to go.

**Jim Hill:** Yeah, Holly, Dr. Bray is one of the most impactful researchers ever in the field of obesity, and we're really, really very pleased to have him today. Now, our listeners might be wondering, why does the century of obesity science matter today? Understanding this history isn't just looking back. It helps us also see where we're headed and tells us which questions we still need to answer. It's a chance to understand why some of the most persistent challenges in weight loss remain unsolved and why new insights from the past might just hold the key to future breakthroughs.

**Holly Wyatt:** Dr. Bray, welcome to the show. We're thrilled to have you here to share your expertise and help us unlock the mysteries of obesity. So, welcome to Weight Loss And.

**George Bray:** Thank you very much. I'm pleased to be here. Well, move ahead.

**Holly Wyatt:** Yes. All right. I'm going to start. I've got my first question ready to go. So let's start a little bit with a historical context. This paper is just an amazing paper that really does just lay everything out for the last hundred years. Your paper looks back over a century of obesity research. What inspired you to explore obesity from such a long-term perspective? Why did you write that paper?

**George Bray:** Well, first I wrote it because they asked me to write it. That was the first thing. Would I like to write one on the history of obesity? And having written on that subject many times over the years, I thought it would be interesting to do, and they were doing a symposium in the International Journal of Obesity on this subject. So I thought I would dive in and do it. What I was surprised by is they only wanted to go back 100 years. And if you go back to 100 years, there really wasn't much happening in obesity in the 1920s. It wasn't a field of great activity. The big activity had occurred earlier than that with the discovery of hypothalamic obesity, with the Lavoisier work on energy efficiency, and the thermodynamic models of the 19th century. So a lot happened in the 19th century and very early 20th century. But that period, mostly pre-World War II, was pretty quiet. Not much happened. Then finished World War II, a lot of activity began to happen. And here we are now with new drugs, which look like they're going to resolve the problem. I'm just a little too old to have gotten in at the beginning of this, but it's a very exciting thing to watch.

**Jim Hill:** So George, you're going to have to do a second paper to go back 200 years of obesity research.

**George Bray:** Well, we've covered enough of that. You go back too far, people sort of roll their eyes up and go to sleep.

**Jim Hill:** So George, how have the definitions of obesity evolved over time, just in your career, and how we define obesity really relate to our understanding and treatment of it?

**George Bray:** You raise a good question. At the end of the paper that you referred to, I put in a list of aphorisms about obesity that I thought were sort of some statements about the current state of things. In the beginning, one is obesity is a chronic relapsing disease process. And this was this working statement from World Obesity for a number of years. I would modify it now by adding stigmatized, so I would say obesity is a chronic relapsing stigmatized disease process, and they insisted on putting process in it, that is the reviewers of the paper because obesity isn't a single event in time. It's a process that occurred over years, and whatever goes on in the adipose cell that leads to all the adipokines that come out and cause troubles takes time to happen. And some people respond better, and some people respond more poorly and more quickly. So that was the first thing. Going back to the definition from the United Nations, the World Health Organization, defines obesity as excess body fat, which is related to the onset of risk of diseases.

If there's excess fat we're dealing with, and obesity really doesn't do that term, why don't we develop something else? And obesity, as you well know, is a pejorative term. No one wants to be called obese. The problem with obesity as opposed to blood pressure and heart disease is if you carry it on your sleeve, you can look at someone and tell whether they're obese or not, and you make an opinion about that person based on that impression. It's a bad problem that we run into by using the word obesity. I'm hoping we can get a discussion underway to replace obesity with something else. Now, what else could we replace it with? Well, the World Health Organization suggests excess fat.

**Holly Wyatt:** Whoa, but George, do you think people want to be called excess fatter?

**George Bray:** No, I do not.

**Holly Wyatt:** Yeah, we're trading one for one.

**George Bray:** How about adiposity?

**Holly Wyatt:** Adiposity, ooh!

**Jim Hill:** I agree. We need another name, and we need to get serious about doing it. I don't have a good suggestion, but there are a whole bunch of smart people that ought to be able to come up with a better term.

