Long Term Weight Loss - More Than Will Power?

Obesity has become a major health epidemic and has dramatically increased over the last decades. Studies show that approximately one-third of the U.S. population is classified as obese and over two-thirds are significantly overweight. While the cause is multifactorial, studies are clear that almost all overweight individuals have metabolic and endocrinological dysfunction that is causing or contributing to their inability to lose weight.

It is not simply a problem that individuals are taking in more calories than they are consuming or lack of exercise or willpower, but rather it is a complex vicious-cycle of endocrinological and metabolic dysfunction. Contemporary medicine has failed to address these dysfunctions in overweight individuals and doctors and patients continue to believe that all cases are a matter of willpower and lifestyle. Thus, it is no surprise that obesity is reaching epidemic proportions.

Research is demonstrating that dysregulation of two key hormones may be a cause or major contributor of weight gain or inability to lose weight in the majority of overweight people. The first is leptin and the second is reverse T3. The exciting part is that doctors can now test for the presence of these physiologic barriers to weight loss and prescribe appropriate treatments with potentially dramatic results.

Leptin

The hormone leptin has been found to be a major regulator of body weight and metabolism. The body secretes leptin as weight is gained to signal the brain (specifically the hypo¬thalamus) that there are adequate energy (fat) stores. The hypothalamus should then stimulate metabolic processes that result in weight loss, including a reduction in hunger, an increased satiety with eating, an increase in resting metabolism and an increase in lipolysis (fat breakdown). New research has found that this leptin signaling is dysfunctional in the majority of people who have difficultly losing weight or are unable to lose weight.

The problem is not in the production of leptin, but rather, studies show that the ma¬jority of overweight individuals who are having difficulty losing weight have a leptin resistance, where the leptin is unable to produce its normal effects to stimulate weight loss. This leptin resistance is sensed as starvation, so multiple mechanisms are activated to increase fat stores, rather than burn excess fat stores. Leptin resistance also stimulates the formation of reverse T3, which blocks the effects of thyroid hormone on metabolism (discussed below).

Testing: A leptin level can be ordered by your physician. If greater than 10, it demonstrates there is a degree of leptin resistance contributing to an inability to lose weight. The higher the number the more significant the leptin resistance.

Treatment: There are currently two medications are shown to be able to treat leptin resistance and can result in significant weight loss. One is Symlin and the other is Byetta. These are currently approved for the treatment of diabetes but can be prescribed "off-label" for the treatment of leptin resistance. They are showing significant promise in the non-diabetic population with the ability to produce dramatic weight loss in a large percentage of overweight patients. The amount of weight loss varies according to the study design, but a significant percent of patients are experiencing weight loss, despite little or no change in diet.

The leptin resistance is not permanent and is shown to improve with weight loss so diet and exercise can be beneficial. The "catch-22" is, however, that it is difficult to lose weight with leptin resistance. High carbohydrate diets and in particular high-fructose corn syrup is shown to significantly increase leptin resistance and is a likely mechanism that high fructose corn syrup is associated with obesity, especially in children. Avoidance of high fructose corn syrup and carbohydrates would be recommended for those with high leptin levels.

Reverse T3

It is well known that thyroid hormones regulate metabolism and that low thyroid hormone production (hypothyroidism) causes low metabolism, but it has only recently been understood that thyroid production can be fine but there can a problem of activation of the hormones inside the cells that can be a major cause of low metabolism.

The thyroid gland secretes an inactive thyroid hormone called thyroxine, also known as T4. This is regulated by thyroid stimulation hormone (TSH) produced by the brain (specifically the pituitary). Normally, the inactive T4 is converted inside the cell to the active thyroid hormone called triiodothyronine (also known as T3). Most doctors will check TSH and T4 levels to see if thyroid levels are normal.

The studies are showing that it is not the production of thyroid that is the problem, but rather it is problem inside the cell that the inactive T4 is not converted to T3 but rather to a mirror image of T3 called reverse T3. The reverse T3 has the opposite effect of T3, blocking the effects of T3 and lowering rather than increasing metabolism.

It is an evolutionary fall-back that was useful in times of famine or in hibernating animals to lower metabolism. Studies are showing that stress and dieting (especially yo-yo dieting) can set this hormone into action as well as chronic illness such as diabetes, chronic fatigue syndrome and fibromyalgia.

The production of reverse T3 is found to be a major method by which the body 'tries" to regain any lost weight with dieting. As soon as the body senses a reduction in calories, the production of reverse T3 is stimulated to lower metabolism. With chronic dieting or stress, the body often stays in this "starvation mode" with elevated levels of reverse T3 and decreased levels of T3, which is a major reason for the regaining of lost weight with dieting as well being the mechanism behind stress induced weight gain (it is not due to increased cortisol).

