Ep. 45: How to Change (Vol. 1) with Dr. David Macklin
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As we think about New Year’s resolutions, host Shaun Francis talks to Dr. David Macklin, who helps people manage their weight. Here, Dr. Macklin takes the tips he’s developed to help people eat better, and applies them to the creation of other positive habits, such as how to become more physically active. Tip number one, Dr. Macklin says, involves exploring the reason you want to change in the first place. Plus: The value of long-term thinking, and how to avoid getting derailed by slip ups.
Dr. David Macklin obtained his medical degree at the University of Manitoba, Winnipeg and completed his family medicine residency at the University of Toronto. He is a certificant of the College of Family Physicians of Canada. Dr. Macklin has focused his career on weight loss, metabolism and obesity management. He is the Founder of Weightcare Clinics, co-founder of PatientTalk in Toronto and one of Canada’s leading physicians in weight care management. He has committed his career to helping others change their behaviour, develop a healthy lifestyle and manage their weight. Dr. Macklin has extensive clinical experience in the management of obesity and preventive medicine with a focus on the behavioural aspects of obesity. Dr. Macklin is a member of the Canadian Obesity Network and American College of Lifestyle Medicine. He was a co-author of Canada's clinical practice guidelines for obesity.
Listen to Dr. Macklin’s conversation with Dr. Arya Sharma about rethinking the treatment of obesity in episode 32.
To learn more about Medcan’s Weight Management program, get in touch with Kelly Cloutier at 416.350.5900 (ext. 8880) or send a note to weightmanagement@medcan.com.
Follow Shaun Francis on Twitter and Instagram, and Medcan @medcanlivewell.
Eat Move Think is produced by Ghost Bureau.
See full web transcript below.
How to Change with Dr. David Macklin final web transcript
Christopher Shulgan
Welcome to Eat Move Think. I'm executive producer Christopher Shulgan. This year even more than most, it feels appropriate to try to peg the new year to the creation of better habits: eating better, eating less, cutting smoking, cutting down on the drinking, working out more. The tendency is to get ambitious, to make some audacious declaration that requires consistent commitment for months at a time. Except then you miss a day, you feel bad about yourself, you give up.
Christopher Shulgan
But it doesn't have to be that way. In this episode Shaun interviews one of the country's experts on behavioural change: Medcan director of weight management Dr. David Macklin, who recently co-authored a chapter in Canada's clinical practice guidelines for obesity. That's valuable because changing your weight is one of the most difficult forms of behavioural change. So here, in an edited podcast version of a live Medcan Presents webinar hosted by Shaun Francis, Dr. David Macklin takes what he knows about eating and apply it to the overall practice of habit formation, to help us all develop habits that stick.
Christopher Shulgan
And if you enjoy this interview, or just want to learn more about the latest thinking in weight management, check out Eat Move Think episode 32, which sees Dr. David Macklin interviewing Dr. Arya Sharma, the scientific director of Obesity Canada. Here's Shaun's conversation with Dr. David Macklin.
Shaun Francis
David, you've talked about chronic disease as being so lifestyle originated. In fact, up to 80 percent of it might be accounted for by lifestyle factors. Can you talk to us a bit about that?
David Macklin
Yeah, it's kind of fun to tie this together with our discussion today. Thank you for having me. Thank you for inviting me. Looking forward to sharing some of my experience. The concept around New Year's and around behaviour change, there's this maybe, let's say lens that we could look at everything through, which is that studies after studies studying population, so epidemiological studies tell us that about 80 percent of all chronic disease will be attributed to really five behaviours that we are the author of, and that we have control over, as best we can control over them. And so the five behaviours are being at a best weight, being fit, strong, flexible, eating healthily, not smoking, and not drinking too much. So if you're online with those five behaviours, the numbers look like you duck under about 80 percent of all chronic disease.
