THE INTRICATE WEB OF WEIGHT GAIN

Weight management is a multi-faceted field, deeply intertwined with our body, brain, genetics, and environment. Understanding the underlying causes of weight gain, particularly when it manifests as spot fat accumulation, is crucial before attempting aesthetic spot reduction. This article delves into the systemic disruptions that can lead to weight gain, the red flags to be aware of, and the holistic approach needed for effective body re-composition.

FAT ACCUMULATION

Excess weight in specific areas is often a sign of underlying health issues that, if left untreated, can lead to more severe problems. Factors such as genetics, psychiatric conditions, hormonal imbalances, aging, systemic illnesses, and side effects from medication can all contribute to weight gain and fat accumulation. Aesthetic spot reduction will not yield long-term results unless the underlying systemic issues are addressed and stabilised.

GENETIC FACTORS

Genetics play a significant role in fat distribution and metabolic function. About 50% of fat distribution is determined by genetics and can be gender-specific. Despite the genetic predisposition, lifestyle choices, particularly diet, can influence gene expression related to weight gain. Studies on non-Western societies adopting Western diets highlight how environmental factors can trigger genetic susceptibility to obesity.

Even if obesity has a strong genetic component, it is not completely predetermined. Your food choices and portion sizes (caloric intake) can have a major effect on which genes are expressed and which are not. Non-Westernized societies quickly develop obesity when they start eating a typical Western diet of high caloric, easily available processed food. Even though their genes do not change, the environment and the signals they send to their genes do. Identical twin studies demonstrate that genes affect your susceptibility to gain weight.

AGE-RELATED CHANGES

As we age, physiological changes, such as the loss of lean muscle mass, can significantly affect weight. Muscle mass is crucial for maintaining metabolism and bone density. Without adequate exercise and proper diet adjustments, aging individuals tend to accumulate fat due to decreased muscle mass. Additionally, age-related sleep disturbances and hormonal changes can contribute to weight gain, particularly around the midsection. changes that can affect weight. Lean muscle mass loss is one of these major changes. You will start to lose about 1% of muscle mass per year from middle age if you are not actively stimulating and promoting lean muscle strength with exercise. Muscle mass preservation is important for bone density and metabolism (burning calories). You simply do not need as many calories if you have less muscle mass to maintain. If your diet does not change to accommodate this decrease or your exercise regime does not adapt to improve muscle mass retention you will consume more calories than you need and simply store the rest as fat.

Age-related changes also affect our ability to sleep well because of decreased melatonin hormone secretion and many other physiological factors. Should you sleep less than 6 hours every night (or on a regular basis) it might affect hormones that regulate your appetite as well. Decreased sleep is associated with higher levels of hormones that make us hungry (for example Ghrelin), lower levels of hormones that tell us that we are full (for example Leptin), and higher levels of cortisol – a stress response hormone that can stimulate appetite and impulsive eating.

Sex hormone changes are also significant. Older men and women experience reductions in certain sex hormones. In women, low estrogen levels are associated with sleep problems and increased body fat, especially midsection distribution. In men, reduced testosterone levels are linked to less muscle mass and decreased need for calories. If muscle mass is not actively preserved or built up, excess calories will be stored as fat, leading to the “middle-age spread.”

In summary, obesity is often linked to low androgen levels in men, and true hypogonadism can exacerbate adiposity and central fat deposition. The pathogenesis of obesity-related hypogonadism is complex and multifactorial, involving obesity-related comorbidities and changes in body fat mass, along with its numerous adipokines and inflammatory mediators. Fortunately, these changes are often reversible with weight loss. Preferred management strategies for these conditions include lifestyle modifications, anti-obesity medications, and weight-loss surgeries when indicated.

CHRONIC STRESS

Chronic stress triggers the release of cortisol, a hormone that increases appetite and can lead to compulsive eating, particularly of high-calorie foods. This response can result in weight gain, especially if stress is not managed effectively. Signs of high cortisol levels include weight gain in the face, midsection, and upper back.

The constant fight-or-flight response triggered by chronic stress may cause consistently high levels of the stress hormone cortisol.

Cortisol is released in stressful times to help the body replenish energy stores. This may indirectly cause weight gain by increasing your appetite to replenish energy stores. It’s harder to manage stress as we get older, if you’re constantly under stress, you might have constant high levels of cortisol. In some people, this may indirectly promote weight gain by increasing appetite (since the body thinks it needs energy). Your pancreas may secrete excess insulin that also promotes weight gain and because your physical output is not necessarily higher than usual the excess energy is stored as fat.

