Robbie: Yeah, I think we’ve all had that client, as you said, and it can lead to a lot of frustration, because you think, as a practitioner, you’re doing all the right things, and only to just not yield the results that you or the client are looking for. So, it can cause a lot of frustration. But I think it’s a no-brainer. All our practitioners, we do a thorough investigation and an assessment. That’s the first and foremost thing that we need to be doing. You’re looking at what they’ve currently been prescribed, in terms of interventions, or in terms of investigations, and see what has been done to date, and therefore, you’re filling the gaps. And I think investigating resistant fat loss, especially when all the traditional methods, like diet, exercise, just don’t get the results that you’re looking for, it does require a more comprehensive assessment and investigation. And I think that that’s where some of these more functional tests can really provide great insights into these various underlying factors that might be contributing to that stubborn fat loss.

Andrew: Okay. So, let’s delve into there a little bit. What sort of investigations do you tend to work with?

Robbie: Yeah. I think, firstly, it’s the obvious ones. You’re really looking at what might be additional factors, and these are typically hormones. So, you might be looking at a thyroid function test, where you’re looking at your TSH, your free T4, and your free T3. Because these are all critical for your metabolic rate. And you’re also looking at the thyroid antibodies as well, which a lot of mainstream medicine or GPs don’t typically investigate. But this is obviously assessing autoimmune thyroid conditions, like Hashimoto’s. Hormone panels are always great, whether it be salivary, urinary, in addition to blood, because that can really break down the metabolites, and we’re looking at things like cortisol, your estrogen, progesterone, and testosterone as well, and even the precursors, like in adrenal hormones, your DHEA as well. Vitamin D, very important. We also know that mainstream medicine doesn’t like to prescribe vitamin D anymore, but that can tell a huge insight into somebody’s immunity.

And then, I typically do a comprehensive metabolic panel. So, that’s looking at your liver, kidney function, electrolytes, your blood glucose levels, fasting insulin, and also the HbA1C, and you can see where I’m kind of going with that, which is looking at potential investigation for things like insulin resistance, polycystic ovarian syndrome, or any other metabolic dysfunction that’s occurring. Finally, I will then also probably look at a lipid profile, because we know that cardio and metabolic go together. So, we really wanna investigate and assess the cardiovascular risk as well, which is your LDLs, your HDL, your total cholesterol, your triglycerides. And then also, looking at inflammatory markers, because inflammation is a key driver to a lot of this stubborn fat loss that we see. So, CRP, and also ESR are just great little insights. And finally, gastrointestinal health tests, which people tend to do last, but doing that, and putting that higher up the list, could save you a lot of time and head-banging against the wall. So, things like a comprehensive stool analysis, looking at gut permeability, and even SIBO as well, small intestinal bacterial overgrowth, because we know that there’s a huge link between obesity, metabolic dysfunction, and also gastrointestinal health as well.

Andrew: With regards to things like cortisol, when you’re dealing with a patient who’s obviously stressed, and distressed, and I’m remembering this patient who, you know, with the first poke at her weight loss, she actually put on weight from, you know, a nice whey protein. But there was so much stress involved in her life. Indeed, she was almost under this pressure. She was like a bubble, about to burst. The pressure, not the vision. But there was so much inflammation that I saw there, and I was just going, “Oh, we’re poking at this with a stick. We’re not getting right down to what’s really going on.” But what was really interesting to me is the impatience of this patient to want to go and delve further. They just wanted something now, and I’m like, “That’s not gonna happen. It’s not. It’s obviously not worked. What you’ve tried before hasn’t worked. Why do you want me to do another one of those things that you’ve tried before, and this time for it to work?” So, how, then, do you get across to these people, what has happened isn’t working. We either change tack, or don’t do it. How do you get across that message?

Robbie: Yeah. Yeah, I think it’s more about the education piece. And it’s the empathy, which I think a lot of practitioners have, right? They’ve seen it regularly in their practice, particularly we functional medicine practitioners, where maybe the system has failed them, with a, either a misdiagnosis or an under-diagnosis. So, you’re really just wanting to communicate with them that you’re wanting to rule out a lot of factors, and then look into new things that haven’t been investigated to date. And when you start talking about possibilities around new complications, or new causes, then they get more excited, because they really understand that, okay, sure, this has not been looked into, so therefore I might go along with this. And you find that at that point of despair, that they will typically take you up on that offer. But again, it comes away how it’s communicated and educated.

