Weight loss is at the top of the list of why people come to our practice these days—also high on that list of primary care visits is depression, anxiety, stomach pain, ADD, and headaches.
Folks often want to know what we can offer them for weight loss---but sometimes they come to their appointment already with an idea of what they want—maybe to get their hormones checked or to start weight loss medications.
While I do offer weight loss medications, all medications come with potential side effects and adverse effects—and often, they are just a Band-Aid—they may offer temporary weight loss, and sometimes can be a helpful adjunct in “getting the ball rolling” for weight loss, but they won’t fix the underlying contributors to weight.
I love to support patients in weight loss. I usually ask them to keep a journal of what they are eating, drinking, how many hours they are sleeping (and when), what kind of exercise they are doing (and how much and how often), and what medications/supplements they are already on.
If I ask 20 patients to do this for me so we can review/analyze their patterns and habits together, maybe one person will actually do this.
Most folks want a quick fix—they don’t have the time or make the time to reflect on the small, daily things they are doing (or not doing) that led to their current weight.
There are a few things I like to “rule out” or address/explore as contributors to weight gain when I first see a patient for weight loss.
1. Underlying sleep disorders—this can certainly cause weight gain and can be checked with a sleep study or helped with certain meds or supplements if needed; sometimes a CPAP machine is also needed. Conversely, too much weight can contribute to poor sleep or sleep apnea, which then messes up the hormones responsible for maintaining a healthy weight, so it becomes a vicious circle of weight gain and poor sleep (and often depression and ADD accompany this)
2. Hormones—I like to check certain hormones to see how these may be playing a role in weight gain/appetite—estrogen, testosterone, cortisol, thyroid, for example.
3. Nutrient levels—Sometimes those with excessive weight are actually nutrient deficient and can increase their metabolism with the right nutrients. For example, low iron can cause odd food cravings as well as profound fatigue, which can make exercise and weight loss difficult. Low B12 can also cause fatigue. I like to check nutrients in bloodwork and by analyzing one’s diet with them. Insufficient fiber and poor gut bacteria can likewise make weight loss harder.
4. Food /drink intake—I’m not a fan of the “low fat” diet, and I’m also not a fan of the strict keto diet—I’m a fan of a “lower carb, complex carb, healthy fat, healthy protein” balanced diet. We NEED fats to burn fats and make healthy hormones (yes, many hormones are built from FAT molecules). We need some carbs—like complex carbs, for specific nutrients. Also, too much protein is really hard on the kidneys. I ask patients to keep a lifestyle journal so we can analyze together which foods are contributing to insulin spikes, which then contributes to weight gain. Alcohol and “sugar free” foods and drinks are also big culprits. I do a lot of education of insulin and glycemic index of foods and how insulin causes weight gain.
5. Mental health—I frequently check-in with patients on anxiety and depression and disordered eating. Binge eating is often a coping mechanism for anxiety or depression—as is often bulimia. Having lived through a severe eating disorder as well as depression and anxiety, I am passionate about creating a safe and judgment-free provider-patient relationship to explore these connections and address the underlying mental health component in weight. Sometimes, addressing the mental health piece with therapy, supplements or medications results in weight loss because food as a coping mechanism is replaced with balanced brain hormones, such as serotonin.
6. Chronic pain and underlying conditions—I have many patients who struggle with both weight and chronic pain. Many tell me that their pain was never “taken seriously by previous providers” because they were “just treated like a fat person.” In practicing mind-body-spirit “whole body medicine”, I believe everything is intricately related. Chronic pain makes it very hard to exercise. Joint diseases like Ehlers Danlos and rheumatoid arthritis may make it very difficult to exercise; some of the medications used in conventional medicine to treat joint pain may cause weight gain, such as steroids. Some mental health medications used for depression or mood disorders contribute to weight. Some blood pressure meds make it harder to exercise, such as beta blockers. Medical conditions that can make exercise difficult include chronic headaches, dizziness, stomach issues, heart problems, asthma and more—we may have to treat and control these issues to make exercise more tolerable. Often, by getting someone exercising, their systemic problems improve.
7. Exercise—the ability or inability to get moving plays a big role in weight. I see many folks try all sorts of fancy diets and meal plan services, but often, if we cut right to the chase, they report to me that they only get sweat-producing, heart-rate raising exercise once or twice a week at best. Our bodies were never meant to be sedentary, and weight is a natural consequence of not moving. My motto with movement has become “some, not none.” If I don’t have time to go to the gym or for a 2 hour bike ride with a friend, I can still go for a walk between patients, even if just 20 min. I can park at the end of the parking lot instead of the front. I can take the stairs instead of the elevator. I can sit in front of my TV at the end of the day and do some crunches and squats—some, not none. Any movement is better than no movement when it comes to weight loss.
