Sunday, May 13, 2018



The scientific community has accepted a round earth since the times of ancient Greece. 
Yet many well meaning people still believe maintaining a healthy weight is ONLY
 about balancing calories in (food) with calories out (exercise.)

Copyright, reprinted with permission

BUT, nothing in life is so neat and tidy.

We have learned much over the last two decades. Yet, years of peer reviewed medical research published in major medical journals has not dispelled "what we know."

Obesity is a Disease.

 This is not simply a matter of political correctness. Food intake and physical activity are important factors, but not the ONLY factors. Why is this so? A number of physiologic processes regulate the balance of the scale. Eat more calories and metabolism speeds up (to a point.) Eat fewer calories and metabolism slows down.  The body wishes to stay in balance. We know this state as homeostasis. We are our healthiest when homeostasis is maintained throughout.  When the balance is upset we can develop disease.


One of the most powerful physiologic controls is endocrine, or hormonal regulation.
  Hormones are chemical messengers made in one group of cells that travel to other cells to deliver a signal. Just about every hormone has a hormone twin that does the opposite function. A good example is Insulin which allows cells to take glucose up from the blood and Glucagon which releases glucose into the blood from glycogen stored in the liver. 
 Hormones tell us we are hungry or  full; and regulates how fast our metabolism "burns" calories. Few would argue a slow thyroid can lead to gaining unhealthy weight.
Are there other hormones that influence metabolic rate?

Yep. You betcha. Meet our friend Leptin. Leptin is released from the largest endocrine (hormone producing) gland in the body - adipose tissue (fat cells.) When adipocytes decrease in size (because we have lost fat) they release less Leptin. The appetite and metabolic centers in the brain interpret this as a sign - if we don't act we will starve!  
A survival response kicks in - and the rate of metabolism slows while appetite increases. Great when you are a contestant on Naked and Afraid; not so good when you are trying to lose weight and prevent Type II Diabetes.To add insult to injury, the appetite center in the brain may experience Leptin resistance. So adipocytes are sending Leptin, it is knocking on the door, but the receptor cells are not hearing it. Oh no, need to slow our metabolism down – we're starving! Not.

Ghrelin is another powerful hormone that stimulates appetite and regulates metabolism. While Leptin is more involved with long term survival regulation, Ghrelin regulates short term needs. Ghrelin cells are found mainly in the stomach, although also in other areas of the body. Ghrelin levels increase when the stomach is empty and decrease as the stomach stretches. It has been shown that baseline levels stay elevated after successful weight loss. Thus, Ghrelin is stronger than our friend Will Power. (Most people believe Mr. Power is an elusive fellow, but now you know the truth.)  Interestingly, many of the Ghrelin producing cells in the stomach are removed with Bariatric Surgery. We have since learned patient who have had Roux-en-Y gastric (RYGB) bypass have lower circulating levels than medically managed patients and have an easier time maintaining a healthier weight. About a decade ago The American Society for Bariatric Surgery changed it's name to American Society for Metabolic and Bariatric Surgery for this among other reasons. Although medications to inhibit Ghrelin have been investigated, Metabolic and Bariatric Surgery is currently the best treatment. More on that later.

Driving with the emergency brake on.

Sleep is restorative, and very necessary to maintain good health. Our bodies repair themselves while we are asleep. Growth in children occurs overnight with the release of Growth Hormone. Sleeping less than 7-8 hours a night? I bet you feel very tired during the day. Most you are likely burning fewer calories. It is more likely you will take the elevator rather than the stairs, park closer to the door, or defer other activities until you feel more rested. There is some evidence your Resting Metabolic Rate (calories burned while you are sitting quietly) is decreased due to your lack of sufficient or quality sleep, although this has not been a consistent finding.

 Other Factors.

There are a multitude of other factors known to influence unhealthy weight gain;

Type II Diabetes or family history of Type II Diabetes
Cardiometabolic Syndrome
Polycystic Ovarian Syndrome (which does not require ovarian cysts to diagnose!)
Cushing's Disease
Obstructive Sleep Apnea
Medications including over the counter agents (e.g. Benadryl.)
Stress and Anxiety
Gut Bacteria
MTHFR disorders
Genetics and Epigenetics
History of Tobacco, Alcohol, or Substance Use
Eating Disorders
History of Abuse

A good work up includes a comprehensive exam, labs to evaluate for the common, and the expertise to suspect the less common etiologies when appropriate. Each patient deserves an individualized work up and plan.  What may apply in one case may not in others, and  it is just about guaranteed to be a combination of factors for each person.

Obesity is a Chronic Disease … and it IS treatable.
Multidisciplinary treatment programs consisting of medical management of the problems stated above, nutritional education and support, physical activity which is appropriate for that individual, and behavioral support have demonstrated success time and time again. Yet, the commentary often comes back to weight regain when it ends. Imagine if we treat Hypertension as such. “Well congratulations on achieving a good blood pressure. You can stop treating it now.” It is NO DIFFERENT.

The time has come to stop repeating the same old tired Twentieth Century advice “eat less and exercise more” and realize that perhaps the correct advice for any particular  individual may be exactly the opposite. “Eat more (protein) and exercise less (as you are not consuming enough calories and triggering a slow metabolism/starvation response.)

Each person deserves an individualized evaluation and above all else the insight we are dealing with a disease and not a character flaw.

It is 2018.

It is time to join The Twenty First Century!