Andrew: Yeah. So, with regards to, you’re talking about looking at the gut, and it’s critical that at least at some stage that this is looked at. And now, obviously, that depends on where they’re on with their journey, how much money they’ve got, how much money they’re willing to put in. I get, I understand there’s so many variables. But, you know, speaking with people like Jackie Bowker, and this beautiful positive speech that she has, you know, everything negative is actually a positive because it gives you information. Brilliant messages that she translates. Awesome. So, talking about things like testing the gut for inflammatory markers, or indeed inflammatory microbes, that might be, say, you know, carbohydrate harvesters, the Firmicutes, how do you get across the importance of doing this to patients?

Robbie: Yeah. Absolutely. And firstly, I’m really assessing what their current symptoms are of their gut. Because that in itself is a bit of an indicator, and usually, if there is some inflammatory or systemic inflammation that’s going on in the body, there’s going to be some gastrointestinal disruption as well. So, you find a lot of these people do have some gut issues, whether it be as simple as bloating, gas, reflux, or, worse, they’re on things like proton pump inhibitors, and medications that are treating GERD or reflux, and that’s when I really wanna know, okay, well, how long has this been going on for? And also, if there’s diarrhea, constipation, pain, and noticeable steatorrhea, so, fat in the stool, and things like that. So, when they start ticking all these boxes, you’re like, “Okay, that hasn’t been looked into yet, so I think you’ll really benefit into this type of testing.” And then it’s more around discussing and communicating the mechanisms linking gut bacteria to metabolic health. So, you’re really trying to communicate that well with them. So, like you mentioned, the energy harvesting, you know, there’s certain bacteria that are more efficient at extracting calories from the diet, which can lead to increased energy absorption and fat storage.

So, these are things that the person starts going, “Okay. I did not know that.” And then it’s looking at how this test can also look into their gut barrier function. So, then you explain that an imbalance in the gut microbiota can certainly compromise the integrity of the gut barrier, which then leads to that intestinal or increased intestinal permeability, or that leaky gut, as we like to call it in industry, which then allows for all those endotoxins to cross over into the blood barrier, and that is a flow-on effect to all those other symptoms they might be experiencing, like foggy brain, cognitive impairment, forgetfulness, lapse in memory, all these type of things, that you start putting the pieces of the puzzle together. And of course, the number one thing we see is dysbiosis, which is usually due to that imbalance of bacteria, which can lead to that, again, increased intestinal permeability, and also inflammation in the gut. And we know that chronic inflammation is the key driver for metabolic dysfunction, and also things like insulin resistance as well.

Andrew: Do you tend to, though, favor, let’s say the word “attack” or “addressing” inflammation? Or do you address the gut as a milder sort of thing?

Robbie: Well, Andrew, don’t you think they go hand in hand? It’s kind of like a chicken and the egg situation.

Andrew: Good point.

Robbie: It’s, you know, it’s, is gastrointestinal dysfunction leading to the inflammation? Or, is the systemic inflammation that this person has causing the gut issues that they might be experiencing? Both might hold the key as to why these type of clients struggle with their fat loss. So, in my opinion you can definitely address both at the same time, and we know that the gut microbiome and the microbiota is a complex and dynamic community, that significantly influences metabolic health, and that includes the insulin sensitivity component. So, again, it’s not just about blood work anymore, and looking at what someone’s fasting insulin is. It’s looking at, at the microscopic level, as to how this bacteria might be influencing how your body is actually metabolizing these type of hormones in your body.

Andrew: How important is the right diet, and which one? Because we’ve got data on, you know, Mediterranean long-term for everything. But then you’ve got, you know, shorter-term, and indeed, there were some long-term gains with, you know, for instance, keto. I don’t know about carnivore diets and things like that. We know that the SAD is, the SAD diet is exactly that, the Standard American/Australian Diet, whichever one you wanna use. It is just not working. But which one do you favour?

