**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. Holly, lots of people that listen to this podcast obviously want to lose some weight, okay, and they really look at the number on the scale. Well, the number on the scale is a pretty good indication of how you're doing. But one of the things that we know is that when you lose weight, it doesn't all come from the same place. Now, where do we want it to come from?

**Holly Wyatt:** Well, from fat, obviously.

**Jim Hill:** From fat, okay, but guess what? It doesn't all come from fat. There are other places that it comes from. And so today, we really have an expert in this area who's going to join us and he's going to clear up all this for us about what happens when you lose weight. So go ahead.

**Holly Wyatt:** So one thing that I think people can get excited about, and so I want to make sure people realize we're going to answer this question because I get this all the time is, can you gain muscle and lose fat at the same time? It's not just about losing it. People want to gain, sometimes want to gain some muscle and they want to lose the fat. And they're always like, well, Holly, I'm going to do it at the same time. And so I think that question, we can answer that today too.

**Jim Hill:** All right. Well, we'll see. Well, our guest today is Dr. John Batsis who's at the University of North Carolina. He's a clinician and a health service research. So he has joint appointments in the division of geriatric medicine. So Holly, we have some real questions about weight loss in older individuals and he's a good one to do that, but also in the Department of Nutrition. So his research interests are in how obesity affects muscle mass and strength and particularly in older adults as they're losing muscle mass. That's a real problem for physical function and for mortality. So he's worked with translating large data sets and he's done clinical trials in older adults focusing on body composition during weight loss.

So it's perfect for what we're going to talk about. He leverages his ongoing experience in providing clinical care in the outpatient and nursing home settings to older adults with multi-morbidity and frailty. And he really engages in transdisciplinary team science with a research focus on developing and applying technology to enhance health, function, and quality of life in older adults. John, welcome to Weight Loss And.

**John Batsis:** Well, thank you very much. Really appreciate the opportunity. And I'd like to say that I'm going to be able to answer all the questions that I'm going to do the best I can today.

**Jim Hill:** Well, if we ever have a guest that answers all the questions, I'm going to be a little bit suspicious, John. But we like to have our guest start with sort of the cliff note version of how you got where you are academically.

**John Batsis:** That's a great question. So without kind of going through my like CV or my resume, so to speak. So I actually, I grew up in a family that I'm actually the first physician in my family, first doctor in my family. So I knew nothing about medicine and really kind of got into it, you know, working with patients, working with people, volunteering way back when in high school and in college and realized I loved working with older adults, but I also surprising to a lot of people. I was a diehard wannabe heart doctor, cardiologist, when I first started, came out of medical school. And as much as I love the heart and I loved working with, you know, cardiac patients, I realized that everybody was an older adult and I liked really kind of general medicine. That's what kind of drove me into thinking about maybe I should get a bit more training in older adults. And then next thing you know, did a bit more training, love the relationships, developing the relationships with older adults in kind of a primary care setting. And that's kind of what I still do to the day. And I love these long-term relationships. You really build these relationships with patients and their families and see them through the thick and thin of things.

**Jim Hill:** Wow. I've become more interested in older adults every day. Let me tell you. Well, thanks. So Holly, we've talked a little bit. We always, John, we always like to start with why people care about this issue. And I don't think we have to really set this up too much. I think people do care about this because what do we want to do? We want to lose weight, but we want to lose it from fat and maintain muscle. Does it matter if you're losing weight? Does it matter where that weight comes from?

**John Batsis:** So I'm going to backtrack a little bit if I can, Jim and Holly, and you know, kind of reflecting when I was, I'm going to say when I was a young, spry, you know, early doctor, you know, kind of in training because a lot of the things that when we think about weight issues in older adults and that's kind of what drove me, I realized that no one was really thinking about this. And older adults are different. So as I was kind of doing my training, realized that as one ages, one's physiology, one's ability, you know, general metabolism, their nutritional nutrition, their ability to exercise and their activity, everything changes as one ages. So with that, we realized we'd be thinking about that, you know, when and not all weight is the same.