**George Bray:** Well, let me suggest one for you, adipositive. Because adiposity is really what we're talking about. The fat cells get bigger, they get more numerous, and that's the problem. That's where all the fat goes. So adiposity doesn't have any pejorative term.

**Holly Wyatt:** Well, not yet. So I guess this could be something we could ask our listeners. We could ask our listeners how they feel about this term. It comes from adipose tissue. So the listeners, that's where adiposity is the fat tissue. We call it adipose tissue. So adiposity would mean excess adipose tissue. We can ask them how they feel about that term. Do they think it would be better?

**Jim Hill:** Yes. So write in. Let us know or if you have a better term, let us know that too.

**Holly Wyatt:** Yeah.

**George Bray:** So I took adiposity. The American Association of Endocrinologists formed the term adipose-based chronic disease, A, B, C, D. And I think that's a very good description of what actually is going on. If we could take adiposity and have grades of adiposity in terms of what the clinical outcomes were, I think we would have the start of a new way of looking at it, which might be more helpful, certainly more helpful than obesity. Obesity is just a bad pejorative term. And I say no one wants to be called obese. Some of my colleagues have told me how difficult it has been to get funding for an obesity laboratory. Who wants to have their name attached to an obesity laboratory?

**Jim Hill:** Yup.

**Holly Wyatt:** I like this.

**George Bray:** Let me know what your viewers say.

**Jim Hill:** Yeah, we will.

**Holly Wyatt:** Jim, let's move to some of the big breakthroughs and concepts that were in the paper, but also I think we can put George on the spot a little bit.

**Jim Hill:** All right, I'll start with one because I think, George if I'm not mistaken, this is something that evolved over your career. And that's highlighting the importance not just of the amount of fat, but where the fat is located on the body.

**George Bray:** Absolutely.

**Jim Hill:** Can you tell us a little about how that came about and why it's important?

**George Bray:** Well, it's been recognized for almost 100 years from the public health data and the insurance company data that people who had a bigger central fat had a greater risk of dying just as they did if they were overweight. The real quantification came with Jean Vague, who in 1948 published a paper saying that central adiposity measures increased waist circumference was associated with increased risk. And that really began the whole area of the waist-hip ratio measurement, of the waist-height measurement, which, as you may know, has been recommended as a supplemental measure to go with body mass index. The NICE, which is the British sort of evaluation format like FDA recommended the waist-height ratio as a way to make an assessment of central adiposity. So I think the waist height measure and hopefully some better measures that can be measured by optical scanning, which are becoming much more common, will allow us to get very good measures of central adiposity. And that is really the important kind of fat. But it's still excess fat. And I'm going to come back to the word excess fat. That's what we're dealing with. If there weren't excess fat in these visceral fat depots, it wouldn't make much difference. It's the excess fat. So that's why I come back to adiposity as a term.

**Holly Wyatt:** So I know what some of the listeners are saying. So we talk a lot about where you carry the fat in the midsection, your waist, that puts you at a higher risk. But what would you tell them? They say, okay, do I need to lose weight a different way? So what if I have a lot of fat in my midsection, does that change? What does that change for me besides my risk? Does it change anything besides risk?

**George Bray:** Well, it increases your risk for diabetes because of insulin resistance and because of fatty liver. And one of the intriguing things about these newer drugs is they're actually very good for chronic liver disease, as well as adiposity. So I think the liver and the pancreas are victims of having too much central fat.

**Holly Wyatt:** Yeah. So that may be to change your approach a little bit more, tailor it. You might use the medications if you have that centralized obesity.

**George Bray:** Well, they're what everybody uses, aren't they?

**Jim Hill:** Seem to be.

**George Bray:** They do.

**Jim Hill:** But there's no way to target central fat alone. People want to say, do I do something different if I have central fat to lose there versus to lose weight in general?

**George Bray:** Well, you're an exercise person, and exercise is one of the few really good ways of modifying visceral adiposity and the effects of it on your health. So I would encourage anybody who has an issue to exercise more. If I weren't talking to you, I'd be out doing my two-hour walk this morning.