Robbie: Yeah. I think, well, first of all, as a dietician, I obviously do a lot of intervention with food and nutrition. It’s really making sure, first and foremost, there aren’t any nutrient deficiencies. Because we know, I mean, I get a lot of people coming to see me who are already following a particular protocol, whether they’ve listened to a podcast about it, or they’ve heard an influencer talk about it, and, you know, what worked for them, think that that’s gonna work for them individually, which is not necessarily the case, as we know. So, I get people coming to me thinking, “Oh, yeah, look, I’ve got this stubborn fat loss. I haven’t achieved it.” They’re either on a low-calorie diet, they’re on a low-carb or ketogenic diet, thinking that carbohydrates are actually the devil, and that’s what’s the cause of their stubborn fat loss.

But it’s not until I do that reeducation, and look at everything as a whole. So, when you ask me about what type of dietary protocol is appropriate, it’s, again, looking at the individual. And if I have these answers at my fingertips, say, the results from a complex gastrointestinal test, like the GI-MAP test, or the gut 360, whatever pracs want to use, that’s giving you a really good indicator as to how their gut is actually responding to the dietary protocol in itself, because we know there are specific things that are important for certain bacteria. Fibre is probably the most important. So, of course, if you’ve got people who are on a carnivore diet, who are not consuming a lot of plant-based foods or whole grains, which then contain this really important fibre for our gut health, their microbiome will be significantly different to, say, someone who might be on a more plant-based, vegan, vegetarian-style diet. So, again, it’s looking at what they’re lacking, and trying to make sure that there is a nice balance. Prebiotics are obviously important. Probiotics are important. We know that saturated fat, or too-high levels of saturated fat, can certainly influence or elevate levels of inflammatory markers in the gut. And then also, even artificial sweeteners have been shown to alter the gut microbiome as well. So, again, I’ve got a little bit of a checklist that I’m looking at in terms of their consumption or lack thereof, and then making the assessment on the back of that.

Andrew: I’ve gotta ask, comment. I wonder if I’ve noted… Like, I’ve seen in the past patients with inflammatory bowel disease being put onto a milk-based liquid diet short-term. But that’s it. Only that. I look here, you know, about the carnivore diet, and you see other people using some other restrictive diet. Let’s instead, rather than restrictive, let’s call it, at least for the short term, oligoantigenic. And I wonder, I don’t know, but I wonder if any of these might have a place in, over the short term only, having this effect of just saying, “Let’s just give the gut a rest for a second.” Then you must heal it. Because you can’t stay on that nutritionally deficit diet long-term. But in the short term, I wonder if part of that…it’s not attraction…part of the key to the therapy, if you like, is that oligoantigenicity. I think I made up a new word there. Have you ever used that? Like, does it gel with you, or…?

Robbie: Yeah, I think there, I mean, there is certainly emerging research around that approach, from a dietary perspective, for inflammatory bowel disease. But there’s also some interesting research around intermittent fasting as well. So, as you say, it goes back to giving the bowel a bit of a rest, and that you’re not providing a huge dumping of food immediately, especially upon waking, and that might give it a little bit of a rest-and-digest ability, so to speak, which can also be beneficial. But in terms of an oligoantigenic diet, you know, as you say, foods to include… It is restrictive, because you’re looking at simple, non-allergenic foods for these type of people. You’re looking at specific vegetables. You’re looking at specific fruits. And, again, it might lack things like protein, for a lot of people, which is problematic at the end of the day. So, you really need to see how the person is responding individually, because I’ve had some people who might respond well, and others who just don’t at all.

Andrew: Right. Okay. So, let’s move on to supplements. What supplements do you use? What do you like here? Let’s go your top five. You know, what sort of things do you find has most bang for buck, when you’re looking at helping somebody with stubborn fat loss?

Robbie: Yeah. And, you know, I think it’s important to note here when we’re looking at this, it’s like, if I were to recommend anything, it’s on the back of results, right? It’s not just like, “Here you go. Try this. See if it works.” We’re really looking at things that have been, have a bit of evidence behind them, that might really improve things like dysglycemia, dyslipidemia, insulin resistance, things that are obviously then picked up, and said, “All right. This is one of the triggering factors to your stubborn fat loss. We need to support that.” And let’s be clear. These people might also be on medications. So, they might be on things like metformin, if they have already been diagnosed insulin resistant. So, I would typically then concurrently support them with that, through, say, these type of supplementation.

