Historical Perspective
The following essay will give you my experience and approach concerning weight loss that I have developed since I first began this type of therapy in May of 1995.
At that time, Fen-Phen was all the rage, with people reporting dropping massive amounts of weight over a relative short period of time. In fact, my star female patients were dropping over 20 lbs of fat per month during the first several months on the program, and some male patients dropping in excess of 30 lbs of fat per month.
For those of you who remember, a tremendous amount of media attention was given to the use of this drug combination. And that is all that it was: “Fen-Phen” is a slang term for the simultaneous use of two different drugs, both of which released and prevented the re-uptake into storage granules of neurotransmitters involved with appetite control (Norepinephrine & Serotonin) and also with the breakdown of fat all over the body (Norepinephrine & Epinephrine).
Phentermine manipulates norepinephrine and epinephrine.
Fenfluramine was used to increase blood levels of serotonin. There were two brands of Fenfluramine available during those years, Pondimin, a 50-50 mixture of the two isomers of Fenfluramine and Redux, containing only one of the stereo isomers. The molecules of Fenfluramine, like many drugs have shapes that are not the same on both sides, one isomer is the mirror image of the other.
Fenfluramine was taken off the market in 1997 after it became associated with fibrosis of mitral (heart) valves resulting in incompetence of the valves, experienced by patients as shortness of breath. Fenfluramine caused a tremendous increase of the blood level of the neurotransmitter, serotonin. And if patients took unusually large daily doses, and consequent intense stimulation of the so-called 5-HT2B receptors, the blood levels of serotonin could become high enough to cause damage to the heart valves. This situation was rare, but more common in patients coming from weight loss clinics where large doses of fenfluramine were commonly used.
An even rarer problem associated with fenfluramine was pulmonary hypertension, or excessive pressure of the arteries of the lungs.
The issue of changes in the shape of the mitral valves came to public notice after several female patients, all from the same weight loss clinic in Fargo, North Dakota presented with shortness of breath at the Mayo Clinic in Minnesota. All of them were taking large doses of Fenfluamine. Several underwent valve replacement surgery. Those not undergoing heart surgery became better over time after discontinuing the drug.
After Fenfluramine was removed from the market, various antidepressant drugs were used along with phentermine, sometimes obtaining beneficial result regarding weight loss. Antidepressants also manipulate serotonin, but do not cause excessive blood levels as with large doses of Fenfluramine.
My patients at that time were taking one pill of Fenfluamine daily and did not experience any of these problems. I had one patient who had shortness of breath taking 2 Fenfluamine pills daily prior to coming to my office. Her shortness of breath was relieved after discontinuing the drug.
Phentermine, although an old drug, is by far the best pharmacologic aid to weight loss in existence. It continues to be in wide use by weight loss doctors. It is well tolerated and its side effects are well-known and can be anticipated and dealt with as long as patients are educated about the drug=s characteristics. There are few absolute contraindications to its use.
It was at that same period of time that I became acquainted with one essential conundrum with weight loss: public attitude!
Most people who do not have a weight problem, along with some who do, consider obesity to be a manifestation of a deficit of character. Any readers out there who have been tremendously overweight, especially women, and have dropped weight to a normal body habitus, know exactly what I am talking about. If you are obese, you are treated differently.
This attitude, although fading gradually as increasing numbers of people are afflicted, contributes to the lack of a rational, biologically based set of techniques for weight management.
If your doctor simply says: “Ya know, you need to drop some weight. I told you this last year, and this year you weigh 20 lbs heavier! What’s yer problem?!”
Implicit in this type of talk is an attitude. A doctor with this attitude is completely incapable of helping the patient drop weight.
What this doctor is really saying is: stop eating so much and get to exercising! Please read on.
As an anti-aging physician, my main interest in weight management is with the person who has 10 to 60 lbs of fat to drop…. and then to maintain that weight loss indefinitely.