David Macklin
20 percent will be bad luck, but that's really an answer to those who start to question, you know, well, really does this help? You know, I could get hit by a bus tomorrow or, you know, I might get sick anyway, or I have a strong family history of this. Is there really anything that I can do from a behavioural perspective that could change the likelihood of health and quality of life? And the answer is unmistakably yes, those behaviours to focus on. Now one caveat: not easy to change, not easy to work on, but those are five really good targets as people start thinking about the new year and behaviour change.
Shaun Francis
I think what you're saying is, you know, we often hear or read that genetics is a pre-determiner. So if I were to repeat I think what you're saying it's 20 percent genetics and 80 percent lifestyle and environment? Or how would you break that down?
David Macklin
Well actually, the best way to think of it is genetics, and most certainly, there are people that are at risk of chronic disease because of genetics. And if you take the whole genetic risk of the whole entire population, the best way to think of it is genetics loads the gun, but lifestyle pulls the trigger, or doesn't. And so it means that whatever we've been given, whatever's passed down when the sperm and the egg collided and all the DNA shuffled, and that's us, whatever we're given, we can duck under 80 percent of chronic disease with that through being on top of those five behaviours. It's a really positive message.
Shaun Francis
But you said it's hard to do, though.
David Macklin
Yeah.
Shaun Francis
How hard for most people?
David Macklin
Well, the short answer is it's really variable. So 80 percent of the size of someone's body, their risk of living with obesity, is determined by genetics. So they can work on finding their best weight, but there'll be an incredible variability in someone's capacity to both lose weight and keep it off, there'll be variability in any behaviour change. And one of the things to kind of backup on, maybe a place to start then, would be, you know, as the listeners are figuring out which of these behaviours they might be offline with and what might be improvements they might look at and how to do it, there's actually a step we take in behavioural medicine that's a step backwards first.
David Macklin
We step back and we say, one perspective for you might be the following: that, you know, we're going to introduce you and invite you to consider that getting to a best weight or eating healthfully or being fit, that these are actually long-term projects. In fact, if someone's going to succeed at the numbers we're looking for, it's best to consider these to be 20-, 30-, 40-, 50-year projects, depending on someone's age. In other words, lifelong. So if this work, managing to be fit, managed to be at best weight, managing to eat healthfully, if this is lifelong work, there's a starting point we use in behavioural medicine, which is to ask why first, right? So the question is, what possibly could be meaningful enough to you in your life that would make you willing to—and willingness is really the key word here—if this is chronic work, managing really to fight biology and be at a best weight or eat healthfully, or be fit, not drink too much, and not smoke cigarettes, if it's long-term work, what's possibly meaningful enough to you to make you willing to do this long term?
David Macklin
And so where we start in behavioural medicine—I hope the listeners will find this helpful—is the concept of introducing the foundation of what's called values clarification. It's a really hot subject in behaviour change medicine. A lot of evidence rests on the fact that if you first answer why, you're actually going to be much more likely to to maintain changes long term, and it's kind of fun to think about long-term change because it's New Year's and people think about New Year's resolutions, and those end up being short term. So that's the starting point, and I can go into a little bit more about that.
Shaun Francis
Do we set ourselves up to fail with these New Year's resolutions? Or are they good things to do?
David Macklin
We actually, in a way, by setting up ourselves for some New Year's resolutions, we don't set up ourselves to fail, but the processes that are in our way are obstacles that will, if unrecognized, make us fail. So let's start with the values piece, and then we'll go on to obstacles. So values. So here's a question. Someone wants to—they're deciding on their New Year's resolution and they want to get to a best weight they want to start—we saw the two. We saw eating healthily, and we saw fit, strong, flexible working out. So it's a fun question. Okay, you want to do those things and make those changes? Why? Well, I want to be healthier. If you can still ask why, you haven't got to the underlying value. And again, finding the value is a key for behaviour change, clarifying your values, clarifying the underlying reason why you'll want to do this.
