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“We are well protected against food restriction, but seemingly not as well against food excess.”
J. Enrique Silva, 2006 (Thyroid Researcher)​

What’s wrong with me? Calories IN, Calories OUT doesn’t work for me.
You’ve struggled for years, and your body seems to defy the laws of physics. The quote above says it all.

Increased Interest in Food
We are designed to survive times of insufficient food. When you decrease food intake, hormonal and nervous system signals change to make you eat more. You think about food more often, it takes more food to feel full – these pathways include stomach and intestinal hormones, as well as the opioid pathways in the brain. So, there are very strong forces trying to keep you from losing weight. It doesn’t matter how much extra weight you’re carrying, your body is designed to protect against weight loss. People who say that you lack will power have never been up against the forces you fight when you try to lose weight. Of course, there are going to be variations between different people on the power of these forces.

Decreased Metabolism
When people decrease their food intake, approximately 90-95% decrease their metabolism to help the body maintain its current weight and thus survive famine. From work on rodents, we know that even 5% less food can be detected by the body. This decreased metabolism does not show up on the thyroid lab tests that we were all taught to run (TSH and T4) and it is often not well treated with L-thyroxine alone. We must dig deeper into thyroid hormones to see the response to insufficient food.

Why doesn’t everyone have these challenges?
Sure, there is always a magazine with a picture on the front cover of someone (famous or not) who has successfully lost weight and maintained it. If this were easy and common, it wouldn’t rate the front cover of a magazine. Given that 5-10% of people do not dip their metabolism, you can always find someone who says: “I lost ___(some large number of pounds)___ - by sticking to ____(certain behaviors) ______ - and I’ve kept it off, no problem” and they make it sound easy. I’d be willing to bet those people are in the small percentage who do not decrease their metabolism. And beyond that, we are all different based on our genetics, personal history, habits, likes/dislikes, and even epigenetic effects passed down from our parents’ history of trauma.

Should I get a ton of Exercise?
Exercise is important for health in many ways, and in general, can be indirectly helpful in weight loss. This may be hard to believe, but if you keep food intake the same and add exercise, your body decreases metabolism at other times of day. Again, the body is trying to maintain your current weight. For some people, this may not be true, and with extreme exercise, it may not be true. But for most people, exercise probably helps with weight loss indirectly by its role in improved sleep and decreased stress. The National Weight Control Registry has studied people who have lost weight and kept it off. They have found that exercise is not an important factor in weight loss for most of their participants but is very important in keeping it off. There’s a lot of current work in this area.

Why is this so unfair?
You’re right, none of this seems fair. While we may have plenty of food today, most of us are descended from peasants. We have these bodies after eons of generations who often didn’t have enough food. We are not designed to lose excess weight. We are designed to defend against losing the weight we have.

How can you help me lose weight when I’ve failed in the past?
For some people, appetite suppressants provide needed help. Others simply need to have their metabolism at a normal level to permit weight loss. A few people just need more understanding of how different foods alter hormones that encourage fat storage, and information on better choices for food types and timing.

Should I take medications for appetite suppression?
Our society teaches us that losing weight will be easy if we just do the right things. But now that you know that your body actively fights weight loss and that obesity is a chronic disease, you understand this isn’t your own failing. As a matter of fact, it means you are highly evolved to protect your current weight to survive famines. The percentage of people who lose weight and successfully keep it off without medication is very small. A 2001 study by Anderson and colleagues collected the information from 29 long term weight loss studies and found that by 5 years, about 80% of people had regained their weight. (American Journal of Clinical Nutrition. v.74: pp. 579-84)

If excess appetite is a problem for you, we’ll encourage you to consider medications. While most people accept the idea that we should treat type 2 diabetes, high blood pressure, and cholesterol problems with medications, many people think that we should not use medications to help with weight loss and maintenance. But problems such as high blood pressure, diabetes, etc., usually improve with weight loss. And there’s a very long list of other things that improve with weight loss including liver problems, weight-related arthritis pain, and cancer risk.

A variety of prescription medications can be used alone or in combinations to help you lose weight and keep it off. Some of these medications are approved by the FDA for weight loss, others are approved for other problems but have decreased appetite as a side effect. These medications can decrease both appetite and cravings. Comments from patients on how it feels to be on these medications:

“It’s easier to eat less – I feel full sooner.”

“I can walk down the chip isle and it doesn’t bother me.”

“Sweets no longer call my name.”

Can you help me if I’ve regained after weight loss surgery
Absolutely! Many of our patients have had weight loss surgery with either unsatisfactory results or subsequent regain. Everything we do for others will apply to you – and we’ll remind you to take those bariatric vitamins.

Can weight loss reverse my diabetes or prediabetes?
Yes. We can’t promise total remission of diabetes, but with weight loss, you can live a much healthier life with your diabetes. Continuous glucose monitoring technology can be a big help for understanding what behaviors affect your blood sugar levels.

How do you evaluate and treat thyroid differently?
We understand that your body’s thermostat is likely to be reset to a lower level when you are trying to lose weight. Remember, your primitive body wants to save energy. So, you’re likely to suffer from feeling cold, cold hands and feet – maybe even your nose, and other low thyroid symptoms. But the thermostat has been reset to a lower temperature and your system is still working well to produce that new lower level of thyroid hormones. TSH will be perfectly normal because the system is working normally. We need to measure several hormones, most importantly the level of the active thyroid hormone, T3 (liothyronine). A decision to treat is based on different values than the usual view. And of course, the decision to treat is up to you.

What’s the best diet? What should I eat and when?
Because everyone is different, we’ll talk about what makes sense for your body type and we’ll discuss what your life is like as well as what kind of changes you feel you actually can do. For example, for someone who feels addicted to chocolate, giving it up entirely may be the answer; others are happier if they have a small amount daily and can be content with that.

What’s lipedema?
Lipedema [lip=fat; edema= swollen] is a fat disorder causing fat deposition in specific parts of the body, most commonly thighs, hips, buttocks, and upper arms. Typically, the amount of fat on these areas is out of proportion to other parts of the body. Lipedema occurs almost exclusively in women. Many people and their providers do not recognize that it is a specific problem. While it has received little attention, we are prepared to help you lose weight with lipedema.

What about stress and sleep?
These two factors can stand in the way of weight loss. We can help you develop strategies for both stress management and better sleep. You may need to be evaluated for sleep apnea.

What happens when I reach my goal?
We don’t just congratulate you and send you away. Obesity is a chronic condition. In most people, chronic treatment is needed. Some people do fine without any help once they reach their goal. But most are impacted by those primitive forces pushing you to regain the weight. (Google Kevin Hall and The Biggest Loser Study to see more.) Just as we don’t stop blood pressure or diabetes medications when the lab results look right, we shouldn’t stop obesity treatment when you reach your goal. Generally, you’ll reduce or stop taking the medications and restart if you have regained a few pounds or are facing a challenging time – e.g., you may want to use appetite suppressants for just Thanksgiving or maybe for the whole winter holiday season. As always, the choice of how to proceed is yours..

Why should I choose a nurse practitioner for my care?
Our education and philosophy teach us to listen to the patient’s history, self-knowledge, and values. We provide education on the matters at hand and work with you as you decide what choices feel best for you. Even if your body type and labs suggest that some plan might be best for you, it isn’t going to work if you know you can’t stick to it. We’ll work together to find compromises that will help you be successful.

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