I think as you, you know, correctly put it. And one of the things I saw in my clinical practice is that when you lose a lot of weight, and particularly after hospitalization, that's I think the first time that I saw it. You have individual patients who got critically ill in the intensive care unit or after a bad bout of pneumonia, they got so weak.

Even if they had excess weight, a lot of weight on board, they lost a lot of muscle, they became really weak. And that really was a trigger to me to say, hmm, you got to be thinking about this really carefully. So that's kind of what drove me apologize for backtracking. But I think it's really important to think about that because that's kind of what led to how I kind of got to here. And then thinking about we got to really not only worry about losing fat because that's really when we think about losing fat, that's, you know, we're trained, we've all been trained as clinicians.

That is bad. You know, losing fat leads to better improvements in blood pressure, diabetes, high cholesterol, immobility and the like. But when you lose weight, you lose both fat, you you muscle, you lose bone and other types of tissues. And unfortunately, we tend to forget about that. And that's really important. And I see that because we see that in older adults because you're bandwidth, your bucket, so to speak, your tank is not as full. Your muscle tank is not as full as say an 80 year old as it was when you're in your 40s, for instance.

**Holly Wyatt:** Yeah. So I think that's true. People get excited about seeing a 10-pound loss on the scale. But if that 10-pound loss is because you lost eight pounds of muscle, that might not be very exciting. That actually might be the other. The other thing I want to just stop because I know our listeners are saying, what is my older? Can we can we just find the older?

**John Batsis:** Oh, the million dollar question. And that's a great one because you talk to 10 different people, you'll probably get 10 different answers. Okay. So I'm going to say this is the John Batsis's answer, so to speak. I use 65 years and above as kind of classified as older adult. Some studies use 60, some studies use 70. But generally we're using 65 that kind of aligns with some of the more public health-based, quote and quote, cut-off, so to speak. And some of the other major aging societies use 65. But that's generally, you know, what, what I consider older adult and many geriatric practices, so to speak. 65 is kind of like the bare minimum in terms of like age cut points.

But again, I want to be very, it's very important and this is a topic for another day. Chronological age. So age 65, you can have a 65 year old that may physiologically, so they may be able to run a marathon at the age of 65 with, whereas you may have a 65 year old who biologically may be 85, which means they can't even barely get out of a chair. So age is just a number. So it's just, it's just something you want to be mindful of.

**Jim Hill:** Remember that Holly, age is just a number.

**Holly Wyatt:** I know. And I think it's also, you know, we like to in medicine draw a line, you know, 65. And in reality, a lot of what you're going to be talking about today may very well impact as you get older, 45, 55, you know, the process of getting older to start thinking about it. And it's not like you have to think about it at 65. It really applies in a broader sense.

**John Batsis:** And you hit the nail right on the head, Holly, trying to reframe the aging process, not age, but aging process and thinking about an aging process starts way back, you know, almost like at birth, you know, we're in childhood or, you know, even in middle eight, you know, we're all aging at every time point. So you got to be thinking about it from a life course perspective or life cycle perspective.

**Jim Hill:** So John, do we know why we lose muscle versus fat? What determines if I were to go on a, if if were to lose 20 pounds, what determines how much of my weight comes from fat, how much from muscle, how much from bone, et cetera.

**John Batsis:** So I think it's just before we kind of, you know, there is a term that I want to introduce to the listeners, a term called sarcopenia. The term sarcopenia, it comes from a Greek term. Sarcos means flesh, penia means loss. And that term has evolved over the last two to three decades, probably a bit more since 1988.

Sarcopenia is the loss of muscle mass and muscle strength with aging. And the definition has really evolved over the last 30 or so years. And thankfully, you know, there's some international consortium and groups that are act that I'm privileged to be part of that are, we're actually coming up with a definition to kind of standardize and that's going to be helpful in the science. Then hopefully that will then allow us to kind of like, you know, be able to incorporate that into clinical practice.

But to your question, well, how do I know what my risk is or how does it allow me to figure out who's going to develop it or not? There are a number of major factors, genetics, you can't change. But there are certain things that over the life course that really you can, your ability, your protein intake, nutritional intake, you you healthy foods, diet quality, for instance, over the course of your life course can promote or can diminish one's risk, reduce one's risk of sarcopenia. Physical activity. I know when folks ask me, what is one of the key elements of healthy aging?