**Jim Hill:** I love that, Holly. He's proposing the exercise message.

**Holly Wyatt:** I know, but I was saving this toward the end, but I'm going to bring it up right now. I can remember when you and I used to have dinner. We used to have dinner, and we'd talk about obesity, and we would ask. And you were not an exerciser. You used to tell me I didn't need to exercise. I, on the other hand, would gain weight like crazy. So what changed? What changed for you?

**George Bray:** I got older. I did, yes. I get out and get two hours of exercise.

**Jim Hill:** Nice.

**George Bray:** Two hours of walking a day. And I go down and work out on the machines. We have a very good gym just down the block from me. So I'm down there three days a week.

**Jim Hill:** Wow.

**George Bray:** And I'm out on the hustings for two hours a day, five days a week, seven days a week.

**Jim Hill:** He's living the lifestyle we recommend, Holly.

**George Bray:** I've become a believer. How's that?

**Holly Wyatt:** Oh, see, I knew I would rub off on you eventually.

**George Bray:** You rubbed off on me.

**Holly Wyatt:** How old were you when you started to exercise? Because I know you weren't. When did you start? What was your age when you started?

**George Bray:** Oh, well, close to 90.

**Jim Hill:** Ha, ha, ha, ha, ha, ha.

**Holly Wyatt:** It took that long before you became a believer. Oh, my goodness.

**George Bray:** I didn't retire until I was 85. So I left the Pennington Center in 1985 when I was at night in 2015 when I was 85. So I didn't really have time to do that before then. But after that.

**Holly Wyatt:** Oh, no, no, George. Now, time is not that. We don't use that as an excuse, do we? We can exercise and still be busy.

**George Bray:** Oh, you can. Oh, yes, you can.

**Holly Wyatt:** Okay.

**George Bray:** You have to commit, but I didn't have the commitment and I have other things to do that I prefer to do.

**Holly Wyatt:** Honesty. I love it. Let's talk a little bit about metabolic and hormonal research. You've seen this develop and you remember when we first discovered leptin. And we thought that was going to really change the field. I remember at first thinking leptin was going to solve the problem (kind of like people are now thinking these GLP-1 drugs might solve the problem), but it didn't. So what can you tell us kind of, what did you think about leptin and how has that changed the field, the research field at least?

**George Bray:** Well, I agree with you. I think we thought it was going to have a greater impact. And of course, companies thought it was too, because they invested in finding drugs that were going to affect leptin levels and response, and it didn't. And maybe that's because there's leptin resistance in the brain because if you're fat, you don't respond to leptin very well. So whatever that process is still is to be unraveled. I must say you were looking for the future. One of those futures is why we make the adaptations that lead people to get obese and not reverse it. It's not a reversible disease with any ease. And even stopping these drugs, current drugs, as best I can see, you still gain back a considerable amount of weight. That they aren't…

**Jim Hill:** That's right. They only work if you take them.

**George Bray:** I've heard that before, Jim. Drugs and like diet, drugs only work if you take them.

**Jim Hill:** Yeah, exactly.

**George Bray:** There's an interesting study I was trying to find, and maybe one of you will remember it. A number of years ago, one of the drug companies at the six-month point in their drug trial took blood samples and measured the blood level of the medication that was there. And surprising, or maybe not surprising, the amount of weight loss was related to how much drug they had in them, those who did better had more, and those who did less had none, or less than those who didn't lose at all or regain had essentially none. I haven't been able to find that paper lately, but it does exist. It's an interesting…

**Holly Wyatt:** Yeah, it shows. That's what we know. And so that is kind of, it speaks to metabolic adaptation, right? A little bit that occurs with weight loss. Do you think that's something people can work with or workaround? Or do you think, no, there's nothing you can do about that, that things change when you lose weight that pushes you back to regain the weight? And unless you stay on the drugs, nothing you can really do about it.

**George Bray:** No, you can. It takes willpower, whatever willpower is. There's a famous book by Cornaro 400 years ago in which he was a fat man and decided he wasn't going to be fat anymore. And he went on a diet and he stayed on the diet and lost weight and, kept it off for a long time. So you can do it.

