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The "Big Three" of Weight Loss

Did you know that the average person tries between 55 to 126 diets in their lifetime? According to the US Centers of Disease Control and Prevention, half of all US adults are on a diet at any given time: 56.3 percent of women and 42.2 percent of men. But despite these high figures of dieting, nearly half of the US population is obese and an additional 32 percent are overweight.

Rates of obesity are rapidly increasing but so are the rates of people on diets. As logic would then dictate: it’s clear that diets aren’t a guarantee for weight loss. So what are more effective ways to lose fat? Why is losing weight so difficult? We’re going to cover all this and more, so keep reading!

Our approach at Weight Loss and Vitality

We practice a ‘big three’ approach to help our patients achieve weight loss and keep it off long term. This approach includes:

  1. Fundamentals
  2. Medical management
  3. Therapeutic devices

We’re going to cover each of these in this article, including the benefits and limitations of each, and why combining all three is the most effective way to lose weight for life.

Why is weight loss so hard?

The first of the big three is fundamentals. Behavior modification, this refers to a patient's motivation, commitment, eating plan, exercise routine, and daily habits like sleep quality and hydration. While we can’t force a patient to be motivated, we can help them understand why it may be difficult to lose weight, so they can work with - rather than against - their biology.

One of the most common questions we receive here at Weight loss and Vitality is why is it so hard to lose weight? Many people struggle with their weight, despite trying diet after diet, and exercising more. The reality is, your body wants to hold on to stored energy, it’s an evolutionary adaptation. A true survival mechanism in each and every one of us.

In the times of our hunter gatherer ancestors, those who could effectively store energy were presumed to have a better chance of survival throughout periods of less food availability. That means that hormonal and biochemical changes take place in your body when you attempt to suddenly restrict your caloric intake after long periods of overeating.

As an example of the biochemical changes that occur - according to research published in The American Journal of Clinical Nutrition, our body fights to maintain your body weight via an effector signal that modulates food intake or energy expenditure, boosting certain hormones, neural pathways and neurotransmitters to increase or decrease food intake or activity.

The role of ghrelin

The hormones leptin, ghrelin, insulin, estrogen, androgen, and growth hormone are all responsible for our metabolism and appetite. When we attempt to restrict our caloric intake, as we would during a diet, these hormones shift to protect ourselves from losing too much fat.

A clinical trial tested the role of the hormone ghrelin in mice and its effect on body weight. Ghrelin is a hormone associated with hunger: it stimulates appetite, promotes fat storage and causes you to increase your food intake. The study found that when mice lost weight, more ghrelin was secreted, which increased the appetite - causing the mice to forage for food and binge until their weight increased again. Once the weight had returned, levels of ghrelin leveled back to baseline.

It’s not easy to ignore a spike of ghrelin and decreased levels of leptin, another hormone connected to food intake. When ghrelin spikes, it activates homeostatic hypothalamic circuits. This passes information around the body, signaling to the central nervous system, gastrointestinal tract and other systems, to eat more and move less, as an attempt to maintain a set body weight. When we’re constantly fighting against the urge to eat (ghrelin spikes), the urge gets stronger, which results in binge eating, as shown in a 2012 study on the role of ghrelin in eating disorders.

Many studies have found a connection between levels of ghrelin and cases of overeating and obesity. One such study, published in 2017 in the journal In Vivo found that obese people have higher levels of ghrelin, a possible mechanism for obesity. When the researchers examined what happened after a sleeve gastrectomy, a bariatric procedure, they reported that it reduced ghrelin levels and resulted in weight loss.

This is because ghrelin is actually produced in the stomach. When the stomach size is significantly reduced during bariatric surgery, so is the production of ghrelin. As a result, researchers believe that the reduction of ghrelin changed eating behaviors and allowed for weight loss.

Ghrelin is a regulator in the reward center of the brain, as discovered by a 2013 study. This means that when you feel stressed or sad, ghrelin triggers you to consume pleasurable foods, as an attempt to regulate your emotions. This is a major issue for weight gain, because pleasurable foods are also extremely addictive.