Testing: There has been a long held belief by endocrinologists and other physicians that adequate thyroid levels can be determined by testing the TSH and T4 levels. Studies are showing that such standard testing will miss 80% of thyroid dysfunction so most endocrinologists and other doctors will tell their patients that their thyroid is fine based on this usual testing. The doctors must run a free T3/reverse T3 ratio. Generally, a healthy person will have a ratio greater than 2 so a person with a ratio less than 2 should also be considered a candidate for thyroid supplementation. Many endocrinologist and physicians are not yet aware of the significance or ability to run this ratio so it may take some searching.

Treatment: The standard treatment of hypothyroidism involves the supplementation with T4, including Synthroid and Levoxyl. These are not effective to remedy such a situation because the problem is not the amount of T4 but rather the excess conversion of T4 to reverse T3, blocking effects of the active T3. One must bypass the abnormality by supplementing with physiologic doses of T3, not T4 (preferably timed released T3). It is not appropriate to give thyroid hormone for weight loss, but rather to correct an abnormality diagnosed by appropriate blood tests.

In summary, emerging evidence demonstrates that a significant number of overweight patients have a metabolic problem rather than a problem of willpower or lifestyle. Identification and correction of these metabolic abnormalities, including leptin resistance and cellular thyroid dysfunction, can result in dramatic long term successful weight loss.

 

Follow Kent Holtorf on Twitter: www.twitter.com/Kholtorf

Comments

[Kent Holtorf]

03:13 AM on 06/05/2009

In regards to the diet & exercise debate: Diet and exercise are always important but studies clearly demonstrate that dieting suppresses thyroid hormones (suppresses TSH and T3 levels and increases reverse T3) and metabolism and people on chronic diets or who lose significant weight will have lower metabolism than a person with of the same weight, including fat free mass, who has not had not lost significant weight or drastically dieted in the past. For instance, in a study by Leibel published in the journal Metabolism entitled Diminished Energy Requirements in Reduced-Obese Patients compared the basal metabolic rate in individuals who had lost significant weight to those of the same weight who had not lost significant weight in the past. The authors found that those who had dieted and lost weight in the past had, on average, a 25% lower metabolism than the control patients who had not lost significant weight.
We check the resting metabolic rate in our patients and find this to be a consistent finding, with many such individuals being 20-40% lower than expected for their BMI. Nobody believes how little they eat, and they are made to feel like a failure despite doing everything right. Until their metabolic abnormalities are addressed, diet and exercise will certainly fail to achieve long-term success.

[jennpereira]

12:45 AM on 06/02/2009

I am also a Registered Dietitian and I also have concerns about this article. While all medical issues should be ruled out, it is not helpful to mislead people with yet another diagnosis if that is not the real issue. People struggle with their relationship with food--they often eat for reasons other than physical hunger. I treat many overweight and obese patients, and they are all aware that this is the true issue for them. Even if they have thyroid issues and take medication, this is done in addition to their work with their behaviors with food. If you ignore this aspect of eating, you are not going to solve the real problem.

http://www.healthylifestylebalance.com

[Loveofcats123]

02:17 AM on 06/05/2009

If you have a hormone imbalance, you can do all the diet and exercise possible it you will not be successful. When the person is not successful, the dietician or trainer will blame the person, not their system that is usually unsuccessful. How often does diet and exercise work for most people; maybe 5% long term. Obviously the diet and exercise system doesn't work for most people.

[huffity]

11:07 AM on 05/19/2009

As Dr Holtorf says, many who are hypothyroid are not diagnosed using the current testing model - and many who are diagnosed do not improve on the t4-only medications most commonly used. In either case, if you are always tired no matter how long you sleep, if your skin is dry, your eyes puffy, your feet always cold, your energy and motivation levels low, but your doctor still tells you it's not your thyroid, it's time for a new perspective - and most likely, a new doctor. Self-education is a must with any chronic medical condition, but especially when your doctor won't think outside the box.
A very comprehensive (although somewhat disorganized) site with information on thyroid symptoms, testing, diagnosis, treatment, and even pointers on finding a doctor who is better informed: http://www.stopthethyroidmadness.com/

[pagelove]