It really is physical activity, not only aerobic, you know, the walking and the running and the like, but really, you know, strength-based exercise, resistance-based exercises. And that in itself is extremely important and a treatment thereof of sarcopenia. We know very much like bone density, muscle mass peaks in the third and third to fourth decade of life. So I always like to say once you've hit middle age is all downhill from there.

Regrettably. But that said, everybody has different trajectories, meaning that decline while it's inevitable. So when you think about it, and this is an, I think they go, this is an interesting anecdote, I think for the listeners. If you look at the world record holders of weight lifters, the age of 40, 50, 60, 70 and say age 90, you'll see their record holders, the amount of weight that they can bench-press is actually diminishes and decreases with age. So that just tells you that right there and then that, you know, the amount your muscles are able to accommodate diminishes with age, but that can be altered, that can be changed. I had a great story with one of my patients that I had this very discussion. He hit the gym and he trained, you know, he did his resistance exercises two, three times a week, came back a year later and he was pretty robust and really able to, you know, he said, oh, doc, I can bench-press now, you know, 200 pounds.

I'm like, well, I think you're overdoing it now. But, you know, he was really, really strong. So I think it's really important even during weight loss measures, that's the key. You can lose weight, but you have to be able to engage in these types of activities that can prevent you from losing too much muscle mass.

**Holly Wyatt:** Yeah. So I want us to do a little bit deeper dive into why, because I know people are going to be like, what can I do? But before we get there, I think maybe a question to ask is if someone is losing weight, because our listeners are trying to lose weight or have lost a lot of weight, how do you know if your weight came from fat or came from muscle? So they've lost 20 pounds. Is there any way that they have an idea if they lost mostly fat, some muscle?

**John Batsis:** Ah, the fun part of what we call body composition in clinical practice. This in my mind is a huge problem in current day, because we have great techniques to be able to measure fat and muscle, but we're having challenges in applying it in clinical practice. So let's take what happens in a given primary care setting, for instance. In a primary care setting, you have the staff that are running around for lack of a better word. They're running around.

They don't have time to do X, Y or Z. But they're measuring height. They're measuring weight, body mass index. They're able to calculate body mass index. Body mass index was never meant to be a marker for fat.

It was meant to be a screener and should be used potentially as a screener. We know, in particular as one ages, the accuracy of body mass index actually diminishes with increasing age, because it cannot differentiate and determine the differences between fat and muscle. That's a problem, particularly as one ages where, you know, you're losing, you know, you want to lose fat, but you're losing muscle. So, you know, that ratio gets all messed up. There are other measures, calf circumference, arm circumference.

They're not great either. So you're left, you can measure strength. There are tools to measure strength. Simple ones. You can do what's called a 30-second sit-to-stand, which basically you have a patient sit in a chair, arms folded up and down for 30 seconds.

Easy, cheap, no problem. You can have them squeeze. There's a machine called what's called a dynamometer. It's a strength machine. Easy to be done can be done.

No problem. The challenges, the strength parts, easy. The muscle mass is difficult. How do you measure that?

To measure it, there are other techniques, bioimpedance or bioelectrical impedance analysis. This is where it sounds really fancy and it sounds dangerous, but it's actually cheap and easy. Think about a scale. You stand on it barefoot. You hold it.

A little electrical current goes in, doesn't hurt you. It takes about 20 seconds and boom, you can get some good data. Problems, it's a little expensive, but can be done, can replace a scale. Its accuracy is not, it's not ideal, but it may serve the purpose in clinical practice. You can't use it on everybody. Individuals that are pregnant, individuals with pacemakers or device or metallic devices, but again, it can give you some information. Not everybody has it. Primary care clinics, very, very few. Maybe some weight loss clinics or endocrine, diabetes clinics may have them.

**Holly Wyatt:** But now you can actually buy scales out there that have that built in. I know a lot of our listeners have that. And I think what you said is true. It's not perfect and there can be high. If you're hydrated, if you have different body water status, you know, hydrated or not dehydrated, it can throw it off. But it gets at the idea that not all weight is equal and tries to give you a little bit of information how much is muscle or lean tissue and how much is not. So I think we're getting better and better and there are some options.

