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Biggest Levers for Weight Loss

(This is an excerpt from a sample entry in SAFM’s Q&A Treasure Chest, a tool with hundreds of entries to support students with their client needs. Students gain unlimited access as part of SAFM’s functional medicine training program.)

Student Question:

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 moderate amount, 20 lbs)?

SAFM Response:

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 often be natural (and sustainable) when sources of stress (emotional or physiological) and inflammation are addressed.  Forcing weight loss on its own, independent from addressing root causes, will not only likely be temporary but will likely cause new body weight reset points that are progressively higher (e.g. via calorie restrictive dieting).  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 often have significant toxicity (as a result of the obesogenic effect of many endocrine disrupting chemicals). Many toxins are also stored in body fat, and ongoing toxic overload can actually be a root cause as to why they are having issues with overweight. Therefore, we don’t want to promote significant weight loss until we are sure detox pathways are well supported. Read 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. This marker is widely available (at least here in the US) and can be proactively used to form a more complete picture of insulin sensitivity and glucose handling dynamics. This topic is addressed in great depth in SAFM’s clinical course Reversing Metabolic Dysfunction (included in our practitioner training program). Some strategies to address insulin resistance are:

  • Eliminate sugars and sweeteners. After a couple of initial, transitional weeks, this should also include elimination of all natural substitutes (e.g. stevia, erythritol) in order to allow taste buds to adapt over time to stop expecting most foods to taste so sweet. Emphasize instead whole fruit or starchy vegetables (e.g. sweet potato) to satisfy our natural desire for sweet flavors.  Give patients a list of alternatives to satisfy their cravings and ensure they identify some options that resonate with them personally.  Without specific ideas and resources, they are much less likely to succeed.
  • Eliminate All grains for a while – or at least foods made with Any grain flour (especially gluten but preferably All grain flours). In many people, especially those with insulin resistance, grains may promote significant blood sugar spikes (and insulin surges), even if they are consumed in an unsweetened food.   Stone-ground, whole wheat flour or oatmeal may promote a blood sugar spike worse than a refined grain food (e.g. pastry) in some people. Wearing a continuous glucose monitor (CGM) for 7-14 days and keeping track of diet/lifestyle can be very helpful for understanding how a unique individual’s body responds to various foods.  Over time, blood sugar spikes promote insulin resistance and increased body fat (regardless of weight), and individuals are often surprised to learn what foods promote increased blood sugar specifically for them (e.g. oatmeal vs. black beans vs. apple).
  • Eat a breakfast that includes protein and healthy fat every day.  Our blood sugar stability and cravings throughout the rest of the day are highly influenced by what we eat for our first meal of the day, as we end a window of fasting (whether this happens at 6am or 11am). Obese clients often experience the greatest ease with weight loss by having at least 20 grams of protein (some need 30-40g for results!) in their first meal of the day in order to congtrol appetite/cravings. Protein intake increases satiety and promotes the secretion of the hormone glucagon which promotes fat-burning.
  • Overnight fasting of 12-14+ hours to encourage fat loss If a person is generally in good health and sleeping well.  There can be a significant acceleration of body fat loss when the fasting window progresses. It’s important, though, that fasting not be a source of stress.  A continuous glucose monitor (CGM) can be helpful for understanding the specific, optimal duration of overnight fasting for a unique individual.
    • Front-loading the day’s food works best for many people (e.g. having lunch be the largest meal of the day) in order to avoid excessively large dinners or late-night snacking. The average American eats an early breakfast of refined carbohydrates and then consumes nearly 50% of the day’s calories after 5pm. As you might imagine, this is metabolically counterproductive for most people seeking weight loss. We start the day with a blood sugar spike and cut short the opportunity to extend the natural, overnight utilization of fat/ketones for fuel. After dinner, most of us are not going to head out for a nice, long walk to promote greater glucose utilization; rather, we are likely to hit the couch, become sedentary, and wind down.

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- or sickness-impaired (e.g. increased degradation of T3 and deactivation of T4 to Reverse T3), and/or inflammation-impaired (e.g. poor conversion of T4 to T3) hypothyroid function. This topic is addressed in great depth in SAFM’s clinical course HPATG Axis: Adrenal/Thyroid Balance and Dysfunction.

Sex Hormone Imbalance, such as estrogen dominance or testosterone deficiency – a common 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. Cortisol can also block 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 disease dynamic that can lead to symptoms such as PMS (usually with cramps), heavy, lengthy, clotting periods, and stubborn weight gain. Most often, estrogen dominance is caused by imbalance 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% chemical-free and, ideally, organic.