**Jim Hill:** Yeah. You know, George, we've worked for many years with folks in the National Weight Control Registry who have succeeded long-term and they're constantly working to fight this drive to regain. And so it never goes away. The idea that you lose weight and suddenly you regulate like people who have never been overweight isn't true. But what I think we found is a lot of people that have figured out how to do it, they will tell you they have to work at it, but it can be done. Right. They do a lot of exercise. We actually did a paper to show they have to do more exercise to maintain their weight than someone at the exact same weight and body composition who's never been obese. So there's a price to pay for being obese, or maybe it's a susceptibility to obesity. But you're exactly right.

**George Bray:** I had one nurse who came in and lost a lot of weight in the program we had back at Harbor Hospital. And when I saw her, I said, well, how are you keeping your weight off? She said, at my lunch break, I walk for an hour and a half every lunch break. And she said, I have to do that every day of the week or I don't keep my weight off.

**Jim Hill:** It's what we see. George, I thought one of the intriguing points you made in your paper is how over time, over the past century, behavior and the environment, those two go hand in hand and have influenced our susceptibility to gain weight. The idea is that we've very much changed the environment in which we live. Can you talk a little about how you see those changes over the past century?

**George Bray:** Yes, I do think we've changed something. And it looks like from the data on the weight gain curve is though it was about the middle 1970s that somewhere something happened and actually in Earl Butz's Secretary of Agriculture time and when Nixon's administration the food policies changed in some fashion and it led to more ultra-processed foods appearing on the market. And I think the ultra-processed food issue has played a real role. But clearly, from the early 1970s, about the time fructose also appeared on the market, and it may be one of the markers of this phenomenon. High fructose corn syrup, that it may be a marker of that. But early 1970s up through 1990 and probably up to the early part of the 21st century, those factors that were involved in whatever it is in the diet came along and interacted with our genetic background for those people who were susceptible. Not everybody gets fat. I mean, look at you. Look at Holly.

**Holly Wyatt:** Whoa, whoa, whoa. No, look at me because I'm susceptible. But you, you used to say all the time, you didn't have the genes to gain weight.

**Jim Hill:** Yeah. George has been lean all his career, at least as long as I've known him.

**George Bray:** Well, you missed my weight gain experiment.

**Jim Hill:** Oh, I remember you talking about it. Yeah.

**George Bray:** I presented it at one of those talks you have to give. And the editor of AJC asked me if I would like to write up my weight gain experiment. So what I did is it's actually a published paper.

**Holly Wyatt:** Nice. I'll have to look that up.

**Jim Hill:** I do want to point out also, George, that over that time, and there is something, if you look at the prevalence of obesity over time, there's something that happened in the 70s that was reflected and a huge bump in obesity in the 80s that we all look at. It wasn't gradual. There was a real increase. But also to point out that along with the changes in food, probably since World War II, physical activity has been decreasing as we've used technology to replace movement in our work and our transportation and so forth.

**George Bray:** Yes, that's been going on, as you said, since World War II. The timing of the increase in weight is pretty close to 1974 or 73, and then it really takes a real change in the slope of increase from there on for about 20 years.

**Jim Hill:** That's right. From the 80s to the 2000s, there was this ramp-up. And now we're increasing gradually, but not at the rate we were during those 20 years.

**George Bray:** Yeah. But now we've got 60% of our population who are overweight or obese.

**Jim Hill:** Yeah.

**Holly Wyatt:** Yeah.

**George Bray:** How many more can we get?

**Holly Wyatt:** Exactly.

**Jim Hill:** Maybe everybody who's genetically susceptible is already obese.

**Holly Wyatt:** Or not that many more.

**George Bray:** I think we're getting close.

**Holly Wyatt:** Yeah, I agree. I'm going to switch gears a little bit because I want to talk about diet trends over the decades. So many people, when they think about what do I need to do to lose weight, they think about what do I need to eat. What diet do I need to be on? So there have been so many different trends over the years. There's low fat to low carb. Based on your research and then the history, is there a diet approach that stands out as the most effective diet approach?