David Macklin
You want to be healthy? Why? Do you want to be healthy so you can sit and watch Netflix with a lot of health? No, I want to have more energy. Okay, why do you want to have more energy? You'll be shocked, Shaun, at the number of people who will actually have not thought through kind of down to the level of a value, wait, yeah, why am I willing—what's interesting to me to take on these changes? And so at the bottom will be something like, well, I want to be healthy and have more energy, because, you know, I'm going to be a grandparent probably in the next year or so is the thinking. And, you know, I really value time with my family, I want to duck under chronic disease, I want to be in the direction to where my weight and my health and my fitness are least preventing me—this is called a value statement—where I want to be in the direction to where they're least preventing me from doing the things I want to do long into the future.
David Macklin
I want to travel. You know, retirement is going to come sometime soon. I want to be least limited from doing activity with my kids, with my grandkids. I really enjoy time at the cottage, I enjoy time biking, I want to travel and do adventures. And I want to be least limited from doing all these things. These are the things that are really important to me. If that's your foundation, your motivation, that that's your fuel to get up and go to the gym or to—even though it's cold outside, go forward with a workout that you had planned, then it's going to be more likely that you'll continue with those behaviours, because these are now founded on things that are meaningful to you, right? That make you willing. It's the underlying values, and they never change. So once you capture your values, write them down. I want to be working in the direction to where my weight and my health are least preventing me, where my fitness is least preventing me, where my drinking is least preventing me from doing blank long into the future. And write it down and put it on your fridge.
David Macklin
That comes before goals. Based on this value, this is my goal this week, I'm going to try to do this three times based on these values. And so I mean, the next question you asked about was, you know, are we setting ourselves up to fail? So this is kind of a transition in subjects, or switching out of intrinsic motivation of what's going to be at the root of what's going to maintain these kind of motivations towards behaviour change. And we're switching to what are the obstacles going to be? You know, what's gonna stand between someone? So what did people say? People said be more active or eat better. Well, what the obstacles are, the foundation obstacle in those two behaviours is as follows: we as humans—and this is a neurology subject, we're going right into the brain, we're going into the listeners' brains—your brain, I would tell anyone who's listening, is built to drive us, drive you towards calorie acquisition and unhealthy food eating, and to drive you to sedentariness.
David Macklin
Well, why the heck would our brain be interested in driving us to both of those? Well, it's because evolutionarily, those were the behaviours that most conferred survival. And so for example, food. I heard eat healthfully. We, our brains were built for a time when calories were scarce and finding food actually required work. And so there has to be this subconscious motivational drive within our brain that will motivate us to do the work of getting food. And once we have food, also the motivational drive to eat as much as we can and store as much energy inside of us, because who knows when food's going to be available again. So it turns out—and again, there's genetic variability here in how strong someone's drive to food will be. It's a reflexive drive. It's in our subconscious. It gets conditioned through our lifetime.
David Macklin
There's variability in who's vulnerable to this, but anyone who struggles with eating is going to have this as their primary obstacle. So they're not set up to fail, but the system is setting them up to have great difficulty. We're driven to sedentariness as well. And some more than others. Go test this out. If anyone's listening, I don't know, if you're sitting down, kick up your legs, and notice that sedentariness is pleasurable. It's pleasurable because it confers survival. Again, in a calorie-depleted environment, using excess energy doesn't really help. It doesn't help survival, that is. And so we will, at a root level, some more than others, be driven. So, you know, when will it show up? it's 7:30 in the morning, you're in bed, it's cold outside, and you have, you know, a plan to go for a jog. Your brain's going to be at a reflective level screaming, because that morning time has been paired with sedentariness and the pleasures of sedentariness so often, that a conditioning has taken place, that you're now subject to a want towards sedentariness.
David Macklin
But if you know that obstacle's there, you can kind of say, "Oh, I know what this is. And because of the clarified values, and because of how important this is to me, and because I know this is just an obstacle, and once I get my shoes on, and once I get my coat on and I'm on my way, I actually feel better, then you start to see how behavioural interventions at a medical level, at a Medcan level can help support someone, not just by telling them what to do, by helping them understand the obstacles between them and succeeding long term.