Is this anti-aging? Well, to some extent. It is a part of the modern problem accelerating the aging process.
And, of course, as in the situation of the low thyroid function patient wishing only to rise above the misery and stupor of hypothyroidism, most obese patients are uninterested in the anti-aging prescription of natural hormone replacement therapy, nutrition, and proper sleep.
So, many of these patients and I are not reading from the same page.
As well, the anti-aging prescription contains diet and exercise, both of which are integral in maintaining weight loss.
Are overeating and under exercising the sole causes of obesity? Not at all.
There are metabolic reasons. I have obese patients who tell me that they have had the experience
of sitting next to a person their own age and height at a banquet who is skinny as a rail and are
eating like a horse. My patient, in every case, was eating like a bird. Of course, she didn’t say what kind of bird…..
And this is not that uncommon a problem. These patients have low temperatures and otherwise exhibit low energy states.
So, here is an example of a situation where a combination of hormonal and metabolic therapies along with diet and exercise can be very helpful.
Now, let’s go back to the issue of epinephrine, norepinephrine, and serotonin. It is well known that manipulating these neurotransmitters causes weight loss. Although causing appetite suppression, norepinephrine and epinephrine can also cause significant weight loss in individuals who have very low metabolic rates and eat very little.
Low thyroid function is commonly associated with obesity. Correcting the low thyroid state can be very helpful in maintaining weight loss, and in some rare cases can cause weight loss. However, skip the idea of using thyroid solely for weight loss…. it doesn’t work.
That is not to say that a patient cannot be on thyroid supplementation and a weight loss program at the same time. Herein brings the importance of monitoring.
Monitoring
Concerning weight loss, monitoring is the technique used to determine changes of fat and water contributing to weight change. Blood pressure, pulse, and temperature are measured as well.
An Aimpedance scale@ is used. The patient stands briefly on a metal platform allowing an electrical circuit to be completed from one foot to the other. (Don’t worry. No one has ever been shocked by one of these scales. The current is minuscule.)
Fat retards the slow of electrons, and salt water allows them to flow more freely, kind of like a copper wire with insulation surrounding it. This difference of electrical impedance allows the scale to differentiate between water and fat. Since the patient’s height has already been inputted into the scale’s computer, the machine then electrically determines weight of fat and weight of watery tissue. Comparing determinations made over a time period will supply the net changes of water and fat.
For example, you may have a weight loss of 5 lbs over a one week period. Checking the impedance figures may tell you that the entire amount of weight lost was fat. Or, perhaps the machine will show drop of 4 lbs of fat and one pound of water. Another possibility is a drop of lbs of fat and a gain of 2 lbs of water. And these are just 3 possible examples resulting in the same net weight change.
It is not unusual for a person to drop fat and gain water at the same time. Then, several days to a week later, the excess water is urinated out and the fat loss is appreciated as a weight drop on the scale. The impedance apparatus can reassure the patient who has dropped fat but retained water.
What else is monitored? Taking vital signs: blood pressure, pulse, & temperature are done at every monitoring visit. As well, patients are asked about any side effects of medication or any problems whatsoever. Telephone conferences with the doctor about problems are encouraged.
My program involves weekly monitoring for weight loss patients. Patients taking natural hormones in my program are required to do so under my guidance as well. For patients taking only thyroid replacement, I expect weekly monitoring in my office during the process of determining a stabel, mature thyroid dose, a process that typically takes 6 to 8 weeks.
Patients on a weight loss program and simultaneously taking thyroid, of course, are fully expected to monitor weekly in the office until they have reached stable, mature doses.
Dealing with one’s self is often very subtle. Physician monitoring can point out some issues that may have escaped the patient busy with life. During the monitoring process, the patient is prompted to describe compliance with diet, hydration, exercise, and supplementation schedule.
Diet
What is the correct diet for weight loss? There are 2 basic diets that work. All the rest are variations of these two: High Protein/ Low Carbohydrate and Low Calorie.