**George Bray:** My preferences for diets are two, the Mediterranean diet and the DASH diet, which are all-around good diets. I hate to say it, but I was involved with developing the DASH diet along with Frank Sacks and a couple of other colleagues.

So, I am leaning towards it, but the DASH diet and the Mediterranean diet get consistently good reviews for diets, either in the low-calorie versions or in the standard versions. So those are diets I would recommend. Is there anything that convinces me that low-fat or high-fat are better? The answer is no. But in a paper that Frank Sacks and I did as part of a trial we did on low-fat and high-fat and low-protein and high-protein, a two-by-two design, we found that overall, in the two years of the trial, the weight loss was identical in all four groups.

What we have found since then is that there's an enormous variability in how you respond to specific diets. That is, some genetic traits make you much more susceptible to low-fat diets and some to high-fat diets. And the genetic background that you mix up when you put 800 people together and wash that out, that if you could selectively pick those out, you would have a very good way of personalizing weight loss information. But as for a moment, is there any convincing data for me other than the DASH diet and the Mediterranean diet? No. I'll tell you a short story. Do you remember the name Robert Atkins, the Atkins diet?

**Jim Hill:** Yeah.

**Holly Wyatt:** Oh, yeah, of course.

**George Bray:** He's before you, Holly, maybe not before Jim. 1972 was when he published his book. That's the first one of his books. And he and I were invited. There weren't many academic obesity people in the 1970s. So they invited me and Bob Atkins to be on an NBC show in 1972. And I pointed out to Atkins, I said, you know, if your diet really cured obesity, there wouldn't be any need for any other diets. And, of course, diets keep coming every year by the dozens. So clearly, no diet manages to successfully deal with obesity, even the Atkins diet, in spite of Rob Atkins' insistence that it did.

**Jim Hill:** You know, George, that Holly and I, along with Gary Foster and Sam Klein, were the first group to actually study the Atkins diet.

**George Bray:** That's right.

**Jim Hill:** Because up until then, there was a sense of, oh, these fad diets, they're not scientific, they don't deserve any scientific study. We actually studied it. And what we found is kind of like what you said, people lost weight on Atkins and low fat and about the same and weight loss improved everything. And then people regained on both those when, you know, over time.

**George Bray:** Right, exactly right.

**Holly Wyatt:** And actually the Atkins diet, it was, I was doing the Atkins diet when I was like an intern, and it prompted me to actually go into this field. So that was how I kind of got here.

**George Bray:** One good outcome.

**Holly Wyatt:** Well, you know, it made me ask a lot of questions about what was going on, and then someone said, Holly, you could study it. So that's how I got here.

**Jim Hill:** Exactly.

**George Bray:** We also got rich, too, and I never did. Ha ha

**Jim Hill:** Holly, we've got more to cover.

**Holly Wyatt:** Okay. All right.

**Jim Hill:** This is really fun. I really want to turn now, George, to surgical and medication options because these new GLP-1-based drugs have been a positive disruption for our field I think if you take the decade, last decade, maybe even two decades, science has moved forward, but nothing major. And these new medications have really changed things in a major way because people on these medications are often reaching their goal weights. So how do you see the medications and then maybe even bariatric surgery as changing the field going forward?

**George Bray:** Well, bariatric surgery was the sort of the landmark of how much weight loss you could expect to get. I think they set a standard and they also demonstrated that if you do lose weight, you will improve all kinds of things, including mortality risk, cardiovascular risk, and diabetes risk. And so they really did set a landmark in that. And I think the Swedish obesity subject studies in Gothenburg were the ones that were, in my mind, the first landmark ones. But there have been many since then that have demonstrated the importance of surgery. The problem with surgery is that not everybody wants to be operated on, and not everybody wants the consequences of that surgery. I think these new drugs have done what we were all looking for, and that's to find a way in which to manipulate the feeding system that would control it long-term and substantially. All of the early efforts were on centrally active agents, the amphetamine-like drugs, that whole class of drugs.