Shaun Francis
David, one of our viewers on this note has a question. He says he's been described by some as burly and it's attributed to his Latvian parents, so I guess this goes back a bit to the genetic side of it. And you always hear some people saying, you know, like, I metabolize slower, I have a thyroid issue, or, you know, you name it. What do you recommend? Is it exercise more? Or is it reduce the food for someone like this?
David Macklin
So this is someone who's saying they're burly and they're maybe struggling with weight to some degree, and their weight may be affecting their health and their quality of life?
Shaun Francis
I think so.
David Macklin
Because that's where we start, right? So first off, from genetic vulnerability, what that means is that this individual with genetic vulnerability, it shows up not through kind of thyroid problems, or secondary causes of struggling with weight are so rare. This is just kind of foundational stuff. So someone who's struggling with weight will, for example, we've learned from really cool twin studies done at Laval University back in the '90s, that if someone eats more calories than they're burning, so in other words, they're creating a calorie surplus, some people gain way more weight than others. You know that there are some people who are genetically able to, when they're eating more calories, their brain will respond by burning off as many of those extra calories as possible, and anything that they can't burn off goes into muscle. There are people on this planet who have that genetic advantage.
David Macklin
Other people, if they create a calorie surplus, it goes straight to fat, stores in fat, and their metabolic rate doesn't change at all. So in other words, their body's not fighting off the fat getting stored into their body. That happens at a genetic level, the drive towards calories, how strongly my attention will be stolen towards an opportunity at food. Some people, God bless them, are not interested in food. They can't overeat for the life of them. At a genetic brain level, 70 percent of someone's risk of struggling with weight in their lifetime is conferred genetically, and nearly 100 percent of those genes are in the central nervous system. They're in the brain, in the places that regulate weight. And so the drive towards calories, the capacity to self-regulate against wanting and cravings, that's where all humans are different. Add conditioning that's taking place through a lifetime, add complicating factors, potentially like stress, fatigue, depressed mood, anxiety, weight-promoting medications. All of these things—ADHD can play in, all of these things can complicate someone's capacity to struggle with weight.
David Macklin
We at Medcan talk about weight as a real medical condition. We talk about it as a genetically-conferred, brain-centred real medical condition for which effective, really effective treatment exists for. So the answer isn't telling you what to do, the answer is advising you you would benefit from supporting your real condition with real treatment, very effective treatment, both behavioural interventions even medication now is becoming better and safe and effective. Someone who struggles with weight deserves treatment, not advice. And treatment will become much more common over the coming years.
Shaun Francis
You just touched, David, on medication. And one of our viewers has that question. I don't want to depend on medication, she says, to stay healthy. So eating well and exercise is top of mind.
David Macklin
Right. So take a condition like high blood pressure. Someone comes into my office, you know, if I'm a family doc, and we get three or four readings in a row that their blood pressure is high. And we talk about eating healthily and exercising and managing their weight. And we look to support them in those changes, and yet they still come in and their blood pressure is up. In other words, they have not, with lifestyle alone, been able to manage this risk factor, which puts them at risk of heart disease and stroke. And so no one blinks at the idea that we would, with this chronic disease of hypertension, when an effort at lifestyle has been put forward yet the blood pressure levels haven't come down into normal, no one blinks to think that you might still do all that lifestyle work, but have the addition of medication to bring down your blood pressure and reduce your risk of heart disease and stroke.
David Macklin
So it will become less and less unusual for people to think in—specifically in weight management medicine, you know, obesity medicine, it'll become much less unusual to think of really good supportive longitudinal behavioural interventions, plus or minus the adjunctive medication depending on the individual's risk level of struggle and capacity to manage with behavioural intervention alone. We don't depend on our puffers, we use our puffers to treat our asthma. We don't depend on our diabetes medications to manage our blood sugars, we have treatment for our chronic condition of diabetes with medication. Certainly not everyone in weight management or other areas of lifestyle medicine require medication, but it's nice to know that medications are becoming more and more effective, certainly well-tolerated and safe. And it will become less uncommon in someone's mind as an adjunct or in addition to the behavioural work that they can do.