Increased stress often results in compulsive eating of readily available sugar, fat, and salt-laden foods as an emotional crutch, triggering potential starve-binge cycles. Common signs and symptoms of higher-than-normal cortisol levels may include weight gain, especially in the face (so-called moon face) and abdomen, fatty deposits between the shoulder blades, and wide, purple stretch marks on the abdomen.

HORMONAL DYSREGULATION

Various hormonal conditions can lead to weight gain. Hypothyroidism, Cushing’s syndrome, and Polycystic Ovary Syndrome (PCOS) are common disorders that cause significant weight changes. Proper diagnosis and treatment of these conditions are essential for effective weight management.

HYPOTHYROIDISM

Hypothyroidism, or underactive thyroid, is a condition where the thyroid gland does not produce enough hormones. The simple thyroid stimulation hormone (TSH) test and free T4 test should be performed in a panel when a patient is having difficulty losing weight despite regular exercise and a well-balanced calorie-controlled diet, or is becoming easily fatigued, has a thyroid that feels abnormal on medical examination, or a heart that beats too slowly (bradycardia) amongst other signs and symptoms.

The opposite symptoms also justify these tests in a screening panel as the patient may have too much of the hormone in their blood causing weight loss, sweating, palpitations and anxiety, etc. This is why it is so important to know that thyroid hormone supplementation should never be taken to attempt weight loss or to speed up the metabolism if not prescribed by a doctor after tests and examination of the gland and diagnosis of the root cause of the underactive thyroid is determined which may be autoimmune, malignancy, side effects of other medication or genetic predisposition to name but a few. The thyroid may be cycling up and down in function, because of an underlying condition where unnecessary supplementation in an overactive production cycle can cause severe side effects.

HYPOTHALAMIC DISORDERS

The hypothalamus is the part of your brain that produces hormones controlling numerous bodily functions, including your appetite. An increased appetite coupled with rapid weight gain is one of the signs of a potential hypothalamic disorder. There are several screening tests to consider if hypothalamic disorder-associated weight gain is suspected.

POLYCYSTIC OVARIAN SYNDROME (PCOS)

PCOS is one of the most common endocrine disorders among women, marked by irregular periods, an excess of androgen hormones, and polycystic ovaries (which are enlarged and lined with follicles). PCOS can cause weight gain, particularly around the abdomen, and obesity can exacerbate the condition. The syndrome is usually accompanied by a metabolic syndrome phenotype – more weight carried around the abdomen/ midsection and insulin resistance as well as subclinical hypothyroidism or overt hypothyroidism and overt type II diabetes and infertility issues in severe cases. Tests like anti-mullerian hormone, sex hormones, and ovarian ultrasound as well as an oral glucose tolerance test and thyroid function tests may be of value if this condition is suspected and the patient should be referred for further investigation.

CUSHING’S SYNDROME

Cushing ’s syndrome occurs when the body produces too much cortisol, either naturally or as a result of certain medications. The most noticeable weight gains appear in the face, midsection, upper back, and area between the shoulders. The upper back fatty deposit was traditionally referred to as a “buffalo hump” in medical literature and the cortisol face is often referred to as a “moon face”. A midnight salivary cortisol level or 24-hour urine test may be considered as well as specialist endocrinologist referral if severe and/or other concomitant endocrine imbalances are suspected causing this metabolic phenotype (body shape).

Cushing syndrome is caused by prolonged exposure to high circulating levels of cortisol. The most common cause of cushingoid features is iatrogenic corticosteroid use, while some herbal preparations can also increase circulating corticosteroid levels leading to Cushing syndrome. Cushing syndrome can be interchangeably called hypercortisolism. ACTH-dependent cortisol excess due to a pituitary adenoma is called Cushing disease, and it is responsible for 80% of endogenous Cushing syndrome.

THE ROLE OF MEDICATION

Certain medications, including corticosteroids, antidepressants, and antipsychotics, can cause weight gain as a side effect. It is crucial for healthcare providers to consider these potential side effects when assessing weight gain in patients.

Some of these medications affect the chemical balance in the brain that regulate appetite and may make you hungrier so that you eat more and gain weight. It is of utmost importance to look at potential weight-related side effects of medication and supplementation when assessing the patient’s weight gain or inability to lose weight despite a low caloric balanced diet and moderate regular exercise program.