That may sound a little dogmatic, but experience is the best teacher. I have seen people drop weight on diets constructed through metabolic typing (blood type diet is an example). I have seen people drop weight using diets constructed by commercial weight loss companies. But, they are all variations of the basic two.
The major dietary change of modern times resulting in weight gain is the tremendous increase of consumption of sugar and starch.
Starch consists of strings of sugar. In your stomach, starch is broken down into its constituent sugars, then absorbed. Insulin increases in the blood to get rid of the extra sugar load. That occurs by pushing sugar into the cells where it is converted into fat and stored.
We are not eating more fat now than in years past, but there is no doubt that we are eating much more starch, and especially, much more sugar. This increase started for most people now on the earth thousands of years ago with the advent of agriculture. But the amount consumed, especially sugar has increased exponentially in recent years. The ultimate dietary bad boy is high fructose corn syrup (HFCS), the modern sweetener. The food industry has found a way to use HFCS to sweeten things like hamburger buns and french fries.
What did our pre-agricultural ancestors eat? Answer: meat, fish, and vegetables. What did our Great grandparents eat at the turn of the 20th century? Answer: meat, fish, vegetables, & bread. Fruit was a luxury to be prized. Oranges and apples were things to be retrieved joyfully from Christmas stockings. Very little candy was available.
Obesity was rare at the turn of the 20th century. When I was a kid in the 1940’s and 1950’s at school, there was maybe one fat kid in a class 30 students.
So, if you want to drop weight, get off of the soda pop, sports drinks, fruit juice, candy, pastries, bread, and all of the things listed on the right hand side of the diet chart accompanying The best short essay that I have seen describing low carbohydrate nutrition is, Low Carbohydrate F.A.Q.: A Brief Introduction to Low Carbohydrate Diets And Answers to Frequently Asked Questions written by the late Wally Ballou and can now be found at: http://lowcarb.bravepages.com/
Hydration
Drink greater than 96 ounces of water daily. This amount is needed to drop weight. The total can be the combination of coffee, water, and tea. It should be imbibed fairly evenly throughout the day.
When fat is broken down through diet and exercise, fat breakdown products are formed which immediately enter the blood stream. There they circulate. There are two basic forces working on these fat breakdown products at all times. One force is causing these products to be reabsorbed and re-stored as fat. The other force intends to waft these fat breakdown products out through the kidneys and into the urine. And, of course, we want this latter force to predominate.
And that is why you should be drinking greater than 3 quarts per day.
If you typically drink this much daily anyway, fine. But if you are a person who typically skimps on water, then you need to be able to quantify in order to be sure of the total. You need to know the volume of your coffee/tea cup, your water bottle, and your drinking glass.
If you are using a 1 liter bottle, then 3 of them equals a total of 101.4 ounces. The most common disposable water bottle available is the 16.9 ounce (or 2 liter) bottle. As well, there are 20 ounce, 23.7 ounce, and 24 ounce bottles available. You can purchase re-usable, wide mouth, plastic water bottles in both 32 (quart) and 33.8 (liter) ounce sizes.
I commonly see weight loss stymied by lack of enough water. Know the volume of the water bottle that you use!
Cardiovascular Exercise
Quite basically, cardiovascular (CV) exercise is whatever exercise raises the heart rate. No need to get too technical here unless you are hooked up to a heart monitor at the gym under the supervision of a personal trainer. Walking is the basic CV exercise. In Alaska, we walk outside in the summertime and outside or inside in the winter. So, we can include cross-country skiing, snowshoeing, hiking, treadmill, elliptical machine, stair stepper or walking your dog. Start with whatever you can do and increase to anywhere from 30 to 60 minutes daily. Daily is ideal.
Resistance Exercise
Resistance exercise tones muscles. Toned muscles burn calories more efficiently. This can be calisthenics, weight lifting, or pilates. For the person looking for a minimal commitment to resistance training, I advise a twice weekly workout separated by 2 days, for example, Monday and Thursday. The workout should include exercises toning the core muscles of the body.