Shaun Francis
Will there be a pill in the future that helps you lose weight?
David Macklin
In weight management? We are actually in a way at the precipice of—I anticipate within exactly six months from two weeks ago, that there will be an FDA approval of what will be the most notable weight management medication that we've seen in our time, both in safety and in the ability to dampen the wanting, the biological wanting, the drive within our mid-brain that motivates us to food as humans. Oddly enough, this medication is extremely effective by replicating a natural hormone that does it ourselves. You know, there's a hormone in our body called GLP-1, and we all make it. And after a meal, it gets released from our gut, and it goes to our brain and it says, "I've had enough, I'm good." It creates a signal, and we all have it and some have more than others.
David Macklin
So the concept of where we're going in medications and weight management is you'll see replications of these natural appetite hormones that some people have more of and some people have less of. And those who have less, will be able to kind of boost up. If someone's low in thyroid, they can take thyroid. Low in estrogen, they can take estrogen. What you'll see more and more over the next five years is simple replacements or analogues they're called, of the natural hormone system that comes from our body to our brain to communicate we've had enough. And again, some people have a ton of it. Some people have very few. And so it's kind of an evening of the playing field. But even with medication and an even playing field and wanting being managed from underneath, it's still all the work. It doesn't take responsibility away from anyone. In fact, it puts responsibility in front of someone, because now with an even playing field, now you're put in a position where you can do the behavioural work that sees you find your best weight and stay there. So it's a real nice kind of marriage.
Shaun Francis
I mean, you often do read about people getting surgery, gastric band surgery, maybe in more extreme cases. What's your position on that?
David Macklin
So the foundation of these questions is based on the following. It is clarified, and I was a co-author and we're very proud, we published six and a half, seven weeks ago, a national clinical practice guidelines for the treatment of obesity. I was a co-author on the behavioural chapter. This was 80-plus professionals in Canada who specialize in weight management writing guidelines that are really an international paper. And Canada leads the world in obesity recognition and treatment and support. It's something we should actually be very proud of. And the foundation of this document, and the foundation of any clinical work with someone who struggles with weight, is to help them understand that their struggle is real. And it's a real condition, genetically-conferred, centred in the brain, progressive in that it gets more and more difficult to manage over time.
David Macklin
Our brain defends against weight loss by—this is unfair, if I've heard anything unfair. If anyone is successful in losing weight, the brain is expert at recognizing fat loss and fighting against it and defending our former weight. If our ancestors lost weight, it was never to—you know, it wasn't to look good in wedding photos, it was because the food supply was interrupted. If we start to lose weight, the brain will counter weight loss with two things: it'll increase wanting, appetite, hunger, and it'll decrease metabolic rate all in the effort that favours weight regain. So we found the answer to your question on that this is a real condition. And then we have three levels of treatment: we have behavioural intervention, which is really the foundation. I think it's very safe to say Medcan excels nationally, maybe internationally in providing an evidence-based, ethical, effective behavioural foundation to weight management, remotely, right, using remote medicine all across the nation.
David Macklin
The second level of treatment is—and again, it's not necessarily one and then the next, but a second level of treatment is the adjunct of safer and more effective medications. And then surgery is just simply that next level of treatment. For those who struggle more, surgery has been shown to be an extremely effective and safe medication. The complications of surgery are on par, in a good surgery centre, on par with the complications if someone has gallbladder surgery. So this is a safe—and it's interesting, you know, the effect of gastric bypass surgery is ultimately on appetite from hormones in the body. One of the hormones after surgery that goes to the brain to block appetite after gastric bypass surgery is actually GLP-1, this hormone that we're now able to give as a medication. So we're really advancing.
David Macklin
I speak to physicians all the time, nationally and internationally. I always say this is an incredibly exciting time for the field of obesity medicine and weight management medicine and lifestyle medicine, because of the direction with behavioural interventions, remote access to patients, plus or minus the adjuncts of medication and surgery. We're really kind of at the stage where now people struggling with weight, it's something we say is treatable, manageable. It's kind of exciting.