Examples include antidepressants such as paroxetine or phenelzine, antihistamines, and sleeping aids that contain the ingredient diphenhydramine. Antipsychotics such as clozapine or olanzapine and mood stabilising drugs like lithium. Beta-blockers such as the drug atenolol or metoprolol. Certain medications especially some of the anti-retroviral drugs may predispose to lipodystrophy (abnormal fat distribution).

ALCOHOL INTAKE

Several studies have linked excessive alcohol use to a higher BMI, explaining this by the fact that each gram of alcohol provides 7.1 Kcal (9). Aside from providing extra calories, alcohol has various epigenetic effects that may modify the risk of obesity. Ethanol disrupts the one-carbon metabolism cycle required for DNA methylation by inhibiting the enzyme methionine synthase and reducing the absorption of methyl donors such as folate and other B vitamins. Consequently, excessive ethanol consumption is expected to interfere with DNA methylation. In previous research, my research group found a link between heavy alcohol consumption and DNA hypomethylation in peripheral blood, as well as higher homocysteine levels, in a cohort of morbidly obese individuals.

WARNING SIGNS AND SCREENING

Healthcare practitioners should be vigilant for signs of underlying medical conditions when treating patients for weight gain. Conditions such as heart and kidney disease, hypothalamic disorders, and lymphatic issues can contribute to weight changes. Appropriate screening tests and referrals are essential for accurate diagnosis and effective treatment.

Heart and kidney disease can cause secondary weight gain or weight loss failure by water retention or easy fatigue-ability favouring a sedentary lifestyle and loss of muscle mass (lean muscle is essentially the driving force behind efficient fat burn – but that is an extensive topic for another time). Also keep in mind subcutaneous collections of fat that may indicate lipodystrophy or lipomas that may affect your assessment and measurement of a patient’s total body fat percentage and composition.

HOLISTIC APPROACH TO BODY SCULPTING

Addressing underlying health issues is crucial for successful body sculpting and long-term weight management. A balanced diet, regular exercise, adequate sleep, and stress management are fundamental components of a holistic approach. Strength training, cardiovascular exercises, and mindful eating can help achieve a healthy weight and body composition. The recommended diet should be rich in fruits, vegetables, legumes, and limited amounts of grains and minimally processed carbohydrates, as well as limited amounts of starchy vegetables. Ample amounts of lean protein are essential to help build muscle, while fat intake should be decreased since it is too calorie-dense to facilitate an initial caloric deficit and will limit the overall intake of other macronutrients.

For individuals without underlying health conditions causing weight gain, lifestyle factors such as diet, exercise, and stress management play a crucial role in achieving and maintaining a healthy weight. Encouraging patients to adopt a balanced diet, engage in regular physical activity, prioritise sleep, and manage stress can significantly improve their overall health and aid in weight management.

Sleep should be prioritised to at least 7-8 hours per night. It is advisable for patients to aim for 10,000 steps daily, monitored via a step-counting device, to optimise non-exercise activity thermogenesis (NEAT) (24). This should be complemented with brisk cardiovascular activity or high-intensity interval training (HIIT) 4-6 times per week for at least 20 minutes. Strength training is recommended two to four times weekly, with a focus on progressive overload, time under tension, and proper technique to minimize injury. Initial sessions should ideally be supervised by a trainer or biokineticist until the patient is familiar with the equipment and techniques and has established a mind-muscle connection. Emphasise the importance of maintaining and building lean muscle to preserve bone density and enhance fat burn as patients age.

CONCLUSION

Effective weight management and body sculpting require a comprehensive understanding of the underlying health issues contributing to weight gain. By addressing these issues holistically, individuals can achieve lasting results and improved overall

DR. JANINE OLIVIER

Dr. Janine Olivier (MBChB, UL) is a medical doctor with a special interest in Internal Medicine, Chemical Pathology, and Aesthetic Medicine, including Obesity Management. She is a member of SAMA, ASAIPA, and AAAM. Dr. Olivier has extensive experience in internal medicine and pathology and has completed a course in Women and Child Health in Sweden. Internationally published in the Journal of Clinical Chemistry, she has also co-authored a chemical pathology handbook and contributed to various aesthetic medical magazines and industry publications. Dr. Olivier is the founder of HuidAesthetic Clinic in Pretoria, South Africa. health. Aesthetic treatments should be considered only after achieving a stable metabolic state and healthy weight through lifestyle changes and medical interventions. The journey to a healthy fat distribution is a gradual process that demands commitment to physical and psychological well-being.