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 may also promote intracellular hypothyroid function. Many people trying to lose weight inadvertently increase their cortisol with excessive aerobic exercise or insufficient calories for example. Of note, sustained low cortisol due to prolonged stress or burnout can also reduce thyroid action via reducing thyroid hormone receptor function. Sources of stress that may lead to trouble losing weight include:

  • Emotional stress
  • Ongoing physical trauma
  • Ongoing chronic pain
  • Excessive exercise
  • Chronic dieting/insufficient calories
  • Lack of rest and/or inadequate quality sleep
  • Too many stimulants
  • Allergen exposure – environmental, food…even food sensitivities, see below
  • Toxicity e.g. heavy metals, mold, chemicals

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.  There is a rich post here on food sensitivities as well.  This topic is addressed in great depth in SAFM’s clinical course Immune Function, Loss of Tolerance, and Hypervigilance (included in our practitioner training program).

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 and detoxification is supported as needed to enable clearance.  This topic is addressed in great depth in SAFM’s clinical course Toxicity, Detoxification, and Heavy Metals (included in our practitioner training program).

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:

  • Ensure good hydration (in order to be able to dilute and eliminate toxins via the urine – a Phase 3 detoxification pathway)
  • Ensure consistently good bowel movements (in order to eliminate toxins via the feces  – a Phase 3 detoxification pathway)
  • Ensure good bile flow – bile helps us excrete fat soluble toxins
  • Ensure good sleep as cerebrospinal fluid (CSF) clears metabolic waste products from the brain during sleep
  • Toxin avoidance – cut out pesticides, herbicides, etc. by eating 100% organic during weight loss efforts. Identify other sources of toxins in personal care products and throughout the home. The less toxins coming in, the more toxins the body can focus on getting out.
  • Ensure Phase 1 and 2 detoxification pathways are being supported (key for biotransformation of toxins that actually enables their excretion)
    • Eat liberal amounts of alliums and cruciferous vegetables, which greatly aid detoxification processes by providing phytonutrients that boost the activity of key enzymes.
    • Utilize a methylated B complex such as Thorne’s Basic B.
    • Enjoy fresh cilantro and parsley.
  • Binders should be used to avoid re-toxification as the toxins are released back into circulation during weight loss. By binding them in the GI tract, we minimize their reabsorption along with bile in the small intestines. Binders can be natural, such as a large increase in fibers and vegetables, or they can be supplements such as the following. Take these 1-2x/day (AM and PM) on an empty stomach at least an hour before (or 3+ hours after) food or other supplements (importantly, with a glass of water, not just a few sips):
    • Activated charcoal
    • Modified citrus pectin
    • Bentonite clay
    • Chlorella (this is one exception that can be taken on an ongoing basis and without regard to timing with food)
    • Many combination formulas are available e.g. Biocidin Botanicals GI Detox, Quicksilver Ultra Binder.

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.

P.S.  If you are passionate about transforming healthcare through the power of functional medicine, we encourage you to learn more about our training program here.

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Nisha Hazari
Nisha Hazari

Do you recommend starting the binders before actual weight loss begins?

SAFM Team
Reply to  Nisha Hazari

Yes, this would be quite prudent. You also want to ensure satisfying, easy to pass bowel movements to support proper detoxification.

Aimee Bearden
Aimee Bearden

Is it safe to recommend a methylated B complex to everyone without regard of knowing their MTHFR status? What harm would it cause to take a methylated B complex if it is a water soluble vitamin? When would it be necessary to check MTHFR? ( I know this may be a loaded question) but my understanding is that the MTHFR mutation will impair the metabolism of B vitamins and that because B vitamins are water soluble, there is a lower risk than the fat soluble vitamins to over dose. With that said, is there any need to check MTHFR status if a person is willing to take a B complex? Thank you!

SAFM Team
Reply to  Aimee Bearden

No, methylated B complex, particularly methyl folate, may not be beneficial for everyone. To your point, some people may have a mutation in MTHFR or other genes coding for enzymes involved in the methylation cycle. On the one hand, this creates an increased need for B vitamins and increased sensitivity to excess methyl groups. Dr. Ben Lynch is a great resource on this topic, and we recommend visiting his website to learn about the details:
https://mthfr.net/mthfr-c677t-mutation-basic-protocol/2012/02/24/
https://www.drbenlynch.com/methylfolate-side-effects/

Aimee Bearden
Aimee Bearden

How long should one take binders for?? Would spirulina or astaxanthin work like chlorella as a binder?

