Altering Your Hormonal Environment
DeShawn is an eight-year-old African American boy who comes to clinic weighing 110 pounds and has a BMI of 35. He was referred due to an orthopedic condition in which both hips slipped out of their joints, limiting his motion and his ability to exercise. DeShawn is obstinate, confrontational, and doing poorly in school. His mother, while friendly and seemingly compliant, is also obese and very defensive. She tells us at each visit that she is doing exactly what we advise, ridding the house of sugared beverages, eating real food, and waiting twenty minutes for second portions. But at each clinic visit, DeShawn continues to show a gain in weight. Within three years, his weight is up to 255 pounds, and he has a BMI of 50. He develops obstructive sleep apnea, a potentially fatal illness, necessitating a call to Child Protective Services in an attempt to save his life. It is the thought of losing her son that forces the mother to face up to her own sugar addiction. She rids the house of the sodas that populated it, and she and DeShawn both get psychiatric therapy. Within a year, each has lost 60 pounds, and DeShawn is conversant, pleasant, confident, and doing much better in school.
No doubt some of you will read this chapter and say, “What planet is this dude from? He talks about altering the ‘hormonal environment,’ but what he’s really talking about is altering behavior. I could have gotten this out of any other self-help book.” Au contraire, mon frère. We, both individually and as a society, need to do something differently to fix this pandemic. Clearly something needs to change. But change behavior? If you try to modify behavior you’re doomed to failure, as evidenced by the sixty million diet recidivists nationwide. Indeed, when it comes to obesity, parents are incompetent at altering their children’s behavior.1 Most of the world views the word behavior as meaning the actions we choose to do or not through “free will.” However, the dictionary definition of behavior is: “a stereotyped motor response to a physiological stimulus.” The operative word here is physiological.
Felix Kreier in Amsterdam argues that “behavior” is the sum output of the genetic, hormonal, and biochemical inputs to the central nervous system that create specific drives.2 What we call “behavior” is actually the cognitive inhibition on those biochemical drives. Yes, you can choose to ignore your cravings and skip the cookie. But can you really keep this up 24/7/365, when a hormone or a neurotransmitter is telling you to act and when the signal gets stronger with time? This isn’t just thinking in the abstract; it has real practical applications. Every human behavior requires hormonal signals for expression (sexual behavior: androgen, estrogen; parental behavior: oxytocin). These behaviors truly are innate; they are the product of our biochemistry, which has developed evolutionarily for our survival. How else would parents not abandon their screaming two-year-old? Their hormones make them protective and form an immutable bond with their offspring. In one generation, our sugar glut has tweaked related hormones and neural pathways to our detriment. Of course, there are exceptions to this rule. But if the majority of us were able consistently to ignore our physiologic responses screaming for that doughnut, there wouldn’t be a need for this book. Your body will always work against you, and you’re doomed to fail.
The Way We Were
In trying to make sense of how all this works (or should I say used to work), I offer the insights of Markus Stoffel of the University of Zurich. He recounted his childhood: He ate lunch at noon, would get out of school at three, and then rush straight to the playground. For three hours, he and his classmates would play their hearts out and drink water from the school fountain. At 6:00 p.m. they’d return to their homes famished. “That six-hour interval of no food, only water, and vigorous activity was absolutely essential…to keep our livers happy, refreshed, and insulin sensitive, so the next day we could go at it all over again.”
Forty years ago, soda was a treat and available only in 12-ounce cans. With the proliferation of the 2-liter soda bottle (patented by DuPont in 1973) and the Big Gulp, we, like DeShawn, now chug sugar as if it were going out of style. Parents work two jobs and don’t have time to cook meals; kids are more stressed; playgrounds have disappeared due to housing and fear of crime, P.E. and sports have been slashed due to budget cuts. Our hormones worked in our previous environment of thirty years ago. They can still work, just not in the altered environment we have created for ourselves. And the sooner we realize what we’ve done to ourselves and to our children in the name of “progress,” the sooner we can unravel it. Because, thus far, finding methods to adapt to our new environment has proven useless—witness the inefficacy of the “obesity profiteers.” Face it: we’re stuck with our hormones and our biochemistry. Many suffer from functional hormonal problems in one of the brain’s eating pathways—hunger (chapter 4), reward (chapter 5), stress (chapter 6), or a combination of these three.
For 50–60 percent of the obese population, the following interventions should do the trick. For the rest of you, these interventions will be necessary, but likely not sufficient. More drastic measures will be required (see chapter 19). To dig ourselves out of this mess we need to fix the hormones to fix the behavior, and ultimately to fix our health. And to do so, we need to fix our environment.