And some of them are effective. Some of them are still used. They're much cheaper and are effective to a point. But the gut active mechanism, that gut limb that's obviously feeding back to the brain to reduce food intake, has turned out to be much more powerful. I can remember Astrup's study back in 1988, where he infused it into people just to see how it would work. And by golly, he got reductions not only at the breakfast meal but at the lunch meal as well. It obviously wasn't far along until Novo Nordisk got into the business and developed the drugs. And now Lily's in it, and I don't know who else is in it. But Donna Ryan tells me lots of other people are now coming up with age and stuff in the last obesity week meeting. So it's going to be an important advance. I say the major unanswered question in my mind is how you keep it off over time.

**Jim Hill:** Ah, that's Holly and I couldn't agree more, George. It's actually putting the effort into weight loss maintenance rather than weight loss. And I think this is good for our field.

**Holly Wyatt:** You said not everybody wants to have surgery, which is true, but not everybody wants to stay on the medications long-term. And the data says if you don't stay on a long term, you tend to regain. So how do we solve that problem, what do we do with that, I think is the real question that's out there.

**George Bray:** One of the interesting things that I've noted in terms of the surgical outcomes of children born to people before and after bariatric surgery is that those born after bariatric surgery have much less risk to becoming obese. There's something changed as a consequence of the bariatric procedure when a woman is pregnant and has had that operation versus when she hasn't had it that alters the way in which their subsequent brain function works so that they're much less at risk for obesity. So clearly there are ways in which we can modify our brain receptor pleasure centers that can be done, but we need to know more about that. You young guys can do that.

**Holly Wyatt:** So at the end of your paper, you talked about this, I think at the beginning of the podcast, there were some key takeaways or aphorisms that you listed, that were my favorite part of your paper. I love it when you have a succinct takeaway that really just sums it all up.

**George Bray:** Yes.

**Holly Wyatt:** Can you highlight your favorite couple? What are your favorite, maybe one, two, or three that you think really are the best ones at the end of this paper that would be relevant to the listeners?

**George Bray:** There are only seven of them so I can read you all seven of them.

**Holly Wyatt:** Oh, you want to do all seven? Okay, read them out.

**George Bray:** Well, we spent a lot of time talking about the first one, obesity is a chronic relapsing stigmatized disease.

**Jim Hill:** Yep.

**George Bray:** The second one is that obesity produces a variety of weight loss. But what we don't know, and I wish you two would help us solve, is how we predict who succeeds and who doesn't succeed. The variability of weight loss across groups is really quite striking. Some people lose a lot of weight no matter what you do, and some people in a program lose almost none or even gain weight. And this variability in weight response is something that we need to be working on.

**Holly Wyatt:** I think understand it and then be able to match treatments, right? Be able to say, based on this, this is the treatment you need. I agree with you 100%.

**George Bray:** And we've already talked about diets only working when followed and medications only working when taken. That's pretty…

**Jim Hill:** That's important, though.

**George Bray:** Oh, it's very straightforward. I think the next one on the list is something we learned from our clinic when we had Fen-Phen, which is a very effective drug combination. But it unfortunately had cardiovascular outcomes, which terminated its use. But we had an executive weight loss clinic, and we prepaid their fee, and at the end of the year, they almost all lost 15% or more weight. And so we said, would you like to sign up for year two? And what was surprising was the number of them who did not want to do so. For, they say, well, we've already solved our problem. We don't need your help or we didn't get enough help to warrant continuing. But the sign-up rate was very low. And I think that's a real challenge. It's like taking medications long-term. People don't do that. The dropout rate for taking medications for obesity is pretty high. I don't know if anyone spotted that in the current drug industry.

**Jim Hill:** It is. And it's amazing because people will do almost anything while they're losing weight. But once they've stopped losing weight, it's a whole different ballgame and they're not willing to continue doing it.

**Holly Wyatt:** So this is important. The listeners that are out there right now losing weight, they want to lose weight. That's a lot of our listeners. You need to stay engaged. After you lose the weight, you have to stay engaged in treatment, some type of treatment. It can be different.

**Jim Hill:** It's going to come back if you don't. If you stop the drugs without a plan, you're going to regain the weight. If you stop your diet plan, you're going to regain the weight.