In one study, sugar was found to be more addictive to lab rats than the class A drug cocaine. Another study tested the addictive properties of hyperpalatable foods like fast food, soda and candy, finding that at a neurobiological level, the neural substrates of these foods are more robust than drugs. This means that they are more rewarding and addictive to the brain than illegal drugs.

As you can see, weight loss is very difficult because you are fighting against your biology. Getting the fundamentals right - eating a healthy diet, exercising, sleeping well, and staying hydrated, will help to get you on the right track and to keep you motivated. But it may not be enough to actually experience weight loss. Here’s why.

The limitations of diet and exercise

Diet and exercise interventions can be effective in the average, healthy person looking to drop a few pounds. However, in metabolically compromised individuals with obesity or other comorbidities like type II diabetes, it is highly unlikely - if not altogether impossible - to lose weight solely through dieting and exercise.

This is in part due to the role of ghrelin and other hormones that promote fat storage and appetite, as mentioned above. But there are plenty more mechanisms that we are yet to touch on that prevent weight loss in certain individuals. Here are some examples.

Insulin resistance

For example, in insulin resistant individuals. When you eat a high carb meal, your blood sugar levels rise and insulin and glucagon are released by the pancreas to control the uptake of glucose by different cells, and to control the release of stored glucose. In the case of insulin resistance, your cells do not respond to the hormone, and so more has to be released for the same effect, or it is totally dysfunctioning and blood sugar levels stay high. The excess blood sugar is stored as fat.

When insulin function is impaired, it is essentially signalling the fat in your cells to stay where they are, rather than to breakdown to use for fuel. Even if you are in a caloric deficit, these fat cells will not respond.

Chronic stress

Similarly, in individuals dealing with chronic stress, weight loss may be very difficult, particularly around the abdomen. Cortisol is a catabolic hormone, meaning it is involved in muscle tissue breakdown, and is associated with feelings of stress. It’s a hormone that also promotes fat storage and increases the appetite and cravings. As you may have guessed, elevated cortisol levels are not good if you want to lose weight.

Thyroid disease

Globally there are an estimated 200 million people who have some type of thyroid condition. When your thyroid doesn’t produce enough of those hormones, it can interfere with your body’s ability to function normally.

The main role of the thyroid in the endocrine system is to regulate metabolic function - the process by which food is digested and converted into energy. Those with ‘fast’ metabolic function quickly metabolize food, storing less energy (hyperthyroidism) and vice versa for those with a ‘slow’ metabolism (hypothyroidism). The speed of your metabolism is connected to the release of the T3 and T4 thyroid hormones.

Hypothyroidism and RT3/T3 ratio disorder is characterized by weight gain, due to less thermogenic activity. However, those with this condition will struggle to lose weight through diet and exercise, because it’s a hormone issue.

Hormonal imbalance

Hormones in the human body are integral for a number of vital processes including body weight regulation, hunger and fullness signals, food cravings, and mood. When hormones are out of balance, they can cause weight gain and prevent weight loss.

For example, imbalanced levels of estrogen (either too high or too low) can lead to weight gain, particularly around the hips and waist. As shown in a 2011 study, estrogen modulates the central processing of the appetite-stimulating and satiating hormones. So when it is out of balance, it can increase the appetite and food intake.

When one hormone is out of balance, it affects the whole system. For example, when estrogen is low, it inhibits serotonin production. Lower serotonin is associated with a bigger appetite, specifically sugary foods, that are known to boost serotonin (in the short term).

How effective is exercising and dieting for weight loss?

Even in metabolically healthy individuals, exercise alone is not an effective weight loss tool. This can be understood by explaining the various factors that influence thermogenesis.

Thermogenesis is the name for fat burning. There are four key factors that determine how much fat you burn each day.

Exercise only equates to 5 percent of total fat burned each day. If exercise is the only intervention for weight loss, it’s extremely difficult, if not impossible, to lose a lot of weight.