Making Hormones Work for You
The roles of specific hormones in weight gain and metabolic dysfunction were elaborated in chapters 4–9. The goal of obesity management is to reverse the hormonal dysfunction by accomplishing the following:
1. Get the insulin down—to reduce your body fat and improve leptin resistance.
2. Get the ghrelin down—to reduce hunger.
3. Get the PYY up—to hasten satiety (the feeling of being full).
4. Get the cortisol down—to reduce perceived stress and hunger, and reduce deposition of energy into visceral fat.
1. Get the Insulin Down: Eat Fiber, Reduce Sugar, Exercise
For almost everyone, reducing insulin is the linchpin to success. Less insulin means less shunting of energy to fat cells, improved leptin sensitivity, and a lower appetite. It also means more energy available to muscles, which improves metabolic health and quality of life. How to get insulin down? That means reducing insulin release or improving insulin sensitivity, or both.
The best way to reduce insulin release is to limit the exposure of the pancreas to the agent that drives insulin up, which is glucose. This means cutting back on refined carbohydrates. Improving insulin sensitivity means improving hepatic, or muscle, insulin sensitivity, or both. And each one is accomplished differently. Improving hepatic insulin sensitivity means limiting the production of liver fat, which requires limiting your liver’s exposure to fat and carbohydrates together (this is why most popular diets work, see chapter 17). The best way to do this is to reduce your sugar consumption, since this is always fat and carbohydrates combined. The easiest means of accomplishing this feat is to remove sugared beverages from your house: soda, juice, Vitamin Water, all of it. Stick with water and milk. A sugar-addicted parent (see chapter 5), similar to one who is drug addicted, will act as an “enabler,” “co-dependent,” or “apologist” for her child. The job of the parent is to convert the house from a minefield into a safe house for the child.
Another way to lower your insulin is to eat more fiber, which reduces flux to the liver and the insulin response (see chapter 12). Opt for brown foods: beans, lentils, whole grains, nuts, and other legumes. And eat the real stuff: the whole fruits and vegetables rather than their processed or juiced derivatives. White food—bread, rice, pasta, potatoes—means the fiber is gone (or, in the case of potatoes, was never there in the first place).
Finally, improving muscle insulin sensitivity is very simple—only exercise will do it, because once muscle fat is stored, the only way to get rid of it is to burn it off. Plus, exercise will burn off liver fat as well.
2. Get the Ghrelin Down: Eat Breakfast with Protein,
Stop Nighttime Bingeing, and Sleep More
Reducing ghrelin, the hunger hormone (see chapters 6 and 11), will diminish total food intake at any given meal. And the best way to do so is to eat breakfast. If you don’t eat breakfast, you don’t ratchet up your thermic effect of food (see chapter 13), ghrelin levels keep rising as the morning drags on, and you will eat more at lunch, dinner, and into the evening. Eating breakfast is part of the equation, but what you eat makes a huge difference. A high-protein load has been shown to reduce ghrelin more than a meal high in fat or carbohydrates,3 so you will burn more just sitting. Plus protein has a higher thermic effect, meaning it costs double the energy to metabolize protein versus carbohydrates. Plus protein doesn’t generate nearly as high an insulin response as do carbohydrates, and doesn’t lead to your blood glucose crashing down, which makes you hungry sooner. Bring on the bacon and eggs.
Some people with very severe insulin resistance, caused by overconsumption of sugar, are enormously hungry—so hungry that standard mealtime changes won’t cut it. The hallmark of this pattern is nighttime bingeing.4 When these patients awaken, they are not hungry and usually go without breakfast (which is a warning sign for big indiscretions later in the day). Indeed, they invariably eat before bed; some of them even awaken from sleep to eat. Eating after dinnertime is problematic for everyone, because any energy consumed that late will have no chance to be burned. It will find its way either to the fat tissue or to the liver, making the patient even more insulin resistant. Some of these patients also have obstructive sleep apnea, and virtually all of them have metabolic syndrome. They are enormously fatigued and can’t find the ability to exercise, due to both the excess insulin and the lack of sleep.
In order to improve their leptin resistance, which means improving their insulin resistance, they must break this vicious cycle of nighttime eating and energy storage. The only hope these patients have is to readjust their mealtimes. This means eating a sensible breakfast and lunch with no snacks added, and dinner must consistently occur a good four hours before bedtime. Any late dalliances with food will only make matters worse. These patients must also get consistent sleep, which can be very difficult due to problems in their airways while sleeping (called obstructive sleep apnea). Patients who snore (and in this category they all do) may need to see their doctor to get a Bilevel Positive Airway Pressure (BiPAP) machine to hold their airway open while sleeping. Some patients may need a tonsillectomy and adenoidectomy to create a larger airway for better sleep.
3. Get the PYY Up: Eat Appropriate Portions, Wait Twenty Minutes for Seconds, Eat Fiber
A kid eats a whole plate of food and says to her mother, “I’m still hungry.” Mom doesn’t want her kid to starve, certainly doesn’t want any whining, and serves up another portion. You parents out there, how many times has this happened to you? Every day? Every meal? For adults, why do you devour a second hamburger immediately after scarfing down the first? There is a huge difference between the phenomenon of satiety versus the phenomenon of lack of hunger (see chapter 12). Putting food in the stomach lowers your ghrelin, but that doesn’t stop you from eating more. The signal for satiety—the switch that turns off the meal—is peptide YY(3-36). Between the stomach and the PYY cells are twenty-two feet of intestine. It takes time for the food to get there. Give it a chance. The Japanese have a saying, “Eat until you are 80 percent full.” This is very difficult to do in America. The key is to wait twenty minutes for second portions. Also, make sure your first portion is an appropriate size—even if you don’t go back for seconds, you’re going to do damage if you’ve supersized your meal. The best way to get your PYY up is to make the food move through the intestine faster, and that’s the job of fiber (see chapter 12). And the best way to get fiber is to eat real food.