SAFM Team
Reply to  Aimee Bearden

The length of supplementation with binders will certainly vary from client to client. It can last from 2 weeks to 3-4 months. Pausing and changing the binders is an advisable strategy simply because different binders have an affinity to different toxins and to minerals, vitamins, and other nutrients.
Spirulina can be used instead of chlorella since it has similar properties. There are some differences though, that one should be aware of – this well-referenced blog post by Dr. Axe is a good place to start exploring those:
https://draxe.com/nutrition/spirulina-benefits/
Astaxanthin is a carotenoid with strong antioxidant properties and is sometimes paired with binders to offset oxidative stress, a natural effect of the upregulated detoxification process. Here are a couple of articles that may be of interest to learn more about this natural compound:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3917265/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6117702/

Marilyn Dellit
Marilyn Dellit

Hello,
When speaking to using natural food, such as an increase in fruits and veggies, as a binder (specifically applesauce – to be used for the effects of pectin), do you still recommend taking away from meals and supplements or is this not necessary as they are all part of a natural diet? Thank you!

SAFM Team
Reply to  Marilyn Dellit

Great question! No, it is not necessary to separate this type of food from the regular food that is consumed, as this one is simply increasing the amount of natural fiber and pectin that is part of the whole food. Most other, more targeted binders that are typically taken as a supplement to the diet should be taken away from food and supplements and one should always start ‘low and slow’ in order to avoid any possible negative effects due to over-mobilization of toxins or sensitivity/allergy reactions to the supplement.

Casie Duet Trosclair
Casie Duet Trosclair

When you say “take breaks from intense weight loss efforts to work on healing the gut intermittently,” what does that look like in your practice?

SAFM Team

When a client is strict about their diet, exercise, and relaxation and supports liver detoxification pathways simultaneously, this will bring weight loss. Approximately after 20-25lb weight loss and depending on each unique client and their specific journey, one would want to focus on more physical rest, supporting gut health with mucilaginous herbs, pro- and pre-biotics, and possibly even glutamine, or with a course of drinking bone broth daily for a couple of weeks and turn down the efforts to upregulate the liver detoxification to make space for the gut mucosal lining to regenarate. Keep in mind that all healing happens in the parasympathetic nervous mode, and processing toxins in the body requires energy and may negatively impact the gut microbial flora.

Isabelle Liliane Achouna Souop Spouse Tsamo
Isabelle Liliane Achouna Souop Spouse Tsamo

In terms of weigh loss, how does eating late night contribute to weigh gain? can you provide me with some insights?
The recommendations often made by Tracy is that, if you are trying to loose weight, do not eat 3 good hours+ before bedtime.
I would really like to have an accurate understanding of this mechanism.
Thank you.

SAFM Team

A lot of dis-ease start with poor eating hygiene, this was discussed at length in this FB live:
https://schoolafm.com/ws_clinical_know/more-disease-begins-in-the-gut-surprising-sources/
As for the late-night eating and gaining weight, you may be interested in this summary of a research paper:
https://www.sciencedaily.com/releases/2020/06/200611094138.htm
Here is the publication that they are talking about that speaks to a possible mechanism of how nighttime eating leads to weight gain:
https://academic.oup.com/jcem/article/105/8/2789/5855227

Allison White

How do we ensure good bile flow? Is there a way to check this?? Does having the gallbladder removed effect detoxification pathways then. Thank you

SAFM Team
Reply to  Allison White

Good eating hygiene and food choices that include high-quality protein and fats and also bitters that support bile formation and flow, as well as avoidance of processed foods (those are often rich in oxidized fats and an overabundance of sugar and fructose) that can negatively affect liver function are at the foundation of ensuring good bile flow. Please also refer to the paragraph on toxicity above as this can have a significant impact on bile flow as well.
Alas, there isn’t one test to check the bile flow quality, but it can be noted on a liver panel and on a comprehensive stool test once the hepatobiliary congestion has been at play for a while.
The gallbladder per se doesn’t impact detoxification pathways that take place in the liver, however, the steady bile trickle into the GI tract does have consequences that eventually can impact the body’s ability to process toxins. You may be interested in these additional posts:
https://schoolafm.com/ws_clinical_know/gallbladder-rescue/
https://schoolafm.com/ws_clinical_know/psoriasis-and-general-autoimmune-considerations/
https://schoolafm.com/ws_clinical_know/gratitude-in-client-success/

Shonna Vaughan
Shonna Vaughan

My client who had radioactive iodine therapy 30+ years ago and has been on Synthroid ever since has lost 30 pounds over 6 months with diet changes, detoxing, and gut healing but has not reached her weight goal and has hit a plateau. I’m wondering if she should approach her doctor about getting off Synthroid and on to a natural compounded T4/T3?

SAFM Team
Reply to  Shonna Vaughan

First, congratulations on your client’s weight loss progress! Yes, as you know Synthroid is a T4 only drug and many patients using it can still suffer hypothyroid symptoms even with normal TSH measurement. Thus, checking your client’s full thyroid panel could be helpful here, and consulting the doctor about the switch to a natural compounded T4/T3 does make sense. Also, keep in mind the interconnectedness of the cortisol levels and the intracellular availability of the thyroid hormone.