07:41 AM on 05/19/2009

As a registered dietitian who has worked with a variety of clients for over 25 years, I know well that there are those whose medical conditions contribute to weight and conditions like diabetes. For those who have issues due to sedentary lifestyle, overeating, and/or poor dietary choices, the answer is education and lifestyle changes—and this must include true and scientifically sound information. For example, one of the facts that people must hear is that no single food or ingredient is the cause of diabetes or obesity. This includes high fructose corn syrup, the subject of so much misinformation. Both sugar and high fructose corn syrup contain four calories per gram, and the body metabolizes them in the same way. Kathleen J. Melanson, et al., at the University of Rhode Island reviewed the effects of HFCS and sugar on circulating levels of glucose, leptin, insulin, and ghrelin in a study group of lean women. The study found “no differences in the metabolic effects” of HFCS and sugar. Singling out HFCS in an authoritative article like this one continues the misinformation to the public, in the same way that people tried blame sugar in years past for being the main culprit behind diabetes and insulin resistance....and it just isn’t that simple. There is a whole host of factors, and HFCS should not be singled out. Let’s make sure we’re arming people with “just the facts.”

Page Love, RD

[MrsRuff]

11:33 PM on 05/21/2009

I believe this article isn't for merely overweight people who are uneducated and sedentary. He's talking about the cellular level of the way a patient with hypothyroidism cannot lose weight and how it has to do with consumption of carbs and HFCS or Reverse T3. The facts are that I am a person with autoimmune hypothyroidism and despite my consumption of whole grains and lean proteins not exceeding 1500 cal/day and walking vigorously 4 miles/day 5 days/week and light weight training 3 days/week....I am still not losing any weight or if i do lose any, I gain it back right away (in less than a week). This article is GREAT NEWS for people who suffer from this disease. Was the study that you mention done on people with hypothyroidism? That's what he is saying here....that people with hypothyroidism have difficulty losing weight with consumption of carbs and HFCS and THEY should avoid it. Please don't mistake me as being rude...I just want to make sure the people reading this article understand that it is directed at patients with hypothyroidism so the facts are much different than those of the rest of the world.

[goodeater]

02:21 AM on 05/17/2009

This is great news! While certainly good eating habits and regular exercise help most people to stay healthy, there was always the question why some don't, even with these regimes. We may have a new insight into this old struggle. Although eating healthy and keeping active, it came a time where my metabolism slowed down and my doctor prescribed medication for my hypothyroidism. It worked for me but not for a friend who suffered from the same condition; on the contrary she did not only lose weight, but she gained more than she had lost. I'll forward this great article to her.
Thanks, Dr. Holtorf
Goodeater-A

[Loraine123C]

03:46 PM on 05/16/2009

Oh My Gosh, this is me. I have had a weight problem all my life. Never ate more than 1500 cal/day (of course no one believes me). I went on a strict medically supervised 800 cal/day liquid diet and did not lose weight. The doctors also did not believe that I strictly stuck to the diet until they put me in the hospital for two weeks and monitored with calorie intake and I also gained weight. I had my basal metabolic rate measured at the hospital several times and it came out to be less than 900 cal/day when it should be about 1600. They want me to get gastric bypass, but eating is not the problem. They keep telling me my thyroid levels are fine despite my inability to lose weight, fatigue, freezing cold all the time (I wear heavy jackets in the summer and my feet are so cold I have to wear thick socks to bed). I am not diabetic and my sugars are not bad so no one has prescribed any diabetic medication. My insulin was on the high side though and one doctor did a leptin level and it was 62 (normal less than 12), but he did not know what to do about it. I am going to show him this article and check my reverse T3. Thank you so much.

[Catothemuchyounger]

11:42 PM on 05/15/2009

Ok, granted, there are a significant number of people with these problems. Does not change the fact that there are a huge number of people who are fat because they don't exercise much and eat too much more in calories, especially junk calories, than they take it. Fact is, the average person is not going to get fat on whole grains, fruit and veggies and meat, especially if they exercise. In may case, I lost about 22 pounds simply by cutting out potato chips and soda.

By the way, there are plenty of skinny people who are in worse physical shape than fat people. A chubby guy who exercises regularly but does not get his diet under control may be in better shape than a skinny guy who does not exercise, and cant run across the street without being winded.

[MrsRuff]

11:41 PM on 05/21/2009

As stated before in my response to the registered dietician....this article is not directed toward people who are sedentary and uneducated about proper diet and exercise. It is geared toward people with hypothyroidism that take all the proper steps necessary to lose weight and are unable to lose if not actually gaining weight in the process. Hypothyroidism patients are not the average person even though this disease has become more and more prevalent in today's society. It's very sad and VERY discouraging so this article is WONDERFUL news to those of us with hypothyroidism. I will be bringing this article to my next endo appointment!