**John Batsis:** And the nice thing there is that there are likely going to be some additional options down the road, some emerging research. And this is where the digital technologies are hopefully coming into play that we're able to kind of use some of these that are more scalable and can be done in the home base setting to kind of overcome some of these other logistic barriers.

But you're absolutely right. Getting some of this data is critical because then it can guide us because if you're losing too much muscle, well, then you got to put the brakes on. And this is where I want to share with the listeners something that I really feel really important and passionate about. We know that when you lose weight and we need to go move away from a weight-centric approach, I think, and particularly with older adults, it's not about the pounds. It's how much can you safely lose to improve your physical function and improve your comorbidities, meaning your high blood pressure, diabetes, high cholesterol, like, but improve your physical function without losing too much muscle mass because there's a sweet spot. That is the key. There's a sweet spot. We don't know what that sweet spot is.

**Jim Hill:** But John, it sounds to me like you would be much more concerned about loss of lean mass in an older individual than a younger individual. Is that the case?

**John Batsis:** So two points. One, yes. And the reason why, because we know as one ages, one's total lean mass actually is lower in an older individual than a younger individual. The counterargument that some folks say, well, persons with obesity or who have excess weight, actually, they have a larger amount of lean mass relative to their body size. That's true, but their muscle quality is often diminished as a result of that. Again, we need further, a lot more research on that. But again, everybody has a given threshold where once that muscle mass diminishes past that threshold, they'll develop a disability.

We don't know what that is for everybody. And this is again, comes into play that I always like to say, this is like a line that I love to use and everybody's saying, oh boy, here he goes again. One older adult is one older adult is one older adult. Everybody's different. There's so many differences that while we generalize and we use science to generalize, and this is where we need to individualize it based on the individual person.

**Jim Hill:** So we know that bodybuilders, for example, can increase muscle. Normal people that aren't doing massive amounts of bodybuilding and so forth, is it possible to actually gain muscle?

**John Batsis:** Yes. So I think short answer is yes. And the challenge here in an older adult is you have some competing forces, multiple competing forces against you. Your ability to build protein diminishes. Your breakdown of protein increases. So it's kind of you're destroying more, but you're not building more.

So it's kind of like your net negative is even more negative. So with nutrition, and this is where we need, you know, the protein guidelines, protein supplementation needs to be augmented and increased in older adults relative to younger adults. You need a larger amount for the same effect in an older adult as a younger adult to get the same effect. Using and then that plus resistant exercises will allow, you know, in a formal training program like that will allow enhancement of physical function and muscle strength. And I think another key point to your listeners is just because you enhance an increased muscle mass doesn't necessarily mean you increase muscle strength. And that's a big misconception.

It's about muscle quality. And we haven't gotten to that. We haven't figured out that relation. They're related, but they're not directly related just because you increase muscle mass doesn't necessarily mean muscle strength increases.

Just because you lose muscle mass doesn't mean muscle strength diminishes. So there's there is kind of an inter intermediary. There's something in the middle that we're missing and we're still trying to figure that out though.

**Holly Wyatt:** So it sounds like that you can increase muscle mass that you can increase strength that there may not be exactly correlated but are exactly the same. But there's something there. So that's good news. But the question I always get and this is why I want to ask you because I know what I say, but for the average person, this happens all the time. They are losing weight. The scale doesn't move. And what they think is happening is they're losing fat but gaining muscle. So they've lost five pounds of fat, but I've gained at the same time, five pounds of muscle. Can those two processes happen? simultaneous. I mean, bodybuilders don't do them at the same time. Bodybuilders tend to build and cut. You know, I always say build muscle, cut fat, build and do cycles. How easy or hard is it to do it at the same time?

**John Batsis:** Everybody's different, right? So can it be done theoretically? Can it happen at the same time? I guess theoretically it can happen at the same time. And I think this is where it becomes frustrating, right? Because we've always been focused on the number.