**Holly Wyatt:** Absolutely.

**George Bray:** The other interesting thing, and this is from Gary Foster's, one of his other papers, aside from the one you described from the use of his diets, was that people who lose 17% of their weight or less are considered a failure.

**Jim Hill:** Yeah.

**George Bray:** That a small weight loss really is not something most people are looking for. They really want to get substantial amounts of weight loss. And finally, you know, we talked about the public health message, which is important because 60% of our population is obese. But if we're going to do something about it, people have to take some responsibility too. That you are the one who eats the food that goes in your mouth. And that's going to require a change on your part, you, the patient, that continues on over time. And how we accomplish that is, I think, a real challenge. How do we get people to change their behavior in a long-term fashion? And I don't have a good clue about that.

**Holly Wyatt:** Well, and physiology, right? Physiology is involved in those behaviors. I always say it's not your fault. We don't need to blame the patient. Definitely physiology, and genetics, as we've been talked about play a huge role. But I do think there is a little bit of responsibility. What do I do with the genetic predisposition that I have? What can I do to make it the best it can be for me? And that's true with obesity. That's true. If you have diabetes, that's true. If you have cancer genes, you know, some people are more predisposed to certain cancers. What can I do? What responsibility can I take to make this the best it can be? Realizing it's not your fault. It's definitely different between different people. Some people struggle more than others. And that's, I think, the key thing here is people don't want to be blamed and they shouldn't be, but you also can't just throw up your hands and say, therefore, I do nothing.

**George Bray:** Right. But they do have the responsibility, if you pardon the use of the word responsibility, to contribute to their own diet maintenance, because if they continue to eat the foods that are ultra process they're going to have the same problem they had right?

**Holly Wyatt:** But realizing, George, though that some of them are going to struggle with that that's going to be harder for some of them than others.

**George Bray:** Tell them about Cornaro's experience 500 years ago. He did it. If you can do it 500 years ago, you can do it today. How's that?

**Jim Hill:** But I think the point there is it's yes there are biological things, but you can't just totally say it's out of your control. There's nothing you can do. It's this middle ground between understanding biological things that are going on, but you can contribute in terms of your behavior and your lifestyle.

**George Bray:** Yes.

**Holly Wyatt:** I agree. I know people out there are frustrated because, and I guess I kind of am too, because the effort it takes me sometimes to control what I eat is huge. It's humongous. It's 24-7. It feels like. And so I think the key is to make sure people understand that people do have struggled with it more. It's harder. It's not simply willpower. There's genetics involved. And for many years, I think people feel like they've been blamed for their weight. And we now know, no, it's not just about the willpower. You have a harder situation. And to let people realize that and understand that.

**George Bray:** And I say that's the area where I think a lot of research needs to be done. And there's one, when I was reviewing stuff, and preparations before talking to you, I came across a review I did for a paper that Jastreboff wrote looking at functional magnetic resonance imaging on obese children and young adults who are getting glucose or fructose beverages and looking at the areas of the brain that lit up. In the fat children, the areas in the brain, the ones that are the pleasure centers in the midbrain area light up, and in the lean children, they did not. And I thought this was very interesting. It means that there is clearly a biological difference in the way in which our responses to glucose, this is a glucose beverage.

**Holly Wyatt:** Yeah. And the pleasure centers, how you perceive it, right? And if your brain doesn't light up that way, you have no insight into it, right? You don't know it, but you have no insight into how it might feel for someone else's brain that lights up in a different way when they eat glucose or fructose. Perfect. Perfect example.

**Jim Hill:** Holly, you want to do one quick question from a listener?

**Holly Wyatt:** Yes. Let me see which is the best one. I'm going to put them on the spot a little bit. So this is from a listener, Dr. Bray. They're asking a big question: what's the one change someone could make today that might have the biggest impact on their weight and health? So, lots of stuff out there but if looking back over the history what's the one thing you would say one change that would have the biggest impact?

