Successful weight management continues to be elusive for millions of American adults.
The Participants Are:
Rosia Parrish, ND, Boulder Natural Health, Boulder, CO, www.bouldernaturalhealth.com
Amy Rothenberg, ND, Naturopathic Health Care, Northampton, MA, www.nhcmed.com
Firlande Volcy, ND, Innovare Wellness, LLC, Stockbridge, GA, www.drfirlande.com
Always a hot topic, successful weight management continues to be rather elusive for millions of American adults. The “middle-age” five- to 15-pound gain is not much to worry about, as it is more so self-esteem debilitating. Those individuals who have a BMI (body mass index) between 25 and 30, however, need professional guidance. Although the mechanism of weight loss—more calories burned than consumed—remains absolute for all people; just like fingerprints, no two overweight people will lose weight successfully the same way. Here are some insights from your peers.
Q: Since the pandemic at-home/quarantine—have you seen an increase in your patient population with weight gain? If so, why?
Rothenberg: I have seen both, some people due to stress, eat less, others eat more. Some people really fell off the exercise plan, others took up the cause. Some people have more time to cook and be mindful with food choices while others are stress eating. So, I would say, I have seen both!
Volcy: In my private practice, my primary focus is weight loss. Many of my patients and coaching clients have gained between 10 to 20 pounds since in quarantine. What has led to weight gain:
1. Easy access to more foods. Being sheltered in place with the kitchen only a few steps away has allowed easy access to food especially processed and snack items. This has led to unhealthy eating habits, increase in appetite, poor food choices, all day and late-night eating and snacking, and an increase in portion size.
2. A more sedentary lifestyle. Many fitness facilities were mandated to shut down during the pandemic and we were encouraged to stay home. Therefore, inability to go to the gym, difficulty adhering to an exercise routine while home, or lack of motivation may have significantly contributed to weight gain.
3. Lack of sleep or insomnia. Sleep is crucial for weight loss. With a change in normal routine, most patients admitted to staying up late binging on their favorite shows and snacks or worrying about the future. All of these activities can lead to weight gain.
4. Increased stress. The coronavirus pandemic has caused a disruption in people’s normalcy and a state of fear. Uncertainties, fears, stress, worries, children at home, relationship turmoil, are all recipes for emotional eating, overeating, and rise in cortisol levels that tend to lead to weight gain.
Parrish: Yes, my patients as a whole are gaining weight during this pandemic, and it isn’t just a result of lacking amenities they previously had access to like gyms and rec centers, but other factors are involved like the social isolation—where they once did activities together in a group exercise class; the only access they currently have is in virtual classes, and virtual settings aren’t always the best option when many people feel the momentum, motivation and energy from being physically around other people. No matter what, the livestream or virtual environments lack the in-person vibes, and it will never create the same atmosphere as live events.
Loneliness has also pervaded during quarantine and many patients are outright anxious or depressed. When patients are yearning for what was, anxious about what is being experienced around them, many of them have no desire to go outside to be around people. Anxieties can create fears about social distancing, about who is wearing masks and who isn’t, and this compulsion can just isolate people further into not wanting to experience the outside world that allows for more movement than just inside their place of residence.
What many of my patients are experiencing from the overwhelming changes is overboard overindulgence that has led some to food addiction and also alcoholism. Not everyone is at that extreme, but many patients have justified this quarantine as a reason to hoard food and alcohol, to isolate and eat and drink, and to justify their behaviors on the premise that all their coping mechanisms and social support have been removed. Primarily, this is occurring with patients who already had a propensity for addiction, but there have been some surprises too. People are eating because of lack of support, but in the interim time that this quarantine has taken place, resources have been implemented to support those who are extremely affected by the quarantine, such as almost all 12-step meetings like Alcoholics Anonymous and Overeaters Anonymous, have gone online, there is ample access to virtual counselors and therapists, and now, some professionals are transitioning to see patients live in-person again.