So, things that I like in these scenarios is good old berberine. I think any practitioner who’s done any form of cardiometabolic, even gut improvement, is looking at berberine. We know it can improve metabolic function through many different mechanisms, such as activating the good old activated protein kinase, to enhance that glucose uptake, and also fatty acid oxidation. We have seen in certain research that it improves insulin sensitivity, and also reducing insulin resistance. It modulates the gut microbiota and reduces those endotoxin levels that I talked about. It has anti-inflammatory properties, antimicrobial properties. And it also enhances mitochondrial function. So, needless to say… Oh, actually, one of the good things I see also about berberine is that it inhibits the hepatic gluconeogenesis, and reduces that intestinal glucose absorption, which is what you want in, obviously, people who have dysregulation, or cannot manage their blood glucose levels appropriately. And, there are some practitioners out there who will argue that berberine supplementation is just as good as metformin in terms of treating insulin resistance out there. So, huge fan. One you have heard of, we’ve talked about many times before, Andrew is Myo-inositol.

Andrew: Yeah.

Robbie: It has so many benefits for different population groups, especially amongst those women who experience things like polycystic ovarian syndrome and endometriosis. So, it does have a great metabolic effect on the body, by improving insulin sensitivity, because it enhances insulin signaling, which then reduces that insulin resistance, and promotes the glucose uptake. It then helps regulate that ovarian function, that we see in that PCOS, like we talked about. Lipid metabolism. So, it reduces serum lipids. And that hepatic fat accumulation, which is really important. So, we don’t wanna see the fatty acid. So, we… Sorry. We don’t wanna see our liver enzymes being elevated, so that’s where I’m looking at those results. It has anti-inflammatory effects, because it lowers those levels of pro-inflammatory cytokines. And it also might improve the good old endothelial function as well, by enhancing the vascular health within the body.

So, two major ones, are pretty much at the top of my list. And just to name a few more, things like chromium are also good, which has been shown to improve glucose metabolism, and also things like cinnamon, which can be used as a spice, a natural spice in the diet. Alpha-lipoic acid, I’m a huge fan of.

Andrew: Yes.

Robbie: Yeah. And that’s because it has antioxidant properties as well, so it’s really helping reduce oxidative stress and any inflammation that’s occurring. And also, it is working towards insulin sensitivity, by also enhancing that insulin signaling as well. It works on mitochondrial functioning, and also can look at, has the anti-inflammatory effects, like I mentioned. And lipid metabolism. So, it has so many great things there that we’re trying to recalibrate, so to speak. And then, through the diet alone, people can just try to increase their green tea intake throughout the day, due to the great polyphenols that are in there, which we know can also improve the gut microbiome. It can reduce beta glucuronidase, if those levels are high, so we need to increase polyphenols in the diet if we see elevated beta glucuronidase in our stool tests. So, green tea is a fantastic way of being able to incorporate that. And I like it for so many more reasons than a, you know, metabolic enhancer, as they like to call it in industry, where they’ve got supplements for green tea, which I don’t necessarily recommend. But more to the point, great, natural green leaf, matcha, green tea, can really do the trick in those situations.

Andrew: Yeah. Couple of things on dosage I’ve noticed. For instance, firstly, there’s a little bit of jockeying about dose with Myo-inositol. And, for instance, there was a professor who, might I say, Professor Annabel Teede gave one of the best podcasts ever on polycystic ovarian syndrome, and the incredible work they’re doing at Monash Uni. Hats off to you. But she’s not in favor of Myo-inositol, and, in polycystic ovarian syndrome. And I suspect that one of the issues she’s faced is the extremely low levels of Myo-inositol that you get in some supplements. You know, 200, 300 milligram. I’ve seen, like, 60 milligram in one. What dosage do you use with this, and things like berberine? ALA, indeed, as well?

Robbie: Yeah, absolutely. So, you’re looking at, in terms of Myo-inositol you’re looking at about 1000 to 2000 milligrams per day. It really depends on, obviously, all the other things that might be going on for this particular client. But, for example, anyone who wants to learn more about hormones, I’m a huge fan of Doctor Carrie Jones, who’s now at Rupa Health in the United States, but who was previously working for Precision Analytical, who does the DUTCH test. So, she was the medical officer for them, and she is, just knows so much about hormones. And so, that’s typically her recommendation with everything.