**George Bray:** Get regular exercise in your program.

**Jim Hill:** Oh my gosh. George has become a convert. I love it.

**Holly Wyatt:** We used to have this conversation and you did not believe that. You've turned around.

**Jim Hill:** I love it. This is wonderful, Holly.

**George Bray:** I've gotten wiser.

**Holly Wyatt:** I thought you were going to say something else for sure. And I was going to come in. Well, let's talk about exercise. But no, you beat me to it.

**Jim Hill:** I love it. All right, Holly, you know what time it is now?

**Holly Wyatt:** My favorite time.

**Jim Hill:** Time for the vulnerability questions, George. We ask you questions to try to get you to be vulnerable. I'll go first. Reflecting on your career, which has been amazing, is there something that you feel like you got wrong early on or something you wish you had understood sooner?

**George Bray:** Well, that's an interesting question and one I hadn't given much thought to. There are things I did that I never pursued as far as I should have pursued. We were doing some studies looking for the factors involved with the OB-OB mouse. And we actually identified what is probably leptin from the urine. We isolated the urine and collected it, but I never pursued it far enough to go anywhere with it. So it's a little things you don't pursue, but you'll never know what they might have been.

**Jim Hill:** Right.

**Holly Wyatt:** Yeah. And I think, you know, a lot of times in that we talk about this in the obesity field and research field, sometimes you get something wrong and that's the next stepping point to figure it out. You see it one way and then suddenly you start seeing it differently and you realize, oh, I was thinking about that wrong or backward or we didn't have the full picture, but you learn something and you move on. So mistakes are part of the learning process, So I think when it comes to science.

**George Bray:** That's certainly true.

**Holly Wyatt:** All right. I have another vulnerability question. I know you like these. What's been your biggest learning from working in the field of obesity? You could just say what one thing that's your biggest learning. What would you put out there?

**George Bray:** I think it's been the difficulty of recognizing obesity as a disease process. It's all of the people who are fat fanciers and who view obesity as the right thing to do and fail to recognize health-related issues. It's been interesting to watch groups get together to try to come up with consensus plans about whether is obesity a disease or not. And as a biologist, there's no question in my mind that it is a disease process. But it's a surprising number of people can't recognize that. And I find that a very mysterious conundrum.

**Holly Wyatt:** I like it.

**Jim Hill:** Okay, Holly, it's time to wrap it up. George, it's been extraordinary talking to you. You have done so much for this field. You helped really develop and define this field. And it's been really our honor being able to talk to you. And I think we've learned a lot of things that have changed over the past 100 years. And hopefully, moving forward, we're going to solve still some of the questions that are unanswered. But it's an exciting time. The new medications and new tools to treat obesity have gotten people in the field excited. So the field of obesity research has come a long way from when you started your career, George, and you had a lot to do with that.

**George Bray:** Oh, yes, it has. It's a long way. I can remember back when Alan Howard and I met before the International Journal of Obesity was founded. He and I met back in 1972 in Germany. He was in a meeting and I was at a meeting. We met and I knew of his work already. And we sort of looked ahead and decided we needed an international journal and the International Congress and the North American Association or study obesity like the one. And gradually all of those little things came true. So I've contributed in that way.

**Jim Hill:** You've contributed in many ways, George. So thank you.

**George Bray:** My pleasure.

**Jim Hill:** For our listeners, if you'd like to share your own weight loss journey or personal insights on the show, we'd love to hear from you. Send us a note at hello at [weightlossand.com](http://weightlossand.com/). That's hello at [weightlossand.com](http://weightlossand.com/). Or visit our website at [www.weightlossand.com](http://www.weightlossand.com/) to tell us your story and what success means to you. Your experiences inspire us and remind us that together we all rise. So thanks, everybody, and talk to you next time.

**Holly Wyatt:** Thank you, George. Thanks, everybody. Bye

**Jim 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.

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**Jim Hill:** We'd also love to hear from you. Share your thoughts, questions, or topic suggestions by reaching out at [weightlossand.com](http://weightlossand.com/). Your feedback helps us tailor future episodes to your needs.

**Holly Wyatt:** And remember, the journey doesn't end here. Keep applying the knowledge and strategies you've learned and embrace the power of the “And” in your own weight loss journey.