It’s that time of year again! Everyone’s talking about which diet they’re going on and what exercise they’re going to do in order to get to their goal weight but, when it comes to obesity, is it really as simple as calories in/energy out?
Our blog this week has been written by Debi-Ann Wrigglesworth, a nutritional therapist with a Masters Degree from the University of Worcester. Debi-Ann looks at how obesity is the most common form of disruption in energy balance, and is a major, and very prevalent, disorder of nutrition.
Adding Another Dimension to the Obesity Crisis
Public Health England defines obesity as adult patients with a body mass index (BMI) of 30kg/m2 or over. Although the BMI scale has been refuted because, for example, a body builder with very large muscles could weigh over this amount but not, technically, be classed as obese. Within the health profession; it is useful as a ‘stake in the ground’ that can help people to get an idea as to what their optimum weight range is and where they are in comparison to the general population.
Obesity is associated with a range of health problems including type 2 diabetes, cardiovascular disease and cancer. The resulting NHS costs attributable to overweight and obesity are projected to reach £9.7 billion by 2050, with wider costs to society estimated to reach £49.9 billion per year. These factors combine to make the prevention of obesity a major public health challenge.
It is now widely accepted that helping an obese or overweight patient isn’t as simple as telling them to cut down on what they eat and increase the amount movement they make. Although these factors may help, there are a great many other factors that can contribute to the difficulty of losing weight, such as: endocrine dysregulation, autoimmune conditions, gastrointestinal dysfunction, psychological issues and toxicity. There is also confusion about what’s healthy and what should be avoided due to conflicting information in the media.
In this article, we will consider the role of endocrine dysregulation in obesity with a particular focus on leptin and ghrelin.
Hormones need to be in balance with each other in order to function as they should – basically, if one hormone goes out of kilter then this will have knock on effects on other hormones. The endocrine system is made up of a network of glands that produce different types of hormones that are responsible for specific responses in other cells, tissues and/or organs within the body. Most of these organs produce more than one hormone and if an organ is producing high levels of one hormone, then it may struggle to synthesise adequate levels of the other hormones it makes.
As well as the obvious discussions around insulin and obesity, there are two other note-worthy hormones that play an important role in the regulation of food intake and body weight – leptin and ghrelin. Both originate in the periphery and signal through different pathways to the brain, particularly to the hypothalamus. In the hypothalamus, activation of the leptin or ghrelin receptor initiates different signalling cascades leading to changes in food intake. Both the leptin and ghrelin systems are disturbed in obesity. They are also very recent discoveries with leptin only being discovered as recently as 1994 and ghrelin being discovered two years later and reported in 1999.
Leptin is a protein produced, not by a gland, but predominantly by adipose tissue, or fat cells. Leptin is a mediator of long-term regulation of energy balance. It is responsible for letting the hypothalamus know that the body has enough energy to engage in normal metabolic processes and it decreases the appetite accordingly. After release by adipose tissue, leptin signals to the brain, giving information about the status of the body’s energy stores.
So, as obese patients have more leptin they should have decreased appetites. Supporting this theory is the fact that serum and plasma leptin levels have been shown to be higher in subjects with a higher BMI and a higher total body fat. In addition, it has been demonstrated that plasma leptin can cross the blood-brain barrier, and cerebral spinal fluid leptin levels also turned out to be correlated with BMI.
If this is the case, then why do obese people not reap the benefits of this decrease in appetite?
Well, problems arise in cases of obesity because the obese person has more adipose tissue, which will produce higher levels of leptin. This means that weight loss is more difficult due to the fact that, as fat is lost and leptin levels decrease, the hypothalamus gets the message that there isn’t enough leptin and concludes that there aren’t enough energy reserves to perform metabolic processes needed for survival. This switches the body into starvation mode with hormones calling for the body to replenish energy supplies. Basically, the feedback mechanism doesn’t function correctly in our modern environment.
Research suggests that those who are obese might be leptin resistant, which is similar to insulin resistance (they share the same signalling pathways). In short, one becomes leptin-resistant by the same general mechanism that one becomes insulin-resistant – by continuous overexposure to high levels of the hormone.
The hormone involved in appetite regulation is ghrelin. Ghrelin is produced by specialised cells called the epsilon cells, in the upper part of the stomach and in the pancreas. Ghrelin is a fast-acting hormone, seeming to play a role in meal initiation – it’s known as the ‘hunger hormone’ – and is responsible for increasing appetite.
Ghrelin levels are high before a meal is eaten and low again when the stomach has food in it. It is produced when our stomach is empty to let us know that we need to eat. Another of the body’s clever ways of making sure that we stay alive.
Besides playing a role in short-term regulation of food intake, ghrelin might also play a role in long-term regulation of energy balance but this is an area that needs more research. In addition, circulating ghrelin concentrations are negatively correlated with BMI, and levels increase when obese people lose weight, and decrease when anorexia nervosa patients gain weight. This suggests that ghrelin levels change in response to dieting to maintain body weight as part of the body’s attempt to maintain homeostasis.