Q: If a patient finds himself/herself gaining weight idiopathically, how do you handle such cases? To what would that be attributed?
Rothenberg: We first examine diet and determine if there has been changes in what or how much the person eats. We use apps to help patients track food. Similarly, we look to see if there has been a change in physical activity levels, either what the person is doing for exercise, how much and how often and how sedentary they are during the day—and figure out if there has been a change in this regard.
Volcy: All cases are handled on an individual basis. The reason one patient gains weight may not be the same reason another person does. First thing is inquiring about any lifestyle changes such as deviations in eating habits, exercises, sleep and stress. The second is testing instead of guessing. Testing the following can help further understand why a person may be gaining weight:
1. Thyroid hormone. The net effect of thyroid hormone is an increase in metabolic rate and O2 consumption. A reduction in thyroid hormone production can lead to weight gain or inability to lose weight as metabolism slows down.
2. Cortisol hormone. A rise in circulating cortisol levels due to both internal and/or external stressors may lead to hyperglycemia, insulin resistance, inflammation and fat deposition, all of which can contribute to weight gain.
3. Food sensitivities or intolerances. Food sensitivities can have serious effects on weight. Running an IgG or IgA panel to test for diverse food sensitivities then eliminating the highly reactive foods can be a game changer for many who have not been able to identify the root cause of their weight gain. Managing food sensitivities leads to reduced inflammation and water weight, better nutrient assimilation, and weight loss.
4. Stool analysis. The gut microbiome plays a significant role in weight loss. Assessing for and treating dysbiosis can help in reducing weight.
Parrish: There are many reasons for weight gain in my patients; for most, it is not just a matter of their macronutrient ratios being imbalanced. I usually start by looking at food sensitivities and food allergies. It is really interesting to see how many people are eating foods that are bothersome to them. I typically test for 96 to more than 200 foods to see what foods could be causing an inflammatory reaction that might be causing an uptick in weight. I don’t typically test for foods that give a patient an immediate reaction like hives or anaphylaxis because most patients are already aware of this type of food reactivity. However, I do test for delayed food sensitivities where a patient could have a reaction up to 72 hours after ingestion. These types of food reactions are hard to track with food diaries because of the delay. If foods are found to be positive on the test and they are removed, many patients find that their weight improves.
Other reasons for weight gain are hormonal imbalances. It is hard for me to guess which hormones are out of balance, so I test for a whole soup of hormones including a few forms of testosterone, several types of estrogen, multi-point saliva cortisol, DHEA (dehydroepiandrosterone) and depending on what is going on, I may order other biomarkers as well. These hormones can help me test for adrenal conditions, polycystic ovarian syndrome (PCOS), and many other conditions, that often increase someone’s susceptibility to gain weight.
I also track basic lab markers for inflammation, thyroid disorders, cholesterol issues, nutrient depletions including anemia, vitamin D deficiency, and other problems that increase the likelihood of a patient gaining weight.
Beyond these more basic causes of weight gain, if a patient’s weight still isn’t budging, I may see if there were any toxic exposures currently or in the past, and I may test for mold exposure to see if there are any mycotoxins in the body that can increase risk for weight gain, or I may test for chemicals, plastics, gases and other commercial toxic exposure if they are suspected.
For others, there is a direct connection between their gut microbes and their weight gain, and if they are symptomatic with digestive concerns, I may run a comprehensive stool analysis or test for a condition such as small intestinal bacterial overgrowth (SIBO); both tests are telling of microbial imbalances in the gut that can lead a patient to gain weight. By treating any infectious causes like bacterial, fungal or parasitic overgrowths or pathologies, patients can regain control of their body, their weight and their life.
I don’t just attribute age to weight gain—there is always a cause!
Q: What do you recommend for those active/youthful middle-agers who “suddenly” find that they are 20 to 30 pounds overweight?
