(This is another rich, sample entry from our Q&A Treasure chest, a database with hundreds of entries to support students with their patient and client work. Unlimited access is included as part of our Core 101 Semester program.)
What are the most common dynamics in the body that prevent people from losing weight? What can practitioners affect that is most likely to actually succeed in supporting weight loss (assuming they want to lose a fair amount – at least 20 lbs)?
Great question! Indeed, there will be many clients that come to us with the goal of losing a significant amount of weight. It is critical to teach people that the body views excess weight as an assurance against an uncertain future. The body will naturally increase adipose tissue if it feels our survival is being threatened. Weight loss will be natural (and sustainable) when sources of stress and inflammation are addressed. Forcing weight loss on its own independent from addressing root causes will not only be temporary but will likely cause new body weight reset points that are progressively higher. Setting proper expectations that weight loss is often the last perceived benefit of addressing the root causes of disease is, of course, critical for patient engagement, commitment, and persistence. You might want to experience this rich video on overall weight loss myths, misconceptions, and truths for practitioners through the functional medicine lens.
Before we dive in, please note one important consideration: clients with significant adiposity will also have significant toxicity. Many toxins are stored in fat, and can in fact be a root cause as to why they are having issues with either weight gain or trouble losing weight. Therefore, we don’t want to promote significant weight loss until we are sure detox pathways are fully supported. I will share more about the important steps for detoxification down below.
The most common reasons people struggle with losing weight are hormone-mediated and ultimately driven by (what else?!) Crap Food, Toxins, and Stress. Hormonal drivers include insulin resistance, hypothyroidism, estrogen dominance, and chronic stress.
Insulin resistance – both a high glycemic diet and chronic stress can increase the glucose load on the body. Over time, increases in blood sugar can lead to insulin resistance. In this case, cells are suffering from low energy, organs and the cardiovascular system are suffering from too much sugar, and the body is storing more and more fat. You want to check both Fasting glucose and HbA1c to get keen insight. However, usually years before fasting glucose or HbA1c begin to rise at all, fasting insulin begins to rise and will be suboptimally in the upper half of the normal reference range. For a deeper dive into this topic, consider taking the Deep Dive Clinical Course Reversing Metabolic Dysfunction. Some strategies to address insulin resistance are:
Hypothyroidism – a sluggish thyroid can cause sluggish anything. Fatigue can result in moving less and sluggish metabolism can cause weight gain. Importantly, you must check a full thyroid panel – TSH, Free T4, Free T3, Reverse T3 and thyroid antibodies (TPO and TG) to look for various types of hypothyroid function (note that sub-clinical hypothyroidism can still have *dramatic* effects). You may find autoimmune (Hashimoto’s), nutrient-impaired (e.g. low T4 from insufficient iodine), stress-impaired (e.g. high conversion of T4 to Reverse T3), and/or inflammation-impaired (e.g. poor conversion of T4 to T3) hypothyroid function. For a deeper dive into this topic, consider taking the Deep Dive Clinical Course Adrenal and Thyroid: Myths and Truths.
Sex Hormone Imbalance, such as estrogen dominance or testosterone deficiency – an issue in both men and women. Testosterone is important for many functions including libido and joint health, and it is well-known to be important for building muscle and decreasing body fat. Testosterone can be low due to stress, excessive exposure to estrogen or excessive alcohol intake, for example. Deficiency can lead to low motivation, irritability, insulin resistance and weight gain. Much of our androgens are produced in the adrenal gland, so if the adrenal gland is busy pouring out stress hormones, testosterone production can suffer, but in addition, cortisol blocks testosterone receptors. In addition, with excess body fat, adipocytes may lead to excess estrogen and low testosterone because adipose tissue is endocrine tissue and can convert androstenedione and testosterone into strong estrogens via aromatization.
Estrogen dominance is a common dynamic that leads to symptoms such as PMS (usually with cramps), heavy, lengthy, clotting periods, and stubborn weight gain. Most often, estrogen dominance is caused by blocks in estrogen metabolism or clearance or increased estrogenic load from endocrine disrupting chemicals (pesticides, herbicides, parabens, phthalates etc.). A good opportunity in this case would be to clean up personal care and cleaning products and eat as much as possible 100% organic. For a deeper dive into this topic, consider taking the Deep Dive Clinical Course Hormones Demystified.
Stress! Chronic stress unpins all of the above dynamics and, as such, is often a major driver of stubborn, excess weight. Cortisol is a catabolic hormone which is released under stressful conditions, breaking down muscle to generate blood sugar in the process of gluconeogenesis. It does this, while simultaneously increasing insulin resistance. High cortisol also reduces thyroid action via increasing T4 conversion to Reverse T3. Many people trying to lose weight inadvertently increase their cortisol (and thus their Reverse T3) with excessive exercise or insufficient calories for example. Of note, sustained low cortisol due to prolonged stress or burnout can also reduce thyroid action via reducing cellular uptake of thyroid hormone. Sources of stress that may lead to trouble losing weight include:
For a deeper dive into this topic, consider taking the Deep Dive Clinical Course Adrenal and Thyroid: Myths and Truths.
Food sensitivities can cause symptoms of all kinds, including general inflammation and weight gain. First try eliminating gluten and dairy 100% for 4+ weeks as a trial. A further elimination diet may be tried from there, and if appropriate, consider food sensitivity testing. None are comprehensive but total IgG with complement (not IgG4) or a combo IgG/IgA are best to help eliminate false positives. This topic is covered in detail in the Deep Dive Clinical Course Asthma, Allergy and Immune Tolerance. There is a rich post here on food sensitivities as well.
Many toxins are stored in adipose tissue and can be a common reason for weight loss resistance. Common toxins we are exposed to are endocrine disrupting chemicals (personal care products, cleaning products and food packaging), pesticides, herbicides, fungicides, VOCs, heavy metals and mold. We not only need to reduce exposure, we often need to remove stored residual toxins from the body as well. For example, mold is a toxin that can lead to weight gain or trouble losing weight. Getting it out of the body will only help marginally if one is constantly being exposed. Full healing can’t take place until the person is removed from the toxic/allergenic environment sustainably.
Regardless if it’s a driving root cause or not, it’s important to be mindful of the fact that as we lose weight, we free up toxins from adipose tissue and put them back in circulation (more here and here). This dynamic is seen with weight loss via diet and via surgery. This can cause an increase in physiologic stress (and cortisol), which will in turn, slow weight loss.
So, before any intensive weight loss efforts, there are a few important things to ensure before proceeding:
For a deeper dive into this topic, consider taking the Deep Dive Clinical Course Toxicity, Detoxification and Heavy Metals.
Finally, it’s also important to take breaks from intense weight loss efforts to work on healing the gut intermittently. All the toxins released can damage the GI tract lining, so to avoid causing other downstream issues, it’s important to take some time to heal the gut after each approximately 25 pounds lost.