In terms of berberine, you’re looking at about 500 milligrams, three times a day, with meals, is what the research is showing that is typically a good dose for berberine. Yeah. Which…

Andrew: Yeah. Yep. And alpha-little… Oh, sorry. Alpha-lipoic acid, which I’ve often termed chili-flavored battery acid. My only sort of caution there is be careful if you’ve got, if you’re giving it in a capsule form to anybody who might have a silent reflux, or a sliding hiatus hernia, because if you burp that up, oh my god. It is horrible.

Robbie: Absolutely.

Andrew: So, I often get people to take that with the first mouthful of food, and push it down, make sure they don’t that up.

Robbie: Definitely. I couldn’t agree more with you. Yeah.

Andrew: Dosage on that, I remember in the early days, they were using huge dosages in patients with diabetics, like up to 1800 milligrams a day. Not really achievable when you look at a supplement regimen. But what do you typically use?

Robbie: Yeah. So, again, dependent on the individual, but you’re looking at around 500 to 1000 milligrams per day. It certainly doesn’t need to be as high as that 1800. And it’s more cost-effective, obviously, in those lower dosages as well.

Andrew: Yeah. And, chromium. Now, this is another one. So, the TGA restricts the good forms of chromium, the polynicotinate and the picolinate, to a total of 50 micrograms per day, in any dosage form.

Robbie: Yeah.

Andrew: So, 25 micrograms in a tablet means you’re allowed to say to take 2 tablets a day. Thirty micrograms in a tablet, and it’s one tablet a day, because two would exceed the 50. But there’s no restriction on, no restriction that I can see, about the chromic chloride, the poor sister, which, you know, it’s something, but it’s not as good. It’s not as well-absorbed as the good forms. What sort of dose do you tend to go up with, therefore, to chromium? Or with chromium?

Robbie: Yeah. So, you’re looking at about a 500, starting-at, micrograms. And then that can go up to, oh, up to 1000 micrograms. But, again, you’re looking at their diet as well, right? So, you’re looking at all the other chromium, and all those other nutrients, mind you, that we’ve talked about, that could be coming from the diet as well, but that’s when you wanna kind of play with those numbers, to make sure that you are looking at that. But, for those who don’t know, and again, because I’m a dietician, I try to really optimize the diet, foods that are typically or relatively higher in chromium are things like your broccoli, barley, if they can tolerate, obviously, wheat, and gluten. Grapes, surprisingly, but more like the dark-colored variety of grapes, so, the red grapes, the black grapes, even. Green beans, brewer’s yeast, oats. And then, of course, nuts. And even tomatoes are quite a good source. And also, they’re rich in antioxidants like lycopene, which are fantastic at the same time. And also potatoes. And of course, lean meats as well.

Andrew: But I like that use of oats as well. You know, I see a lot of bodybuilders using oats as a sort of mainstay of their breakfast, and I wonder if they’re using it to help even out the blood sugar swings throughout, you know, later throughout the day with the use of chromium. That’s interesting. That’s really interesting.

Robbie: Great segue. Yeah, great, great segue, because that is also so important if we’re talking about stubborn fat loss, right. You’re looking at glycemic index, but again, that is one component of it. People really just focusing on the glycemic index, which is the rate that your body is absorbing the glucose, or the sugars, from the carbohydrate-based foods, but not necessarily focusing on the glycemic load, which is the full amount of glucose that is being put into a meal in itself. So, yeah. That’s definitely something I educate my clients on as well, is showing them things like foods that are high, moderate, or low glycemic index, and then also looking at the dosage, and how much they’re consuming in one particular sitting. Yeah.

Andrew: Yeah. So, basically, glycemic index alone, and carrots are bad, or watermelon is bad, glycemic load, and you realize, no, it’s actually a really good healthy food, with no problem attached to it at all. What about movement, exercise? You’re an exercise scientist. There was a thing, oh, some years ago about instead of doing cardio first and strength training later, about swapping them, to do strength training first. Take us through this, or, indeed, what do you favor nowadays?