A systematic review of intervention studies using exercise for weight loss, found that exercise energy expenditure had absolutely no correlation with weight loss. Numerous studies conclude that exercise has, at best, a modest impact on weight loss but it’s less than most people believe.

According to science the best way to lose weight is combining a healthy, reduced dietary intake with some exercise. This is summarized in a 2015 meta-analysis of over 200 studies that found that diet brings about the most change to body weight, but when combined with exercise (particularly resistance training) the body is healthier and weight loss is maximized over the long term.

Ultimately it’s important to understand that there are particular incidences in which exercise and dietary interventions will not be effective for weight loss. For example it’s very commonly reported amongst people trying to lose weight that they struggle to shift fat in certain areas. This is due to resistant fat, which we will come onto. Any diet or exercise plan will not shift resistant fat.

Plus, if you have a metabolic condition or chronic disease that impacts your ability to lose fat, exercising or dieting alone is not going to give you the results you are looking for.

The other benefits of exercise

We’ve mentioned that exercising alone does not guarantee weight loss. However, it does improve your health in other ways.

Studies show that individuals who regularly exercise have a 35 percent decreased risk of developing heart disease or stroke, a 50 percent decreased risk of developing type II diabetes and obesity, age slower, have less age-related illnesses like sarcopenia, and experience less mental health problems. So even if your main focus is not weight loss, exercising regularly is important for maintaining good enough regardless.

It is extremely important to have a healthy amount of muscle mass for a number of reasons including:

Aging benefits

From the age of 30, you lose three to five percent of your muscle mass every 10 years, which is substantial if you do not have much muscle mass to begin with. Increasing your muscle mass by lifting weights at the gym will help to retain muscle mass loss.

Metabolic benefits

The more muscle mass you have, the faster your metabolism is. A study found that increasing muscle mass increases the metabolic rate and better regulates food intake, by inhibiting myostatin, a growth factor.

In short: exercise may not help you drop all the weight you have to lose, but it will help you build muscle, which will repair your metabolism and slow down the effects of aging.

You burn more calories throughout the day!

What is resistant fat?

We all have areas of stubborn fat that don’t seem to go away regardless of any dietary or exercise intervention. This is known as resistant fat, and it’s essential to understand this if you want to successfully lose weight and keep it off.

The amount of fat cells we have in our body is largely genetic, and cannot be changed, regardless of any diet or exercise plan you may go on. That doesn’t mean you are genetically guaranteed to be overweight, but it does mean you may have more propensity to gain weight in certain areas due to fat cell distribution. For example, some people have more fat cells in their thighs. Even if they lose fat elsewhere, they may still hold extra weight in their thighs.

In each fat cell, there are receptors: either alpha (A2) or beta (B2). Alpha receptors in cells are resistant fat cells, whereas beta receptors signal fat breakdown to provide fuel for energy. If you have experience in losing weight, you may have noticed that certain areas are first to go, whereas others never shift. This is the difference between alpha or beta fat cell receptors.

This is in part controlled by the sympathetic nervous system (SNS). The SNS releases norepinephrine - a hormone and neurotransmitter that sends signals between nerve systems. Norepinephrine is responsible for activating the breakdown of fat cells to use for energy, and higher circulating levels of this neurotransmitter are linked to fat loss and better body weight regulation.

Researchers have found that resistant fat cells “gobble up norepinephrine”, which prevents them from being broken down to be used for energy, as they normally would. A 2018 study examined this, discovering that when the organic cation transporter 3 is removed and norepinephrine uptake is inhibited, white resistant fat cells become brown adipose tissue with beta receptors - as a result, increases fat breakdown.

However, this is a medical intervention, and can not be done through diet or exercise alone.

What is medical weight loss?

As just mentioned, increasing the amount of circulating norepinephrine and inhibiting its uptake into fat cells can have a drastic impact on your weight, by increasing fat burning of resistant fat cells. However, this is not something you can do alone. It is a medical procedure, administered by a professional.