Lack of adequate sleep is known to stimulate ghrelin encouraging a tired person to overeat. Could this be one of the reasons that people crave a large breakfast after a night out consuming lots of alcohol and then getting inadequate sleep? Or, that those who work nights, or shifts, may struggle with weight management? There are lots more studies needed on these two recently discovered hormones but the current research is proving very beneficial in helping us to understand the complexities of weight management on a case-by-case basis.
An interesting 2014 study showed that childhood abuse or neglect may also be a contributory factor by impairing weight-regulating hormones. This study, in the Journal of Clinical Endocrinology and Metabolism, looked at levels of the following hormones; leptin; irisin (which is involved in energy metabolism); and adiponectin, which reduces inflammation in the body, and found that these hormones were out of balance in those that had been abused or neglected as a child. Higher levels of leptin and irisin, and low levels of adiponectin in a blood sample were linked to obesity. This could explain why those that have dealt with childhood upset face a potentially higher risk of developing excess abdominal fat and the related health conditions.
So, what can we do about leptin resistance in those with obesity?
When working with clients with weight management issues nutritional therapists need to take all things into consideration. Full and detailed personal history, working with the functional medicine signs and symptoms algorithm is hugely beneficial in identifying driving factors of obesity on a case-by-case basis. An integrated approach is essential if we are going to make a difference to these clients, not just losing weight but keeping it off in the long term.
We also need to look at meal patterns – how and when the client eats, habits, compositions of the foods eaten and the driving factors for eating these foods – habit, appetite, learned responses to hunger, emotional factors such as stress, climate/season, cultural practices, family/friends, taste, smell and sight of foods, eating disorders; and psychological factors such as childhood traumas and other life events.
The following general suggestions may be useful:
- Implement a good, clean naturopathic diet with lots of organic vegetables making up the mainstay of the diet. High fibre foods can keep the stomach fuller for longer so that less ghrelin is released.
- Ensure that appropriate amounts of protein are eaten on a daily basis. 0.8 – 1.2 grams of protein per kilogram of body weight.
- Eat the protein portion of the meal first. When the protein portion of the meal is eaten first the stomach stays fuller for longer leaving a greater feeling of satiety and longer periods of time between the stomach emptying. By eating protein first there may be longer periods between ghrelin signalling meaning that one is less likely to eat as much, or as often.
- Balance blood sugar levels – all hormones dance together so keeping blood sugar balanced will help other hormones as well.
- Initially, eat 3 meals and 2 snacks daily. Make the snacks protein-rich – nuts, seeds, hummus on oatcakes etc., and watch portion sizes. Use the hands as a portion guide – the whole of the left hand represents the vegetable portion on a plate, the right palm (size and depth) represents the protein portion of the meal and the right hand fingers represent the complex carbohydrate portion of a meal.
- Cut all sugar and refined carbohydrates out of the diet altogether. These have a huge impact on weight management. Sugar has been shown in several studies to be the culprit in weight gain and fat storage. At the same time avoid artificial sweeteners which have been shown to increase appetite.
- Encourage clients to make friends with fat again and drop low fat options. The low fat argument has raged for many years and most health professionals now agree that healthful fat is needed for health and weight management. Encourage consumption of healthy fats including: nuts/seeds; oily fish – salmon, mackerel, sardines, trout, herring, kippers and anchovies; as well as coconut and coconut oil; avocado; and organic butter and meats.
At present, it is still not clear whether abnormalities in the leptin or ghrelin systems contribute to the development of obesity. Nevertheless, disturbances in both systems seem to play a role in the maintenance of obesity. In addition, nutritional status and hormonal cues such as leptin and ghrelin are now recognised to impact behaviour and emotion beyond feeding, including anxiety and depression related behaviours.
Debi-Ann Wrigglesworth MSc DipCNM CNHC
Having been told by a nutritional therapist that she was allergic to dairy products and that this was the source the health problems that the doctors couldn’t get to the bottom of, Debi-Ann became greatly interested in the impact that nutrition and food has on the human body leading her to enrol on the College of Naturopathic Medicine diploma course.
Debi-Ann qualified from the College of Naturopathic Medicine with a diploma in Nutritional Therapy. The CNM course is recognised as one of the most respected within the industry. She then passed her Masters degree from the University of Worcester while also running a busy clinic.
Debi-Ann also attends regular industry conferences throughout the year to keep up with the latest developments within the industry.
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If you have any questions regarding the topics that have been raised, or any other health matters please do contact me (Clare) by phone or email at any time.
firstname.lastname@example.org, 01684 310099
The Cytoplan editorial team: Clare Daley and Joseph Forsyth.
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