And finally, once these topics have been addressed, I go through options with my patients.
1. Meds-There are medications such as phentermine and topamax that aid in weight loss.
2. Fine-tuning of hormones, such thyroid or testosterone, can aid in weight loss
3. Intermittent fasting—this is one of my favorite, safest, and most natural ways of maintaining weight or losing weight. Click here for my detailed blog on HOW to start intermittent fasting
4. There is the option of surgery for some.
5. Supplements- there are many supplements that claim they support weight loss, but not many are safe or scientifically proven. Berberine does have some evidence in lowering insulin levels, which can help control weight and blood sugar-- green tea, maca, chromium and ashwagandha have been looked at for their role in stimulating metabolism and regulating cortisol production. When it comes to supplements for weight loss, please talk with your provider to make sure you not harming yourself or wasting your money.
WHAT IS Intermittent Fasting and how do you do it?
Simply put, intermittent fasting (IF) is eating only during certain hours and "fasting" during others. The most popular method is to fast for 16 hours, leaving an 8 hour window when one can eat smart, balanced foods. IF has been used for decades in other countries to help with a myriad of health conditions, ranging from diabetes to joint disease, autoimmune disease and mental health. IF has been gaining a lot of scientific traction and acceptance in Western medicine here in the States over the last decade.
I love how Dr. Fung, leading physician/nephrologist talks about IF and insulin in his book "The Obesity Code":
"Predominantly, we are talking about the insulin response in your body. Insulin tells the body to store fat. When you eat, insulin response goes up, and it tells the body to store excess blood sugar as fat. When you don't eat, like when you sleep, insulin levels fall. So you have to mobilize calories from fat to burn energy to live. If you eat too much sugar or too many carbs, you have to store all those calories as fat. After you do that, there is no energy available -- so you go out and eat more. And again, when insulin goes up again, all the new calories are stored as fat.
"Some foods are more fattening and some foods are less fattening. People who eat more salad don't get fat while people who eat more cookies and cake (or any sweets) do get fat. So, the next step is to understand how the hormonal response to the type of food you eat tells your body to store fat or not store fat. This is why people care about the glycemic index (GI) of food. The lower the GI, the less your insulin response spikes.
"If you never let your insulin drop then you never tell your body to pull calories from fat. So there is a whole movement among athletes to training in the fasting state. If you train without eating, then you need to pull calories out of storage to get through an intense workout. If you eat in the morning -- let's say you have a muffin before your workout -- then you use up that source and your body never uses calories from fat and your workout was not effective if the reason you're working out is to lose fat.
If you're plant-based and eating beans, legumes, vegetables and whole grains like quinoa, that all keeps insulin low, unlike bread, pasta, rice, cereal. sugary yogurts and smoothies.
"If you fast, and don't eat at all, for 12 or 14 or 16 hours, then your insulin is going to fall-- therefore, your body is going to switch over and naturally burn fat. So your body wants 2,000 calories a day, and your body has maybe 200,000 calories stored (as fat). So your metabolic rate doesn't fall, even without exercise. You just start to burn all those stored calories from fat."
"If you drink alcohol it is metabolized like sugar, so you have to count wine or beer or spirits in this equation -- so people who drink a lot of wine, they need to know that it's metabolized in the body just like sugar. Two glasses of wine are like having dessert. If you want to lose weight, skip the carbs and the alcohol. Insulin gets mobilized the same way, whether it's carbs in food or the sugar in alcohol.
My husband’s longest fast was 10 days long. This is not IF—this is called an “extended fast.” During this period, we ran a baseline EKG , a half-way point EKG, checked his blood pressure and heart rate and checked what we call a comprehensive metabolic panel—to ensure his sodium and potassium levels were normal and blood sugar not too low. During this fast, he exercised most days, including a 30 mile mountain bike ride one day. Exercise + fasting =biggest weight loss.
We monitored his blood pressure and fasting blood sugar levels and ketones daily. For 10 days, he fasted on lemon water with Himalayan salts, some black coffee, and homemade bone broth. He lost 10 lbs and now, a month later, has kept it off. EKG and blood work is not necessary for IF, when one is eating one meal a day or in a small window), but it is a good idea for extended fasts.
Is fasting safe for everyone?
Intermittent fasting is generally quite safe, but diabetics on insulin should only fast under the very careful scrutiny of their PCP or endocrinologist. I always advise people ask their provider about their plans before starting fasting—some providers are well-versed in IF and others may not know much at all about it.
Try Intermittent Fasting for 16 hours. Between 16 and 24 hours twice a week is probably the most popular amount of time, though most folks end up liking it so much they do it daily.