Medical weight loss is part of the service offered by Weight Loss and Vitality, and is number two in the big three. Medical management includes prescribing bioidentical hormones, weight loss medication, biologics, weight loss aids and supplements to help trigger thermogenesis (fat burning). This is particularly beneficial for metabolically compromised individuals who will not be able to effectively lose weight through dieting or exercise.

What are the limitations of medical weight loss?

While medical weight loss can be extremely effective, medications alone do not guarantee long term weight loss. If you have an emotional and physiological addiction to sugary food (which is extremely common), a medical intervention may not be enough to keep the weight off long term. This is because over time, you may resort back to your eating behaviors during periods of emotional stress, for example.

Plus, weight loss is not the only factor to consider when it comes to improving your health. Therefore, medical interventions that only focus on fat burning may not improve your general health like your body composition (amount of muscle mass) for example.

What are therapeutic weight loss devices?

So far we have covered the benefits and limitations of diet and exercise, and medical weight loss. Now we’re going to introduce you to the final part of the big three for weight loss: therapeutic devices. In the world today, there are two major weight loss surgeries: liposuction and bariatric surgery.

Rates of bariatric surgery are increasing in the US. According to 2017 data, 228,000 bariatric procedures were performed in the US, with patients losing up to 50 percent of their weight within 6 months.

However, bariatric surgery isn’t a quick fix or necessarily a long term solution. Some people do regain weight or experience complications. Not to mention, you have to lose a significant amount of weight before you are eligible for surgery. This is also the case with liposuction.

In 2017, there were 246,354 liposuction procedures, making it the second most common surgery. In liposuction, fat cells are removed from the body and they cannot grow back. But what can happen after lipo is that the remaining fat cells get bigger, as a result of weight gain.

Complications from both types of weight loss surgery can happen when a patient does not address the root cause of the weight gain. Common weight loss centers only target the fat, rather than what caused the fat - hormonal imbalances, food addiction, a sedentary lifestyle etc.

At Weight Loss and Vitality, our therapeutic devices include non-invasive fat loss machines and surgical options. These include:

We have purposely chosen specific non-invasive therapeutic devices that have been well-established in research with proven results. For example:

The main difference between conventional weight loss surgeries and what we do at Weight Loss and Vitality comes down to how we administer therapeutic devices. We do not use a ‘one-size-fits-all’ approach. For certain individuals, therapeutic devices are not the best solution, for others, they are the only solution - such as in the case of resistant fat.

The big three: losing fat for life

Now that we’ve covered the components in our ‘big three’ approach, we can finally explain why we believe this is the most effective way to guarantee weight loss long term.

The majority of patients who come to Weight Loss and Vitality are experiencing a number of health issues that are contributing to their weight gain, and inability to lose weight. This may include one or more of the topics we have discussed, such as:

For these individuals to successfully lose weight, combining fundamentals (diet and exercise), with medications and therapeutic devices will discover and target the root cause of the weight gain. Each patient is given a custom treatment plan based on their goals, blood work, and suitability. This treatment plan typically includes a meal plan, medication, supplements, non-invasive fat loss devices, and surgical options.

This ‘big three’ approach helps the patient understand the ‘why’, not just simply the ‘what’. The end result is successful weight loss, adjusted habits, and repaired internal systems, to ensure that the weight stays off for good.

Author
David J. Bauder, PA-C David Bauder, PA-C, is a certified physician assistant and the medical director at Weight Loss and Vitality in Alexandria, Virginia, and Washington, DC. He enjoys helping patients optimize their physical and mental health to improve their overall well-being. He earned his physician assistant degree from the University of Texas Health Science Center at San Antonio. Afterward, he gained admission into the reputable graduate program for physician assistant studies at the University of Nebraska Health Science Center in Omaha. David has over 25 years of experience working as a physician assistant. He’s practiced in podiatry, family medicine, emergency medicine, general surgery, urgent care, and functional medicine.

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