For the obese beginner, the initial workout program could consist of “pushouts” from the wall (instead of pushups from the floor) and sit-ups utilizing the assistance of a device like the “AB Lounger TM” or similar device. As well, the beginner would do well to enlist the services of a personal trainer.
Small work-out centers for women only abound now because major gyms did not understand the market for overweight women who want privacy and a non-threatening atmosphere. Many overweight people would not set a big toe into a gym.
I have patients who primarily enjoy cardiovascular exercise and those who like weight training much more. Each has its merits and devotees. I am asking my patients to include each type of exercise in their routine.
For the beginner or the person wishing to have a minimal approach to resistance training that one can maintain over the long haul, I suggest working out twice weekly, like on a Monday and Thursday, allowing two days of rest in between for muscle recuperation.
Weight Loss Medication And Amino Acid Supplements
With the exception of the hCG technique (discussed in another article), all weight loss medication and amino acid supplements that actually work for weight loss, without undue side effects, do so by manipulating neurotransmitters.
So, what are neurotransmitters? They are substances that take messages from one brain cell to the next. And there are stores of them at the junctions of nerve cells.
Think of the brain as made up of various columns of cells, each column having its very own substance for sending messages. There are over 130 different neurotransmitters in the human brain, but for weight loss, we will concern ourselves with only 3 of them:
As the following discussion ensues, please continue to refer to the above summary table.
Glutamine controls cravings for alcohol, sugar, and starch. It has been used for years in alcohol treatment programs. Robert C. Atkins, MD pioneered the use of L-Glutamine for weight loss.
The simple amino acid, L-Glutamine, is itself a neurotransmitter. L-Glutamine can be found at any health foods store. It is sold as 500 mg capsules or tablets, sometimes as 1,000 mg tablets, and as powder. The dose varies considerably, with alcoholics typically requiring the smallest amount, perhaps 500 mg per day. Most of us require more than 500 mg per day to obtain an effect. Therefore, I advise using a rounded teaspoon of powder, delivering about 5,000 mg to be added to water.
There are several ways to do this. One is the quick and easy way for those of us who are relatively impatient. Just stir the powder into the water and quickly drink it down. In this way, the powder is in suspension in liquid. It’s a little gritty, thus bothersome to some people. An alternate way is to vigorously shake the teaspoon of powder in a bottle of water to allow it to go into solution. This method requires a wide mouth water bottle or the use of a funnel.
The usual dosing regimen is to match timing with the daily occurrence of cravings or interest in snacking. For most people, that means taking the Glutamine in the late afternoon, say upon arrival home from work, and again in the evening after dinner so as to avoid the return of cravings just before bedtime. Keep in mind that a very bad time to eat is at bedtime!
This is not to say that you cannot use L-Glutamine at other times during the day. Some people have problems with cravings during the mid-afternoon or during the morning. Of course, they can use Glutamine at those times as well.
After being swallowed, the Glutamine is absorbed into the blood and carried to the head. There, it saturates the glutaminergic nerves, causing an exaggerated effect of satiation.
The next two neurotransmitters, Norepinephrine (NE) & Serotonin (SE), should be thought of as one large system, each providing a complementary and seemingly opposite effect to the other.
NE is the neurotransmitter of wakefulness & alertness. SE is dominant during relaxation, satisfaction, even sleepiness. As you can tell, they are two sides of the same coin.
There are little packets of extra NE near the bundles of NE nerves. During times of excitement, for example, like when slamming on the brakes to avoid a collision with an animal in the road, these little packets are caused to discharge their contents and the outpouring of NE saturates the NE nerve endings.
Under such a condition, you are absolutely not hungry. Your appetite is powerfully suppressed. Moreover, you are breaking down fat like crazy! Both NE and its cousin Epinephrine from the adrenal glands cause fat stores to start releasing their contents. And as long as you are drinking your requisite amount of water, you will rinse these fat breakdown products out through your urine.