We're always hoping that the number decreases. But if you're the relative changes favor more muscle and fat, that's actually, it's a good thing. Your muscle is a main driver of your metabolic rate at the end of the day. That is really what's more important than the fat.

You know, it's, it's the balance though. So when, when folks say, oh, I haven't lost weight, I'm like, well, but you know what, tell me what you can do functionally. Well, yeah, I can go up now five flights of stairs and I'm not short of breath anymore, or I can play pickleball, you know, and I use that as example because I just saw two patients that were diehard to pickleball fans this morning, you know, in the clinic that, that for me is great. If they're functionally able to do something that they weren't able to do before, I really am a firm believer need to move.

What is the goal? It's not the pounds. It's really what can you do? Are you able to get on the floor and play with your grandchildren? No, well, maybe that's a goal. Maybe the goal is to be able to, you know, play a sport. Maybe the goal is to, you know, walk around the block. Because right now, I have too much pain and, you know, that I can't do that. Everybody's different. And that's where the individualization comes into play.

**Jim Hill:** John, in the obesity field right now, one of the kind of things that everybody hears about are these new medications, the GLP-1 based medications that are producing a lot of weight loss. Holly and I talk a little bit about that, you know, there's so much good news coming out. Are there things we should worry a little about?

And one of the things that we feel like we don't quite have enough information on is whether these medications, particularly in older adults, might be resulting in more loss of muscle mass than we would like. What are your thoughts on that?

**John Batsis:** I appreciate you bringing that up. I'm a firm believer that the wave of treatment of obesity is changing if not has already changed. We are in a new era of treating obesity. And it's I am super excited for our patients and for society and from a public health standpoint as a whole.

Now, that's on my, my favorable exciting part. Now, I always like to put my scientific and my geriatrics hat on here. My geriatrics hat on is start low, go slow. And I'm super cautious.

And that's just the way I guess maybe geriatricians like myself are trained. I want to see the data. And right now, when you look at the data on GLP-1’s, and I'm going to say newer novel increments, because the GLP-1’s, as we all know, they've been around for a while, but they're just different generations for lack of a better word. The newer ones that are around have been released, you know, for treatment of obesity. When you look at the studies, irrespective of the issues of body composition, the majority of the studies, they're very, very few that have been tested solely in older adults. And some of the cardiovascular, the heart failure ones, median mean age is in the mid-sixties, what does that mean?

Likely half or over 65, half or under 65. So you need to be mindful of that from a, you know, does it apply to the patients that you're seeing in front of you? I think importantly, too, is that you need to be mindful of some of the outcome measures. What are outcome measures that you're looking at? You're thinking about body composition, as you said, you know, muscle mass, physical function, a lot of subjective physical function, but they've been also on younger populations with very few objective functional measures.

Six-minute walk is pretty much at least to my reads, that's the only one that I've seen in number of these clinical trials. When you look at age breakdown, I have not, the studies have been very limited in terms of age breakdown, 65 to 75, 75 to 85. And taking a quick sidebar, when you think about when you recommend weight loss, there's no upper age limit in terms of when you should stop recommending weight loss. When you look at the guidelines, no guidelines say at over this age, you shouldn't. Clinically or epidemiologically, when you look at the data over 85, the curves, the risk of death, for instance, flattens after the age of 85. At least the clinical trials that I run, and like some of my colleagues run, we generally exclude individuals over the age of 85. So the data, forget about over 85, but even 75 to 85 is markedly limited, if not nonexistent. So there's a lot of gaps there, and there's a paucity of data on body composition data. So you got a lot of gap, the skepticism, this is a scientist in me saying, okay, promising data, we have definitely on younger populations, improvements in comorbidities, you know, blood pressure, diabetes, resolution, you know, these studies on improvements in cardiovascular events, sleep apnea, kidney disease, etc.

Great, super happy. However, we don't know their effects on lean mass. To the extent that we want to know, bone is another issue that we haven't really talked much about. But we know from the same from the bariatric surgery literature when we think about bariatric surgery, weight loss surgery leads to profound amounts of weight loss, that has an effect on muscle, and it has effect on bone.

There are other metabolic reasons for having lost bone with bariatric surgery, but you're still losing a considerable amount of weight. These are unanswered questions that need to be answered, though.