Shaun Francis
One of our viewers is asking, what is what is your best weight? How do you determine that for someone?
David Macklin
Great question. Falls under the concept of expectations. So I'm going to say something provocative. It's a funny way to think of it, but the advice from clinicians in ethical, effective, behavioural weight management is the following: the invitation is consider that your weight is actually not something you have control over. What we mean by that is that it's not a behaviour, it's not something you can do. In fact, there's a one-million-year-old appetite system that recognizes fat loss and tries to push against it. How strongly is your brain going to push against weight loss? It turns out, that's a variable trait primarily determined by genetics. So we invite people instead to develop the following: here's the path, here's your invitation on expectations in weight loss. The question is, would you consider your organizing to be finding the least amount of calories, the most modest lifestyle you can put together that still very powerfully maintains a loyalty to fun and food and friends and socialization and celebration, all the things you value from food, at a level of effort that is sustainable, and livable, and doable? So in other words, you work on finding your most modest lifestyle that is enjoyable and sustainable, and then just stand back and let your brain and body tell you where your best weight is.
David Macklin
All human weight loss looks like this. People start losing weight, it starts to go down, it slows and slows and slows and it kind of just pulls in somewhere, formerly called a plateau. We actually invite people to consider that that flattening is where you're pushing down, your brain's fighting back and you guys are forming a peace treaty. And that's a spot where you can land and consider staying because you've arrived at that best weight living a lifestyle that you can maintain long term, at a level of effort that you can maintain long term.
Shaun Francis
The journey begins with you wanting to start the journey, it sounds like, and trying to lay the foundation for why are you doing this? Like, what problem are you trying to fix and why are you trying to fix it?
David Macklin
So all lifestyle change, back to the big list, we're talking about eating healthfully, getting to a best weight, being fit, strong and flexible, not drinking too much and not smoking cigarettes. So the concept is finding the intrinsic motivation as to why, as I mentioned earlier is the beginning. And so now, the next step is to find out what obstacles stand between us and these changes. We talked about how we're driven naturally to foods that are higher in calorie, more dense in energy, higher in quick energy, fat, sugar, salt, these types of foods are what we're naturally driven to because of evolutionary advantages these foods offered us. And so the human brain is driven at a natural point to favour these types of foods. That is an obstacle.
David Macklin
We talked about how from the activity, so maybe the listeners are thinking about becoming more fit and really wanting to push their activity levels. Yes, the intrinsic why is where we start. What possibly could be important enough for you to set on your 30-, 40-year journey of maintaining activity regularly? But then the next step is, what are the obstacles between me and regular physical fitness? And the answer again is that we are, at the root, at the brain level—and this is where we land, at the brain level we are at risk of experiencing a natural drive, a wanting, a desire to sedentariness. How do we overcome these? Here's some good practical tips. So let's go to the end and go backwards.
David Macklin
With physical activity, this is fascinating clinical trial that was done that states—it cost millions of dollars and it stated the most obvious thing. So I love this for helping kind of as a practical point for listeners to help understand how they maintain physical activity levels at a level they would like to maintain long term. This study found that the predictors of long-term success in humans in physical activity are two things. And it might sound super straightforward, but if you think about it, it's something that any one of our listeners can work on today if they're really interested in improving their physical fitness. One is, if people enjoy the actual activities that they're doing, and two is after activity, if people find that there's a positive emotional experience. In other words, they feel good afterwards.