Between meals, as long as we don’t snack, our insulin levels will go down and our fat cells can then release their stored sugar, to be used as energy. We lose weight if we let our insulin levels go down. The entire idea of IF is to allow the insulin levels to go down far enough and for long enough that we burn off our fat.
So what DO I drink while fasting?
I highly advise getting the book "The Obesity Code" by Dr Fung which has this all laid out, but basically, black coffee with just a touch of cream (no artificial stuff or sweetened cream), plain teas, bone broth, and water with unsweetened electrolytes are what you have during your fasting hours. In your non-fasting hours, meals should be simple, lower in carbs (and those carbs should be complex carbs, mostly veggies), lean proteins or plant proteins and healthy fats like avocado, olives, flax seed and flax oil, fish.
Below are photos of my husband making home-made organic bone broth, which he uses for both intermittent and extended fasting.
Patient Cases
Case one:
“The Philosopher” as we will call him, was a patient of mine who came to me with frustration and distrust. He thought I was going to “lecture him on getting on insulin” because his diabetes was out of control. But he didn’t want to go on insulin, he insisted. “Well, you’re in the right place then,” I told him. “Because I don’t want to put you on insulin except as a last resort. And I’d like to get you off your diabetes medications in general.” He looked at me with skepticism. “If we can get your weight down and change how and when you eat, we can lower your cholesterol AND your blood sugar and likely get you OFF your diabetes medications and keep you from having to go on a statin for high cholesterol. But you have to be willing to work with me diligently on this.
He agreed, and together we met weekly for a couple months while I walked him through the intermittent fasting journey and fine-tuned what he ate.
Within 3 months of IF and exercise, he lost 20 lbs and dropped his blood sugars from a diabetic level to a non-diabetic level. His cholesterol went from a dangerous level needing a statin to a normal level.
Case two:
“The trail runner” –Terry is a hard-core runner who is as fit as fit can be. You wouldn’t know it by looking at him that his blood sugar levels were pre-diabetic and his cholesterol dangerously high. He had a penchant for eating a lot of snacks at work. His twin brother, also an insanely fit athlete, had a severe heart problem while competing in an Iron Man race. Terry came to me because he wanted to “get healthier and avoid heart disease and diabetes.” We started on the IF journey together and cut out his snacking—we replaced his processed foods with whole foods and complex carbs, and within 3 months, we got his “bad cholesterol” (LDLs) from 197 to 140, dropped his triglycerides by 100 points, and increased his “good cholesterol” (HDL) by 10 points.
Case three:
“The Truck Driver” was living on energy drinks and gas station foods. He was obese, diabetic, and had very high cholesterol and blood pressure. He had recently been started on blood pressure medications and diabetes medications. He decided to stop these medications and get serious about his bad habits and lifestyle. He started doing low-carb IF and exercising, and within 3 months, his A1C (a measure of average blood sugar) went from 11.6 to 6.8. A patient is considered diabetic if their A1C is higher than 6.5. His triglycerides (unhealthy fats that greatly increase risk of stroke/heart attac) went from 800 to 200, and his blood pressure and weight normalized.
Interested in trying IF or starting a “work up” for weight loss?
We are accepting new patients and happy to be part of your journey in health!
Havilah Brodhead, FNP, is a board-certified family nurse practitioner who believes in treating the whole person with a mind-body-spirit approach. She incorporates alternative and plant-based medicine into her conventional medical practice. This is known as integrative medicine. She is the owner of Hearthside Medicine Family Care in Bend, Oregon. Hearthside is accepting new patients of all ages and accepts most insurances.
For the detailed blog on how to start intermittent fasting and how it works, click here
Sources
Effects of intermittent fasting on health, aging, and disease. de Cabo R, Mattonson MP. New England Journal of Medicine, December 2019.
Effect of Alternate-Day Fasting on Weight Loss, Weight Maintenance, and Cardioprotection Among Metabolically Healthy Obese Adults: A Randomized Clinical Trial. JAMA Internal Medicine, May 2017.
Alternate-day fasting in nonobese subjects: effects on body weight, body composition, and energy metabolism. American Journal of Clinical Nutrition, January 2005.
The Obesity Code, by Jason Fung, MD (Greystone Books, 2016).
Intermittent fasting interventions for treatment of overweight and obesity in adults: a systematic review and meta-analysis. JBI Database of Systematic Reviews and Implementation Reports, February 2018.
Metabolic Effects of Intermittent Fasting. Annual Review of Nutrition, August 2017.
Early Time-Restricted Feeding Improves Insulin Sensitivity, Blood Pressure, and Oxidative Stress Even without Weight Loss in Men with Prediabetes. Cell Metabolism, May 2018.
If you want to read more from Dr. Jason Fung, get a copy of "The Complete Guide to Fasting." And his other book, "The Obesity Code." Life in the Fasting Lane is available for pre-order on Amazon.