**Jim Hill:** Yeah, and you know, that's the way research works. Hopefully, we're going to get some of those answers. And right now, you know, as we learn more, we'll communicate that.

**Holly Wyatt:** If you're, let's say, a listener out there is on the GLP-1’s, and they are concerned, you know, we don't have the data, we're not sure what it's doing to bone. We're not sure what it's doing to muscle, especially as you get older. What would you recommend? How could they, is there anything, I mean, you don't know for sure, obviously, we don't have the data, but preventing maybe something that you would, they could try to maybe prevent that loss.

**John Batsis:** And maybe what I can do is it can give you the approach that I give in my practice, my primary care practice with folks. I have a frank conversation with them to say, you know, there's other issues in older adults from a coverage standpoint, because Medicare will only cover if there's a coexistent diagnosis of diabetes with some of these newer agents. But irrespective from the coverage and insurance issues, I want to make sure that they've actually engaged in a lifestyle intervention. I've referred them to a dietitian, I've had them see an either an exercise physiologist or physical therapist, and they've actually engaged and tried. Not, here's a prescription for a medicine and off you go. Just to make sure that they've done an engage in that foundation.

Why? Because if I'm prescribing a GLP-1 medication, I want to make sure that they're continuing those lifestyle measures while they're pursuing and while they're taking that medication. It's really important that they do that. Because then, because we know from the lifestyle studies, and I think that's really the key here. There are the seminal lifestyle studies in older adults of obesity. Those individuals that engaged in resistance, exercise, training, while losing weight actually had a mitigation of muscle and bone loss. They still lost a little bit, which is fine. Their physical function synergistically, there was marked improvements in physical function.

They lost some amounts of muscle and bone, but it was much less than just the weight lost or just, you know, the control group. So that's really important to be mindful of.

**Jim Hill:** Holly, can we take some questions we've gotten from some of our listeners?

**Holly Wyatt:** Yes, absolutely. You want to start?

**Jim Hill:** Yeah. Okay. John, here's one from Brian. I'm 65 years old and retiring this year. I have time to finally work out more. I want to gain some muscle. What and when should I eat to gain muscle?

**John Batsis:** So the million dollar question is timing of food. And, you know, there's been some interesting studies coming on in terms of like time restrictive eating and the like. And actually, I was at a conference last week that actually shared some of that data. I think the jury is still out on that, you know, in terms of, you know, and particularly in older adults and in particularly how it affects, there were some interesting outcomes on cognition in terms of memory and how that can affect memory. But I think that the jury is still out in terms of time-restricted eating. What we do know with protein supplementation, it appears protein supplementation post-exercise is likely where you want to, if you're going to supplement protein, it's after exercise.

Why? You've exercised, you've primed your muscles, muscles are hungry for protein, you're giving them protein, and they're eating the protein and they're like, give me the protein, and it's there. Boom. You're able to kind of, and it's there for them.

**Holly Wyatt:** Yeah. So can you tell us, again, our listeners, how much protein in a typical day should they be maybe shooting for if they're trying to gain some muscle? And also then how much supplement if you're in that window that you're talking about?

**John Batsis:** Yeah, you know, and this is where it gets really tricky because you start dealing with like, you know, the average recommended daily allowances, you know, about 1.2, 1.3 grams per kilogram per day. I, someone asked, it tells me that to myself. And I say, I don't know how much that is.

What does that come out to? And this is the importance of what I like to call interdisciplinary team-based care. You're working together with a dietitian that could potentially help you figure out what does that look like individualized with your own diet to say, this is what a given protein amount per day looks like. Spreading it during the day would be helpful. We've seen in some of our own protein-based studies, you know, 25 to 30 grams of protein, you know, particularly some of the whey-based protein, either shakes or supplements post-exercise can be helpful.

And that's usually, you know, it's a scoop full of powder and mixed in water after exercise.

**Holly Wyatt:** Yeah, so you're saying the window kind of look for 25 grams might be someplace to start for that. I think that's a good number people can look for. And then total in a day, I know we kind of do it by body weight. But what kind of what do you look at? 1.5, two times?