David Macklin
So hold on, let's back up. I know that sounds really simple, but it rests on a learning theory that is the most common learning theory in humans, which is called either skinnarian or operant conditioning. If we conduct a behaviour and the behaviour is enjoyable and it's followed by a reward immediately, in other words, in this case, feeling good, it's just more likely to happen. So we can counsel people to say, okay, you're interested in physical activity? Would you consider checking these two things out? Find stuff that you enjoy, and find—spend some time after your physical activity to reflect and notice if you actually feel better. So what would that look like? We see people often taking on physical activity, that they're killing it, and they hate it, but they know they got to do it. And so they're in the gym and taking on things that they don't really enjoy, but they feel they just have to. And in fact, they don't even feel good afterwards. Because they've maybe induced pain or discomfort. So I know this might sound very straightforward, but if it's about long-term behaviour change, find something that you do that you enjoy. And that can take some time, but once you do, also reflect afterwards and notice that, you know, yeah, actually, I feel a sense of accomplishment. I feel light, I feel my mood is better, I feel kind of happy. I feel in the direction of the things that are important to me. Thank you, I kind of focused on the outcomes, and that's reinforcing. And it's going to make it more likely that at 7:00 am when it's cold outside, that that person's more likely to get up because they'll say listen, sure, I can stay in bed, but I know if I get up I'll feel better.
Shaun Francis
Do we chunk this down into smaller steps, versus saying hey, I want to work out more?
David Macklin
We can break it down to as small the steps as we wish. We focus on our values, we focus on the obstacle of being driven to sedentariness. And actually, really, the last point is the following: Tell me, Shaun, if this makes sense. But the last concept is this, and this is really big in New Year's behaviour change. Again, I don't care if we're talking about less drinking, quitting smoking, getting to a best weight, eating healthfully or being fit, all those behaviours. What's going to be common in all of those—and this is a very common message from Medcan staff to people who are looking to change behaviour—the concept is, I'm going to introduce to everyone looking to change their behaviours that they can anticipate one thing which is setbacks. Setbacks in any of these behaviour changes are natural. You're going to miss that workout day. You're going to actually twist your ankle so you're going to miss a week of being active. You're going to have an off-track eating day. You'll get on a scale and see a number not in your favour. You'll end up eating foods that you had really tried to stay away from and yet you found you ate those. You'll have quit smoking and you'll find yourself out in a high-risk setting and you'll have had a cigarette. All of these things are going to happen.
David Macklin
So the next question is, it turns out—rather next statement is, it turns out success in any behaviour change, in any lifestyle change, one of the absolute key predictors is not whether you have setbacks—you can actually count on having setbacks—one of the key determinants of successful behaviour change long term to turn a New Year's resolution into something that's 20-30 years, one of the key determinants is not whether you have these setbacks, but how you respond to them. So it just turns out—and here, we're going to jump into the psychology This is where think affects eat and move. This is the feedback loop from eat, move, think, this is think looping back into eat and move. And it works in the following way. If a human has a setback, and this is something that they have to any degree struggled with in the past, there'll be an automatic set of thoughts that will get generated. Things like, "Oh, I'm so bad at quitting smoking. You know, I've tried so many times, and now I screwed up again. It's never gonna work. You know, I'm trying to eat healthily, and on Saturday I ate way too much food and this stuff's no good. Clearly, I'm no good at this. I don't have enough willpower. I'm not strong enough." Someone misses a workout and they're like, "You know what? Crap. You know, for a short time I can be active, but I lose momentum always. This is just like me. Really, ultimately, I'm lazy. Clearly, I'm no good at this."
David Macklin
All of these will be automatic thoughts that someone will experience. And they're opportunistic. They don't come all the time. They come after a setback in behaviour change. And so if your team can help you understand both that setbacks are natural, and that when they happen, automatic thoughts come that speak poorly about your capacity to make these lifestyle changes, if you now are in recognition of these automatic thoughts, now you're in a position to change them, to say, "Wait, is that really true? This is just like me?" So people can already start to challenge those automatic negative thoughts by saying, "But that was me on my own, not being supported and treated for what I've learned is actually a real difficult thing to change long term." So they can start challenging their thoughts. That's called cognitive restructuring. That's the foundation of cognitive behavioural therapy, helping someone change their thinking so they can change their behaviours. So be wary as you set up your New Year's resolutions. The advice is: setbacks are going to happen, automatic thoughts that speak poorly about your capacity to succeed long term could come automatically, result in frustration, disappointment and demotivation. And by recognizing that obstacle, that's a real nice door-opener to turning what is a new year's resolution into a 20-, 30-, 40-year new behaviour.