Volcy: If the person is an active/youthful middle-age individual who is finding him/herself gaining between 20-30 pounds “suddenly,” I recommend to:
1. Cut out sugar, flour and processed foods
2. Replace all sugary beverages with water
3. Eat three healthy meals per day with no snacks
4. Remain hydrated
5. Restrict caloric intake after 7 p.m.
6. Practice intermittent fasting
7. Use exercise as an adjunct to healthy eating and not as a substitution for unhealthy habits
8. Decrease stress level
9. Get enough sleep. Get in bed before midnight to allow restorative sleep.
10. Check for hormone imbalances, especially thyroid and cortisol as well as testosterone, estrogen, and progesterone levels.
Parrish: I tend to be a bit more functional when it comes to weight gain, so I order a lot of labs to create a data set to rule in or rule out potential causes. For middle agers, I make sure basic lab work has been reviewed, and I start by ordering food sensitivity testing and hormone testing. I also do an overhaul of their diet and may prescribe the anti-inflammatory diet, a modified version of that, or just have them eliminate all sugar, and the more known inflammatory foods like gluten, dairy, sugar, soy and citrus, to start, while lab results are pending. Many patients wish to have more information with a nutritionist for diet guidance, and my clinic has a nutritionist whom I often refer to for more menu meal planning and dietary guidance.
Rothenberg: We first do information gathering, have a heartfelt conversation determining what and how much the person eats and how and how much the person moves. For most people I will begin with an elongated overnight fast. My goal for the patient is 13 to 14 hours. We do not start there if their typical fast is 7 to 8 hours. We work up to that. It helps to enhance insulin sensitivity, and over time it decreases appetite. Many people will lose 4 to 6 pounds without extreme effort.
Q: How do you help patients with excessive cravings? What usually causes intense cravings for sugars and “comfort foods?”
Volcy: To help patients with intense cravings, first identify the root cause of the cravings. Are they caused by vitamin and mineral deficiencies, dehydration, yeast overgrowth, stress or boredom? Second, once the root cause is identified, implement the proper treatment protocol to help the cravings. I would add a multivitamin mineral mix for vitamin and mineral deficiencies; encourage proper hydration, perhaps drinking 6 oz. of water every 20 to 30 minutes; remove any yeast overgrowth; provide stress management techniques that may be beneficial, such as deep breathing exercises, yoga and meditation; promote activities such as exercise, music lessons or coloring that may help overcome boredom. Lastly, I would have a plan in place for short-term and long-term solutions. For instance, retest for yeast overgrowth within three months; encourage purchasing a water bottle or setting alarms as reminders for water consumptions; eat complete meals daily instead of snacks; and have a daily practice of mindfulness while eating.
Parrish: Some patients do well on supplements that curb cravings; we have several glycemic formulations that are customized for patients with intense cravings. Others may need supplements in combination with meal planning and dietary guidance. Some do not need any supplements or nutritional guidance—they actually need more group emotional and food support, and that’s when I recommend groups like Overeaters Anonymous, Food Addicts Anonymous, or Jenny Craig and Weight Watchers (WW).
Rothenberg: In my experience, cravings come about for several main reasons:
1. Emotional. Many people are emotional eaters, it gives a sense of comfort or pleasure. In the healthiest sense, this can be wonderful! But it can be for other less healthy reasons, to correct for loneliness, anger, frustration, disappointment and more.
2. Nutritional imbalance. When the diet is not balanced correctly and appropriately for an individual, cravings for certain foods may set in. This is especially true for those trying to lose weight who avoid specific foods. Often they will crave what they know they are not supposed to eat.
3. Blood sugar. Blood sugar being out of balance can cause people to crave sweets, the quick fix or caffeine for energy.
When working with a patient who has excessive food cravings, we work together to understand the whole person, his/her relationship to food, the things that are sure triggers for cravings and then come up with a plan to help. The plan contains both psycho-emotional support, behavior modification approaches and the replacing of less healthy food choices with more healthy options. This is a process where truly “doctor as teacher” is paramount, reminding the person of their self-agency, and of the many tools available to them to make better choices related to food.