**John Batsis:** Well, you want to be careful too much. And again, you know, when it comes to weight loss efforts, it's between and the actual range is still kind of a little up in the air, we're still recommending about 1.2, 1.3 grams per kilo per day, kilogram per day, too much, you know, you got folks that are worried from a, you know, kidney liver standpoint, although some of the more recent data is showing that that's probably not as much of an issue as, you know, we were worried about 10, 20 years ago.

**Holly Wyatt:** If their kidneys are functioning normally, if you have someone who has kidney failure or problems with their kidneys, and absolutely, there may be some limitation.

**John Batsis:** Different story. Correct. Yeah.

**Holly Wyatt:** Yeah, I think it goes kind of nicely into what we were just talking about. So this one's from Debbie. I mean, she's asking, are there any over-the-counter supplements that she could take that would help her maintain her muscle mass and function? So she's heard about function before as she gets older.

So she's kind of like, I don't necessarily want to gain it, but I want to prevent it from going down. What else can I do? Is there any supplements that would work?

**John Batsis:** There are a number of supplements that are currently on the market. And a lot of them are protein, you know, are in the kind of the pathway for muscle buildup, so to speak.

Beta hydroxymethylbutyrate is one. And there actually is some literature. We're actually in the process of conducting a study on that right now. But there is some data that's showing that that actually may be promising as an adjunct to exercise to build muscle. Here's the challenge with some of the supplements is that we know that we need more data again.

They're not as regulated. They're not medicines. And you want to be able to have a discussion with your clinician to say, if I'm interested in this supplement, what's the data behind it? Are the people that it's been tested on? And the studies are these studies legitimate? Have they been published in peer-reviewed journals? And have they been published? And what are the methodologies? We actually published a couple of years ago, as part of a group that we published weight loss supplements and the impact of weight loss of supplements on weight loss. And we went through over 20,000 peer-reviewed articles and realized that while there's a lot of articles out there, the methodology of a number of these articles is really fraught with challenges. So it's just something to be cautious. I wanted to share with the readers.

There's a lot out there. Talk to your talk to your providers, because the methodologies of being able to extrapolate and make say, Hey, you know what? This study is a good study. That study is not a good study.

**Jim Hill:** All right, last the last one here from Elizabeth. As I get older, what's the best BMI for me to shoot for? I've heard it's okay to have a little extra fat after age 60. Is that true? Or should I try to be leaner?

**John Batsis:** So BMI, I always like to say is not the greatest measure. This is actually really important when you look at the data of what is a normal BMI of an older adult? When we think about BMI, BMI is weight in kilograms divided by height and meter squared. We know individuals can naturally gain weight with aging, but they also lose height with age. And when you look at the relationship between body mass index BMI and mortality, there's actually one really well-done study that combined, it was I think over 197,000 individuals and looked over a 12-year period of time older adults over the age of 65. And it found that the lowest risk of death was a BMI in the overweight range, about a BMI of about 27.

And it comes full circle to what I said earlier in our conversation about it's inability to really discriminate between fat and muscle. We know that a BMI of 35 and above is bad, is not good. 30 to 35 is probably not good.

25 to 30 depends on what study you're looking at. A BMI of 20 to 25, this is where having another measure is really important. And if I can put a plug in for waist circumference, so you could have a normal BMI. Someone comes in, say even a BMI of 25, you'd be like, Oh, BMI of 25, fine. But if their waist circumference is significantly elevated, that's a problem because we know that waist circumference is a marker of what we call visceral fat. Visceral fat leads to a lot of inflammation. And that we know increases the risk of mobility problems, cardiovascular disease, frailty, etc, etc.

**Jim Hill:** Now I agree with you on the value of waist circumference. A lot of athletes with a lot of lean body mass have a small waist circumference. So it's one way of distinguishing. Holly, you know what time it is?

**Holly Wyatt:** What time is it, Jim?

**Jim Hill:** It's time for the personal vulnerability.

**Holly Wyatt:** Oh, my favorites. My favorites.

**Jim Hill:** I have one. You may have one too, but I have one.

**Holly Wyatt:** Okay. All right, let's hear it.

**Jim Hill:** All right, so John is not an older adult. I'm not going to talk about his age, but he's certainly not an older adult. My question for you, John, is what are you doing now that is going to help you in healthy aging in the future?