[Echayt]

01:52 PM on 05/14/2009

For patients suffering from hypothyroidism, those of us who have gone from doctor-to-doctor in an effort to find a solution to the frustrating and draining side effects of an underactive thyroid, including weight gain, digetive discomfort, emotionalism and even dry skin, Dr. Holtorf is among the few who have rejected conventional testing and treatment methods in order to achieve a successful outcome for the disease. As one of those patients, he has given me a new understanding and real sense of hope that his somewhat unorthodox treatment of hypothyroidism is thus far the only one positively affecting my condition. I suspect Holtdorf, who is dedicated to educating himself about the most current and relevant medical studies around the globe, is ahead of the curve, leading the way for others to follow his new and better understanding of endocrine problems and solutions.

[ThyroidAdvocate]

05:47 PM on 05/13/2009

Three cheers for Kent Holtorf and to the Huffington Post for this article! On the same topic, here are several other overlooked factors.

Subclinical hypothyroidism -- The thyroid stimulating hormone ("TSH") test is considered by many doctors to be the "gold standard" for thyroid evaluation. Doctors don't agree, however, on what constitutes an "elevated" TSH. (Elevated TSH signals hypothyroidism -- an underactive thyroid, which slows the metabolism, and can contribute to weight gain, or make weight loss impossible.) Since 2003, experts recommended that TSH levels above 3.0 be considered hypothyroid. But six years later, most labs and many doctors STILL use the old, outdated level of 5.5 The result? Millions with hypothyroidism are told their thyroid is "normal," aren't getting proper diagnosis/treatment and as a result, struggle with weight issues.

Autoimmune thyroid disease -- Many people with normal thyroid levels have an autoimmune thyroid condition called Hashimoto's disease, where antibodies attack the thyroid. This causes hypothyroidism symptoms -- including weight problems -- long before blood tests reflect the damage. Few doctors understand Hashimoto's disease, leaving many people untreated. (This is the condition that afflicts Oprah Winfrey.)

Thyroid conditions sabotage even the best diet and exercise programs, so it's essential that anyone who is gaining weight -- or unable to lose weight -- have a complete thyroid evaluation.

Mary Shomon
Patient Advocate, Thyroid Activist
Author: The Thyroid Diet: Manage Your Metabolism for Lasting Weight Loss
http://www.thyroid-info.com / http://www.goodmetabolism.com

[Pearlswan]

05:53 PM on 05/13/2009

Three more cheers for your comments! Thanks.

[Isabel Azevedo]

04:54 PM on 05/13/2009

The first two paragraphs of this post are perfect. From that point on, it can be seriously misleading.
See, for example, the post just before this one (Feeling Spent? 5 Easy Ways to Overcome Exhaustion, by
Dr. Frank Lipman). The inconvenient behaviour that leads to the state Dr. Lipman calls SPENT, likewise contributes to obesity. Together with many more habits and things of the so-called modern era, sedentary life, agro-business products, lack of interest in life, absence of projects, self-centered attitudes, etc., included. But for a few very specific cases, any reductionist counseling will be no more than another false start.

[jojoball]

03:50 PM on 05/13/2009

Wow, finally someone is taking this seriously. For years I would go on starvation diets and exercise only to gain the weight back time and time again. It was very frustrating and I had given up many times, until one day I went to my doctor and asked him to try and figure out what was wrong. I told him that I was fearful of becoming diabetic or developing heart disease like so many in my family already have, and no matter what I did it was impossible to lose the weight or keep it off. He ran a few blood tests (mainly leptin and reverse T3) and my levels were greatly elevated even though they were still in the normal range. After being prescribed a small dose of T3 to lower the Reverse T3 and Byetta to lower the Leptin level it became easier to actually get the weight down and I am showing no signs of gaining it back. I feel like I have been given a secret weapon to give me an advantage in this weightloss battle.
Thanks for thinking outside the box.
Joanna B

[violettefemme]

03:50 PM on 05/13/2009

Lightbulbs are going off in my head reading this. I'm going to look into it, as it described me my whole life! Thank you, what a service this article is doing.

[traveler501]

03:46 PM on 05/13/2009

IMO you are way too focused on the details..step back and take a look. Find me an obese person who exercises daily and eats well...find me just one. The problem is obvious...and measuring and tabulating various imbalances that result from chronic abuse mean little. Nor does the argument that many people get by with no exercise and lousy nutrution. Partly because they often show imbalances of other kinds over time, and partly because...big surprise, we are all different.

