When Your Body Won't Let You Lose Weight

Many patients are found to have elevated liver enzymes (ALT, AST, Alkaline phosphatase primarily) on routine laboratory work done during a yearly physical exam. Frequently these patients are referred to me for a hepatology (liver) consultation. 

After performing a full battery of tests a diagnosis can typically be reached. In patients without a history of viral hepatitis and with risk factors for contracting viral hepatitis, the single most common diagnosis is a fatty liver on the ultrasound and insulin resistance on blood testing.

Historically, problems with sugar metabolism were diagnosed by checking fasting blood sugar. Then we advanced to checking Hemoglobin A1C, a measure of how much sugar was bound to hemoglobin over months. This allowed us to determine blood sugar levels over several months on an average basis. 

Now we have multiple ways of determining blood sugar control problems before hyperglycemia (high blood sugar) develops. The use of fasting insulin and other markers make it possible to see that the body is having an increasingly difficult time controlling the blood sugar. 

This early type of detection, especially in patients at risk for diabetes, allows the patient to intervene with the help of their physician before any irreversible damage occurs to the multiple effected organs: heart, eyes, vascular system, etc. 

Frequently, patients present with elevated liver enzymes and a complaint that they exercise and diet and can't lose weight. This common phenomena may indicate the presence of insulin resistance in a process that goes by several names – Dysmetabolic Syndrome is my preferred term as it is most appropriate as a description. Insulin does more than just regulate blood sugar. 

One of the other major roles is to prevent the metabolism of peripheral fat and fat in the liver from being used as energy by the body. By preventing the movement of fat out of the liver due to the body's perceived high blood sugar level, fat then accumulates in the liver. 

The problem is that the fat is in the form of free fatty acids that then can leak out of the liver cells storing them and cause injury to the liver. That injury then causes the release of liver enzymes to the blood that otherwise would mostly be found in the liver cells and not the blood.

Once insulin resistance develops, it is very difficult to break the cycle with just diet and exercise. The use of metformin, an inexpensive generic medication, can markedly reduce the insulin resistance and make weight loss possible. 

Alone, metformin will not make you lose weight, but combined with an appropriate calorie-restricted low-carbohydrate diet and regular exercise in the appropriate setting it can result in dramatic weight loss.

A comprehensive metabolic evaluation is commonly needed. Evaluation of thyroid function, testosterone in men and Vitamin D levels are some of the most common tests done. 

A low thyroid hormone level, called hypothyroidism, can down regulate the bodies metabolism and cause weight gain, depression and many other problems. 

A low testosterone level in men will cause loss of muscle mass, poor glucose metabolism, high blood sugar, decreased libido, depression and loss of calcium from bones resulting in osteopenia or osteoporosis. 

Vitamin D deficiency is finally being recognized as an epidemic in our population.  Vitamin D is critical in many aspects of normal physiology including bone calcium metabolish, immune response and insulin regulation and blood sugar metabolism.  Unfortunately, oral Vitamin D is commonly poorly absorbed and intramuscular supplementation is needed.

As a part of an evaluation for weight loss, a patients nutritional status needs to be assessed. Frequently, obese patients, while calorie enriched, are nutrient deficient due to the lack of a normal balanced diet. Vitamin, mineral, micro and macro nutrient depletion must be addressed to improve health and will curb your appetite. 

If the body is deficient in nutrients you may experience hunger. That hunger is too often satiated by eating inappropriate high salt and carbohydrate foods rather than natural foods, think things that grow out of the ground and have not been processed.

A proper, balanced calorie restricted diet of 1200-1800 calories is necessary.  I prefer diets that emphasize the use of regular food in smaller portions rather than liquid replacement diets. 

Consultation with a dietitian can be helpful.  Jenny Craig and Weight Watchers, if adhered to strictly, can be very helpful.  I believe that the use of prepackaged food is advantageous from the educational point of view.  It shows you how much you should actually be eating for a meal or snack.

Finally, exercise is the final necessary piece to the health puzzle.  A stroll after dinner with your husband or wife is nice and good for your relationship but not adequate to maintain your metabolic level. 

With calorie restriction your body will tend to decrease your metabolic rate to conserve energy.  Start with walking three times per week.  You should start at 10 minutes per day depending on your baseline physical condition.  This should increase by five minutes each day every week until you achieve 30-45 minutes per day three to four times per week. 

Walking must be done with intent, you should be tired and sweaty when you finish.  Purchase a heart monitor watch and then evaluate your exercise tolerance.  By maintaining your heart rate at between 120-140 depending on your age and condition, you will benefit more for the same time spent exercising. 

The use of a professional trainer is not necessary but can be very helpful in those who are not accustomed to exercising or who have not exercised in many years.  On occasion, I will refer patients to a physical therapist if they are debilitated and there is concern for injury due to deconditioning.

Its your life.  Live it well.  Enjoy yourself.  By being healthier life will be more enjoyable.