**John Batsis:** Well, that was an easier question that I was anticipating. Boy, I was getting scared there for a minute.

**Holly Wyatt:** Oh, wait, wait, mine, I haven't asked my question yet.

**John Batsis:** Oh, no. Oh, I thought I got out of it. I could say saved by the bell, but I guess not, not just yet. I think there's a number of things that are really important from a healthy aging standpoint. Eating healthy, I think is really important. I'm going to tout my Greek heritage as something that I try to kind of instill in myself and my family.

So try to, you know, maintain a Mediterranean diet as best as I can with my, the olive oil that, you know, privileged enough to kind of get from the family back from the motherland, as they like to say. But also social connectedness, I think is really important. And I know we haven't talked about that in this context, but that's really important is just really being close to family.

I think that plays into a part, I think, just about any, anything, you know, health related these days.

**Jim Hill:** Okay, Holly, now get yours.

**Holly Wyatt:** All right. So kind of thinking back over your career. And I love that you have passion about it. I can tell this is something you love to do. So this is, this is good. This is good. What did you get wrong? What's your biggest mistake that you made? And we all make them. This is vulnerable. But you know, that it's, it's all we all do it. What's your biggest mistake that what you got wrong, what you would do differently, maybe if you could go back?

**John Batsis:** Ooh, that's a good one. What would I do differently?

**Holly Wyatt:** In retrospect

**John Batsis:** I think, the thing that I would do differently would probably be, you know, I've learned a lot in terms of leading teams and working with different individuals. And I think, being able to, you know, I've tried to always learn and process improve. I think that's one thing that is really for me really important, learning from mistakes. And I think one of the things that I think those could have been helpful for me is really, I had good mentorship. And then I think having more mentors, I think earlier on, you know, in later in my career, you know, kind of, I had good mentors early on. And then I think having consistent multiple mentors, I think that's where I'm missing. I think would have been good.

**Holly Wyatt:** Connection, connection to others. And that's sometimes get really can get those ideas going and and learn a lot that way. So yeah, great. Awesome.

**Jim Hill:** All right, Holly, you want to sum up what we've learned in this episode?

**Holly Wyatt:** Oh, Jim, you do that so well. I'll let you do it. Give them the pie and the plate. What do they take away from this?

**Jim Hill:** I think the messages here are when you're losing weight, you're going to lose some as fat and some from other sources, muscle, connective tissue, bone, and that's okay. You probably have excess of that when you're overweight or obese. What you want to do is to maximize fat and minimize loss of muscle.

Some of that is genetic out of your control. And maybe if you're an older adult, and we're going to say above 65, you really need to be a little bit more concerned about loss of muscle just because you're losing it anyway with age and you want to preserve it. You can't change the genes, but probably what you can do to minimize the loss of muscle is the lifestyle is the healthy eating and the physical activity. And I think in physical activity, you probably want to include some resistance training, something that causes you to get a little better at lifting weights and so forth. And again, you may not be able to increase your muscle mass, but I think the goal is to try to minimize loss of muscle mass. And the best thing we can do right now is lifestyle. If you want to look at something like bioelectrical impedance for measuring your body composition, recognize it's not super accurate. But as long as you use it in the right way, it may give you a sense over time of how you're doing in your weight loss. How'd I get it, John?

**John Batsis:** Sounds good. Yeah, you nailed it.

**Jim Hill:** So again, weight loss is a great thing. Just realize it's not all fat, but enough of it is likely going to come from fat to really improve your health. So thanks, John. We really appreciate your time. And we've learned a lot today.

**John Batsis:** Well, really appreciate the opportunity to speak to you both and to the audience, of course.

**Holly Wyatt:** This was great. Thank you so much.

**Jim Hill:** Yep, we'll talk to you next time on Weight Loss And. Bye. 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:** If you want to stay connected and continue exploring the “Ands” of weight loss, be sure to follow our podcast on your favorite platform.

**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.