Btw...nutrition would consist of fresh fruits and vegetables, whole grains and limited lean meat...in this day and age, I suppose that needs to be clarified Also, I don't mean to ignore or downplay the emotional aspects of this problem...although I do think that a healthy regimen and improved chemical balances, not to mention improved self-image, are a much better platform from which to resolve those other, perhaps foundational, issues. Kinda like bailing out the banks before we restructure and break them up LOL

[Pearlswan]

05:58 PM on 05/13/2009

"Find me an obese person who exercises daily and eats well...find me just one."

How about Oprah Winfrey? She even has a personal trainer. She diets constantly. Did you see her season opener? Check it out. No matter what she does, the weight always comes back.

[BJD44]

01:40 PM on 05/14/2009

Oprah Winfrey is NOT a good example. She just proves that you can have all the moola in the world, but that doesn't give you self-control either. There are so many emotional factors that go into weight problems, so much so that it's very difficult to even get past 'the chicken vs. the egg' syndrome - meaning which causes which in the way of weight gain vs. depression, poor self-esteem, poor dietary/exercise habits. I would venture to say that, even though they won't admit it, most all people who are overweight have some form of depression or self-esteem issues. But it's difficult to determine if those issues cause the weight problem or the weight problem causes those issues. And that would be the same no matter if you are an adult or a child, as children also have problems with depression and self-esteem, not to mention parents who overfeed them or just plain feed them junk. Many overweight folks NEVER HAD PARENTS WHO FED THEM CORRECTLY OR NUTRITIOUSLY, so they grow up NOT KNOWING HOW TO EAT. Then, once they're adults, it is EXTREMELY difficult to break those longtime poor eating habits, not to mention that I doubt they exercise much.

Anyway, back to Oprah. You note that 'she diets constantly.' Let me tell you.....that's only part of her problem. I would venture to say that her underlying problems are MUCH deeper and that they started long ago.

[Mike Ippolito]

06:54 PM on 05/18/2009

"Find me an obese person who exercises daily and eats well...find me just

Oh my, how insulting is this statement. I am logged in as my husband but I am speaking for myself. I AM that person. I am very active, eat correctly and healthily. I can work out at the gym every day and not lose one ounce. I swim every single day.
It is true, yes there are obese people out there just eating too much but not EVERY fat person just eats too much.
Can you even imagine what it would be like to try to lose weight and stay on a diet every single day of your life and make NO progress?
Get real!

[Suzie Edwards]

07:02 PM on 05/13/2009

I am a Hashimoto's patient. Before being diagnosed, I rollerbladed 50 miles a wk & ate healthy. Although my body was fit, regular self pep talks & every bit of will power helped. Due to an injury, I did slow down my regimen and within three weeks put on over 20 lbs, I was exhausted and depressed. TSH tests came back normal. When i mentioned that my tongue was swelling at times, I was sent to an allergist who cleared me of any allergies. The allergist suggested a test for antibodies. The result indicated high levels of thyroid antibodies. To feel "healthy" again, I took up running 30-40 miles a week. I've been on thyroid medications for about 3 years now. I dont know if its due to the medication but now I have suddenly developed degenerative arthritis and am unable to perform as I did in the past. The pain and bone spurs in my neck and back were never there before the medication. My point is, as a Hashimoto's patient, it takes EXTREME measures even with medication. The way my body behaves is unpredictable.

[redplanet]

05:53 AM on 05/15/2009

I hope you will look into taking Armour thyroid. I also have Hashimoto's and on anything but Armour - or plain T3 - I get pain in my neck so bad I cannot turn it. Armour ended ten years of severe neck pain. I strongly suggest Mary Shomon's work or http://www.drlowe.com/

If you are on Synthroid, you may be worse than if you did nothing. I don't expect 90% of doctors to agree with that, but they didn't suffer and I did the research and I know why it doesn't work for most patients. If you are on Armour, you may need to increase. Talk to someone about that. I have been pain free now for 12 years. But if I run out, welcome pain.

Or it may have nothing to do with it. Obviously I don't know, but I am giving you my experience because you can take it as a starting point for more research if it makes sense to you.

[DalLdy]

08:38 AM on 05/15/2009

Suzie,

Please tell me more about this degenerative arthritis. I recently started having severe ankle and foot pain. I'm on Armour and have been very active over the years, however, now I am finding it really hard to stay motivated. I was recently under a great deal of stress - selling one house and purchasing a new house at the same time. After several months of double bills, we finally sold our house. My pain started right around this time. I recently had new bloodwork done and had a severe Vitamin D deficiency. I also had some other abnormalities but don't have my results with me. :( I also feel pain in my hands, and shoulders. I put on about 20lbs during this time - all of which seems to be in my mid-section. How do I find out if I have degenerative arthritis? I'm feeling sick to my stomach over this.