Robbie: Yeah, definitely. And research is always emerging, and changing. So, what was recommended before may not necessarily be the case 6 months’ time, 12 months’ time. First and foremost, I think it’s important to note that people have different abilities, and maybe restrictions. But all I recommend, first and foremost, is move more. We are seeing such an epidemic of prolonged sitting, and they’re calling, you know, prolonged sitting the new smoking, purely because of all the effects it has on the body, which can lead to risks of developing chronic health diseases and conditions. And we know, in terms of our metabolism, it requires movement in order to optimize that. So, in order for our metabolic rate to behave, or to improve, we need to be moving frequently. So, first and foremost, just sit less, move more.

If we’re talking about exercise prescription, we know that there are several types of exercise that have been clinically proven to enhance metabolic function, and therefore improve insulin sensitivity, which is the overarching goal here, promote glucose metabolism, and support overall metabolic health. And they include your aerobic exercise, so, that’s cardio, your resistance, or strength training, your HIIT training, so, that higher-intensity interval training, and also yoga and Pilates as well. So, there is a whole range of exercises that people can engage in, rather than just one alone.

But, I will be clear, I am a huge advocate and promoter of incorporating strength training, and resistance training, because obviously, that’s working on improving and increasing lean muscle mass, and that is one of the most important factors when you’re trying to optimize your basal metabolic rate, at the end of the day. And we know also the biochemical reactions that occur when we are building or increasing lean muscle mass. So, for example, it provides more storage for glucose. And we know that our muscles are one of the largest glucose storage sites in our body. So, more muscle mass means greater capacity to uptake and store glucose, reducing blood glucose levels, and improving insulin sensitivity. So, that’s very important, off the bat.

We’ve also know that it can improve muscle insulin signaling pathways. So, it basically works on the insulin receptor activation, and resistance training enhances that activation of insulin receptors on muscle cells. And this improvement in that activity boosts the entire insulin signaling cascade that we see within the body, making cells more responsive to insulin. So, big tick there. And that’s really important. And also, we know that, as a result of strength training, it can reduce the intracellular, sorry, the intramuscular fat that people might experience when they go and get a DEXA scan, for example. So, I have a lot of clients coming to me with a DEXA scan, and really able to look at where they’re holding that fat mass, and looking at that intramuscular fat, which is what we’re trying to reduce in these scenarios. And then that can just help with decreased lipid interference as well, because we know that high levels of intramuscular fat can interfere with insulin signaling. And like I said, it all starts there.

Andrew: Yeah. What about, like, we’ve spoken about the intramuscular fat, the Wagyu marbling, but in humans. But what about things like fatty liver disease, as a hurdle, if you like, to overcome before fat can be metabolized in the extremities, I’ll say, but rather than visceral fat, the abdominal fat, that sort of thing?

Robbie: Yeah, absolutely. And in correlation to that, you’re also looking at their lipid markers as well. We know that the liver is the main organ responsible for producing cholesterol. So, you’re looking at levels of cholesterol in these people as well, and their triglycerides. So, by establishing what their liver enzymes are doing, you can see if there is risk of non-alcoholic fatty liver disease, or just fatty liver in general. And then you wanna really improve the function of the liver, because you know that it’s going to be inhibited if it is experiencing excess, or, fat, that is being, all that visceral fat that is coating the liver itself. So, yeah. I would typically look at what’s going on there, and then if we do need to do a small amount of support or detoxification, then I’ll certainly include that as well, in order for it to work more optimally, for sure.

Andrew: Right. There’s so much we could go into here, Robbie, I’ll tell you. Like, this is a seminar, not a podcast. But I can’t thank you enough for taking us through some real hit points. This has been great today. Like, this has been just one point after another. It’s fantastic stuff. Your brain, like, I don’t know if you need a coffee after this. It seems like you’ve just gone  It’s fantastic information. Thank you so much for giving that to us today. It’s been awesome.

Robbie: Oh, it’s my absolute pleasure. I just love sharing education and knowledge with everyone.

Andrew: And thank you, everyone, for joining us today. Remember, we’ll be putting everything that we can up on the Designs for Health website, to help you help your patients overcome stubborn fat loss. And of course, you can pick up on all the other podcasts, again, on the Designs for Health website. I’m Andrew Whitfield-Cook. This is “Wellness by Designs.”