So, to repeat, NE, when released from storage packets, causes weight loss 2 separate ways: suppression of appetite and breakdown of fat stores.
Now we are back to the drug, Phentermine, mentioned in the Preface of this article. Phentermine works by releasing NE from storage packets. So, remember that Phentermine does not cause weight loss directly, but only by release of NE.
So, here is where the main problem with the efficacy of phentermine arises. When Phentermine is used by itself for about a month to 6 weeks, it stops working. Why? Because the storage packets have become depleted of NE. Constant release of NE caused by Phentermine produces this depletion. The body simply cannot keep up production of NE fast enough.
In order to promote more efficient replenishment of NE, weight loss patients can take the simple amino acid, L-Tyrosine, an over-the-counter nutritional supplement. Tyrosine is converted into NE over a multi-step process. The amino acid, L-Cysteine, also obtainable from the health food store, taken together with the Tyrosine, makes this process more efficient.
L-Tyrosine 500 mg is taken 3 times daily. L-Cysteine 500 mg is typically taken twice daily, eliminating the early morning time slot so as to avoid Cysteine’s major side effect, nausea & stomach pain. Phentermine is usually taken twice daily with the major dose at 12 hours before bedtime and the minor dose at 6 to 8 hours prior to bedtime, as depicted in the following Medication Schedule:
This is so that the weight loss properties of the system of enhancing these neurotransmitters is concentrated toward the evening, the usual time of excess calorie consumption. The trick, of course, is to time the dosing so as to walk the fence of appetite suppression on one side balanced with the ability to go to sleep at a reasonable bedtime. Typically, the mornings do not present an appetite problem, with most people becoming hungry the first time during the day at 12 hours prior to bedtime. The above demonstrated Medication Schedule shows one such regimen for a person who goes to bed at 10 p.m.
Serotonin is enhanced by taking the precursors L-Tryptophan or 5-Hydroxytryptophan (5-HTP), usually at bedtime. Tryptophan is converted into 5-HTP over a multi-step process, then 5-HTP is immediately converted into Serotonin. Thus, L-Tryptophan is consumed from a dietary source. (The famous food with high levels of Tryptophan is turkey meat.) And 5-HTP is an entirely normal product of human metabolism. So, taking pure 5-HTP delivers a natural nutrient in concentrated form. This in turn, produces enhanced blood levels of Serotonin. Serotonin typically gives a sense of satisfaction & fullness. It causes most people to be sleepy.
Conclusion
Why do we engage in weight management? Yes, to feel better and to look better. But even more importantly, to promote health by preventing the disease states associated with obesity: heart disease, diabetes, and destruction of joints.
Modern lifestyle and food choices promote obesity. Modest weight losses of 5% to <10% were associated with significant improvements in CVD risk factors at 1 year, but larger weight losses had greater benefits [1].
Besides diet, lack of exercise is a major cause of chronic diseases [2]. In addition, physical activity primarily prevents, or delays, chronic diseases, implying that chronic disease need not be an inevitable outcome during life [2].
Yes, it is frustrating to drop weight, and then during the course of life events to regain weight, sometimes even more.
But remember, the health benefits of periodically dropping weight is worth it!
Engaging periodically in a program to drop weight is a whole lot better than dealing with arthritis, diabetes, and heart attack.
So, keep up the good work!
Bibliography:
1. Wing, RR, et al. Benefits of Modest Weight Loss in Improving Cardiovascular Risk Factors in Overweight and Obese Individuals With Type 2 Diabetes. Diabetes Care. 2011 Jul; 34(7): 1481B1486. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3120182
2. Booth FW, Roberts CK & Laye MJ. Lack of exercise is a major cause of chronic diseases. Compr Physiol. 2012 Apr; 2(2): 1143B1211. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4241367/