Shaun Francis
David, we hear often how important sleep is. Is this another foundational element for everything you've talked about, or is it something you're also genetically programmed not to do as well as we age?
David Macklin
So what does poor sleep do? Poor sleep replicates actually stress. If you really want to think about short sleep duration, which is the phrase, if you want to think about short sleep duration and the consequences of fatigue and why it is associated with sedentariness and poor fitness, it's associated with obesity, and it's associated with poor eating styles, and it's associated with smoking and drinking too much. So why? Why is it associated with all those things? Because it actually emulates the stress response in our brain. It turns out that if our ancestors didn't sleep much it was because they couldn't, because there was a challenge to their survival. This is very much on par with stress. Cortisol gets released. When a stress response happens in our body, the signal to our brain will drive up the drive to sedentariness and try to relax. We will be drawn away from physical activity, we'll have stronger drives to high-calorie foods and higher amounts of food. This is a really straightforward connection. And again, it's from the body to the brain. You can count on poor sleep duration and fatigue amping up the drive to overeat, dampening your capacity to be physically active because you're tired, and driving up your drive towards alcohol, towards cigarettes, towards eating poorly.
David Macklin
But there's one more piece with sleep. So we talked about how it increases the drive from underneath towards off-track behaviours. And if this is isn't unfair, I also don't know what is, but from the top down, our capacity to self-regulate, to stop and say, "Wait a second. I don't need this, I'll feel better if I don't. Wait a second, this activity's important to me, so I really want to push through and do this activity, you know, because it's aligned with my values." We call that top-down, executive self-regulation. It's actually where all of the work happens in the front of our brain. That part also goes to sleep when we're too tired. So we have a stronger drive from underneath to go in the wrong direction, and we have a weaker capacity from the top down to self-regulate over these impulses. So it's really like an unfortunate one-two punch. So it's not that sleep is directly impacting our health negatively. It's how it affects our behaviours that impact our health. And so defending your sleep, never underestimating how important it is, is a really, really nice piece of sustained behaviour change.
Shaun Francis
Thank you, David. Well, it sounds like it's a—you know, we need sleep, and it's a lifelong challenge to fight against our genes to stay healthy and have that longest, highest quality of life.
David Macklin
Yeah. I mean, the take-home executive summary to everyone would be that obstacles exist, and there is a kind of a progression of expert teams. And I think Medcan is just an incredible example of this, of expert teams in healthcare that help support someone with intrinsic motivation overcoming obstacles and maintaining resilience as they move forward into taking something that is tough on your own. But with a real supportive expert team can become, not a flash in the pan, but instead a sustained behaviour change.
Shaun Francis
Thank you.
David Macklin
Thanks, Shaun.
Shaun Francis
Thanks, everyone.
Christopher Shulgan
That's it for this episode of Eat Move Think. If you enjoyed Dr. Macklin on this show, check out his interview about the way Canada is leading the world in weight management innovation. That's an interview with Obesity Canada's scientific director Dr. Arya Sharma, and that's in episode 32.
Christopher Shulgan
Dr. Macklin is on Twitter @davidmacklinmd. Macklin M-A-C-K-L-I-N.
Christopher Shulgan
We post episode highlights and full episode transcripts at eatmovethinkpodcast.com. Eat Move Think is produced by Ghost Bureau. Senior producer is Russell Gragg. Social media support from Emily Mannella. Editorial direction from Chantel Guertin.
Christopher Shulgan
Remember to rate and subscribe to Eat Move Think on your favourite podcast platform. Follow host Shaun Francis on Twitter and Instagram @shauncfrancis—that's Shaun with a U—and Medcan @medcanlivewell. We'll be back soon with a new episode examining the latest in health and wellness.