4. Get the Cortisol Down: Exercise
Now here’s the hard one. Cortisol is your short-term friend and your long-term enemy. Keeping cortisol low, which means keeping stress down, is virtually impossible. There are more stressors today than ever before, and no natural way to deal with them. Our ancestors may have run away from the attacking lion, but it is considered poor form to bolt full speed from your yelling boss. Stress-induced eating may be one of the toughest challenges to overcome. First, because it’s not the stress, it’s the response to stress that matters (see chapter 6). This may be either genetically or prenatally determined (see chapter 7), and unlikely to respond to simple willpower. Second, since excess cortisol drives visceral fat, insulin resistance, and further food intake, it’s the triple whammy for metabolic syndrome. Finally, cortisol alters the output of the amygdala in a positive feedback, or vicious cycle, manner, so that more cortisol results in more amygdala activation, resulting in more cortisol the next time, and so on. Since nobody’s stress is going away in this lifetime, the overeating won’t go away either. If you’ve got poor coping mechanisms and everything in life is chaotic, it’s pretty hard to ignore your troubles, and they tend to multiply.
There is one simple, cheap, and effective way to reduce your cortisol: exercise. Although exercise raises your cortisol while you’re doing it (to mobilize glucose and free fatty acids for energy), it reduces your cortisol levels for the rest of the day. It burns off fat in your muscles to improve muscle insulin sensitivity, and in your liver to improve hepatic insulin sensitivity. In our clinic, the rule is to buy your screen time with activity. Every hour of TV or computer games means an hour of playing sports. This is the hardest for families to do, because parents tend to use the TV as a babysitter, and modern children tend to prefer playing sports with a joystick.
Many parents start dreaming about what college their child will attend before the kid is out of the womb. Your children feel that stress—which affects their mood, their actions, and their studies. The pressure on children today is enormous. Where can they find the time for everything? Here’s perhaps the most important idea in this book for raising children. If your child lays off the soft drinks and exercises, he will create time. If he exercises vigorously for one hour, his five hours of homework will take only four hours because he will be more focused and efficient. He will have created time. There are numerous studies from around the country documenting that increasing exercise improves kids’ school performance and behavior. Parents, creating time is what life is all about in the twenty-first century. You can’t increase the number of hours in the day, but you can increase your child’s productivity.
Sadly, your kids’ school doesn’t get it. They’re saying, “We have to teach to the test, otherwise No Child Left Behind will pull our funding.” Teachers, here’s what you need to know: No Child Left Behind is really No Child Moving Forward and No Teacher Left Standing. Teachers, exercise your kids during the school day. Lose forty-five minutes from the daily schedule and devote it to real huffy-puffy, sweaty exercise. The kids will do better in school and exhibit better behavior.
The Way We Need to Be
Processed food altered our current environment. All the pieces are available for us to retool. For example, how about crockpot dinners made that morning? Salads don’t need cooking—just be careful about the ingredients in the processed dressings. Kids need to bring lunch from home and not purchased at school, where, with a few notable exceptions, the food is highly processed, sugar-laden, frozen (so, it contains no fiber), shipped cross-country, and just plain nasty. Like DeShawn’s mother, take the soda out of the house. Try to ensure that your child doesn’t eat the home and school lunch or trade it with a classmate. Talk to your school principal about the food served at school; the school can do better. Make sure the convenience food trucks don’t line up outside the school waiting for kids to exit with dollars in their fists. If your kid is old enough, how about having her cook for the family? She needs to learn sometime, or in college the freshman 50 will no doubt replace the freshman 15. Of course, these changes are applicable only to the middle and upper classes of society. The poor still do not have access to healthy foods or areas in which to exercise. This is one of the many reasons that public health solutions are also necessary (see chapters 20–22).
There are two ways to look at how our environment relates to obesity. The first one says that genes and behavior interact to drive weight gain. But both genes and behavior are unalterable; so in this paradigm, all is lost. The second says that behavior is the output of hormones (see chapter 4) and hormones are responsive to the environment. Obesity is a hormonal problem, and hormones are alterable, so in hormones there is hope. In this chapter, I’ve provided the rationale and methods to alter the environment, for even the most recalcitrant of patients. But that doesn’t mean it will work. The precepts will work for 60–70 percent of the obese population. Sadly, genetics, epigenetics, developmental programming, and environmental obesogens can overwhelm any environmental alteration. Sometimes medicine and surgery are necessary.