Eat Less, Move More?

There is no shortage of information and one sided documentaries covering the diet wars that have sprung up over the past 15-20 years.  Some say vegan is the best way to lose weight and others claim that Paleo or Atkins will produce the best fat loss.  Although I've written on this topic before, I'm going to refrain from nutrition commentary today and focus on the "forgotten factors" of weight loss.  Eat less and move more has been the underlying theme of most weight loss plans, but there are so many additional things that matter when it comes to losing weight. 

Eat less food and move around more.  It's a refrain that we have all heard again and again for decades.  Everyone is now lean and healthy, right?  Unfortunately, this common medical advice has failed again and again.  Certainly the topsy turvy mainstream medical dietary recommendations have had something to do with this (low fat, everything in moderation, etc.).  There are a lot of great articles out there about the dietary part of this by people like Robb Wolf, Chris Kresser, Peter Attia and others.  However, for this article I’m going to talk about a few other factors that effect weight loss

Sleep is probably the most neglected aspect of weight loss.  There is good evidence that healthy people become borderline diabetic when they are mildly sleep deprived for short periods of time (1-2 weeks).  The metabolic shift that occurs when a person is not sleeping well can also make fat loss very difficult and even lead to weight gain.  This can be a very difficult issue to address in a culture that values those who sacrifice sleep.   Which leads us into the next issue (hormonal imbalance) because most of the hormone systems are rejuvenated during sleep. 

When some of the major hormone systems go awry weight loss can stall, or the patient can begin to gain weight. Thyroid function is one of the most obvious systems that leads to weight gain.  Of course insulin levels are a huge part of this and may be why a low carbohydrate diet is so effective for weight loss.  Sex hormone level imbalances, deficiencies or excesses can also lead to weight gain.  In fact, this is one mechanism that people gain weight as they get older.  However, these problems can be difficult to diagnose and are frequently missed.  The adrenal cortisol system is also a key player in weight loss or gain.  High cortisol levels can be especially bad on fat accumulation because cortisol is anabolic (tissue building) for our body fat.  The other thing it does is catabolize (break down) our muscle mass.  This is a big hit whenever someone is trying to lose weight.  Yet, very few doctors investigate the cortisol side of the story.  These 4 systems are the main hormone systems that are at play with weight loss and weight gain.  However, there are others that we are just now being able to measure (like leptin and ghrelin) that will become more important in clinical practice.

In my clinical experience, the gut biome is also playing a role in weight issues.  Certain types of pathogenic bacteria are associated with obesity.  This side of the story continues to develop but at this point we can't really say if there is some causal relationship or if it is just an association.  I will say that, in my clinical experience, I do see people lose weight as the gut improves, but again, it's a chicken and egg type problem.  Stay tuned to this side of the story.

These are some factors that I try to look at when I see a patient in clinic who isn't losing weight. Of course, there are other more nuanced factors that I have left out of this short article.  However, I see many of these problems in patient's that are really working hard on the diet and exercise part yet still not losing weight.  I'm not trying to downplay the importance of nutrition and exercise because certainly both must be on point for weight loss to occur.  However, some of the above factors will slow or stall even the best diet and training.



Dan Horzempa, MD is a physician located in Tucson, Arizona. He completed a residency in Family Medicine and a fellowship in Integrative Medicine at the University of Arizona. His clinical interests include functional medicine, evolutionary biology, clinical lipidology, exercise physiology, longevity, endocrinology and sleep medicine.

Daniel Horzempa