Medical Author: Carolyn Janet Crandall, MD, MS, FACP
Medical Editors: Melissa Conrad Stöppler, MD and William C. Shiel Jr., MD, FACP, FACR
Ms. W. J., a 55 year-old woman, comes to her doctor saying, "Doctor, I have never been this heavy in my life, even after I had my kids. I am trying to diet, but it's not working. I'm so frustrated. Is it due to my hormone pills? It seems like it's worse since my mother passed on last year." This type of encounter occurs every day across the U.S. Over half of all Americans are overweight, meaning they are at a weight that is associated with increased health risks. Even though Ms. W. J. has worked hard at trying to lose weight, she needs to know some of the possible reasons why she hasn't been successful. Her situation brings up four major issues, including menopause, hormones, personal loss, and diet failure.
Menopause and hormones
Women have more body fat throughout their lives as compared to men. After menopause, women generally gain weight. Research is still conflicting as to whether this is due solely to menopause or solely to age (because men also typically gain weight as they become older), or perhaps a combination of age and menopause.
When women are taking hormone therapy, they are just as likely to gain weight as women taking a sugar pill (placebo). This means that the hormones are not causing the weight gain but rather that menopause itself, in conjunction with age, is likely to be responsible. It is not Ms. W. J.'s imagination that she is heavier than she has ever been during this menopause period. This is very common.
What about personal losses?
Ms. W. J. has suffered a major loss with the death of her mother. Weight gain commonly occurs after emotionally traumatic events. A woman with significant stress in her life should not pick that time to try to lose weight but should focus on eating a balanced, nutritious diet to maintain her strength and fitness. Successful weight loss requires a large amount of energy that she may not have after a traumatic event or loss. This can be too much for her to expect of herself and may lead to additional disappointment. The same goes for a woman with untreated depression. She needs to be sure to discuss any symptoms of depression and begin treating them before she makes serious efforts at weight loss. That way, she can avoid failure in losing the weight and achieve an overall healthier state.
Ms. W. J. needs to confirm that she doesn't have depression that began after the death of her mother, which may require special treatment. Many women don't realize that weight gain can actually be a symptom of a clinical depression.
A woman with any single warning sign of depression, such as easy tearfulness, anger that seems out of proportion, difficulty concentrating, or feelings of social isolation and guilt should tell her doctor immediately.
Dieting has not helped her. Why?
When women diet to lose weight, especially after menopause, they will not be able to continue losing weight unless they also exercise. This is because exercise prevents the decrease in metabolism that occurs when women diet without exercising. Exercise also prevents loss of muscle. If you diet without exercising, you lose muscle along with the fat, which is not healthy.
Exercise for weight loss does not have to involve working out in the gym. Actually, the "right" exercise is simply the one you will actually do. Walking daily, for example, is typically sufficient to prevent the plateau in weight loss that occurs with dieting alone. If lower body aches and pains prevent walking or impact aerobics, a woman can try upper-body exercise, for example with a rowing machine. Sometimes, swimming or exercise bicycles are tolerated when weight-bearing exercise is too painful.
Most people don't know how to properly start an exercise program. It is critical to know the proper sequence of steps in starting to exercise to ensure success in the program and to prevent injury. The first task is to exercise consistently, preferably daily, even if it's only five minutes of walking per day. After achieving consistency in the exercise, the next step is increasing the duration of the exercise, trying to increase it very gradually to 30 minutes daily. This gradual increase is especially necessary for people who haven't been walking much. Lastly, the intensity should be gradually increased. Thus, the proper order is consistency, duration, and then intensity. This sequencing is important in preventing the person from tiring from the exercise and giving up if they try to start too aggressively all at once. People are healthier and more satisfied if they pursue exercise in the recommended order.
Ms. W. J. is trying to walk daily, so she's already tackled that problem. She should be encouraged. However, this means that although she's working hard to reduce her weight, there is still something wrong with her diet. A proper diet for weight loss is complicated. If it were easy to lose weight, Ms. W. J. would have already lost the weight. However, she has not. Many, many women have had this experience.
It is important to note that a person will not lose weight until the proper balance of each type of food is attained. It can be very difficult to figure out this proper balance without consulting a qualified dietician. This is why people have so much trouble keeping weight off after going through a group weight-loss program. People often need individualized counseling by a good dietician. If the problem were easy to solve, Ms. W. J. would have been successful on her own. For example, a dietician often determines that people are not eating sufficient protein and need to change the proportion of protein in their diet to lose weight. This is not something that people can easily figure out on their own. The dietician is not going to focus on brownies being fattening or on decreasing the total number of calories every day (which most women already know). Rather, he or she will concentrate on more subtle issues, such as the exact balance of each component of the diet. The dietician will also individualize a plan so that Ms. W. J. can eat the foods she actually likes and that fit her busy work schedule.
Ms. W. J. is ready to comply with the dietician's instructions because she realizes there must be something in her diet that is blocking her from being successful. However, she now asks: "What should be my goal weight?" Actually, this is a difficult question to answer.
Unless weight loss is due to a medical or psychiatric illness (such as anorexia nervosa), being too thin rarely presents a problem. In other words, weight-related complications keep decreasing as people weigh less and less.
The fewest health complications probably occur at a body mass index of about 24. To determine what your body mass index is, divide your weight in kilograms by the square of your height in meters (see MedicineNet.com's Obesity article). However, it is a common mistake to set an unreasonable goal for weight loss.
A reasonable goal should focus on being healthier and not on a specific number. When people consult a dietician and start changing their diet accordingly, and also start exercising, they are already on the way to being much more healthy, no matter what their actual weight number is. The weight will fall into place on its own given a little time. When women are surveyed, they almost always have a weight goal in mind that is almost impossible to attain. They also expect the weight loss to occur quickly. What they may not know is that weight loss of ½ to 1 pound per week is the weight that stays off over the long-term. Thus, in order to achieve long-term success, the weight loss needs to be gradual and based on improving habits.
Here are some tips for Ms. W. J. before she sees her dietician:
Remove serving dishes from the table. Also, after she serves herself, immediately put back half the food into the serving dish. Both of these changes force her to verify that she is still truly hungry before taking another serving.
Before a woman consults the dietician, she should write down anything that is keeping her from losing weight. People find this process unpleasant because it means taking a hard look at their habits. It means asking, Do you "stress" eat? Do you go without eating all day and then overeat at dinner? Do you eat just out of boredom? Is eating a "comfort" measure when your mood is down? Do you have trouble resisting snacks that coworkers bring into the office? Any habit that you determine has prevented you from keeping weight off in the past needs to be reported to the dietician.
Ms. W. J. should know that she will probably need to visit the dietician more than once. As is the case with seeing a doctor, you generally don't go to a dietician just once. If your treatment wasn't successful seeing a doctor once, you would need to go back. The same goes for a dietician. The diet plan may require adjustments over time as the dietician and patient determine what works and what doesn't work.
Finally, it is important to understand that there is still no quick fix for losing weight. There is only hard work, usually over an extended period of time.
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