The real challenge with weight loss is keeping the weight off.
When you lose a significant amount of weight (greater than 10% is the number that’s typically used, though certainly there is individual variability), the body does what it can to return to its original weight. The body seems to have a functional weight set point that it defends irrespective of the extent of its internal stores of energy (in the form of fat). The set point can increase over time because of environmental and physiological reasons. For example, the hormonal changes of pregnancy or significant prolonged cortisol release from stress can increase the set point. Also being placed in a new food environment such as going to college or working from home during a pandemic. Interestingly, the set point can be raised but it does not seem to be amenable to lowering.
When we lose weight below the set point, the body counters with metabolic adaptive physiological processes that evolved to defend itself from starvation. These include the following mechanisms.
- Thyroid function changes. Reverse T3 increases, T3 and T4 decrease, effectively rendering you hypothyroid
- Muscle efficiency increases (improved muscle function per calorie, less wasted calories)
- Neuro-humoral changes: leptin, CCK, peptide YY all DECREASE, thus removing inhibitory actions on ghrelin, increasing appetite
- Decrease in resting energy expenditure due to weight loss and less available metabolically active tissue
- Adaptive thermogenesis decreases resulting in reduced resting metabolic rate
- Decreased sympathetic tone, increased parasympathetic tone
- Commitment amnesia: relapse of maintenance behavior that were required to lose the initial weight
As a result, fewer than one out of six people who have lost a significant amount of weight can keep it off after a year. Even more alarmingly, there is a concern that by weight cycling, you end up resetting your basal metabolic rate lower across all weights. So even after you regain the weight, you are still burning less calories, even at rest. Why might this happen?
With weight regain, the body’s imperative can be understood as follows: it wants to reconstitute fat free mass (FFM). This includes lean muscle but also the weight of organs, bones and other non-fatty tissues in the body. In Keys’ famous Minnesota weight loss experiment with conscientious objectors to WW2, over-eating and weight gain did not abate until FFM was reconstituted. During weight regain, there was a desynchronization in the reconstitution of fat mass and fat free mass, so subjects ended up with an overshoot of fat return. Meaning when you regain the weight, you end up with an increased percentage of fat as compared to muscle. Fat is a less metabolically active tissue and so you should theoretically have a lower BMR at the new weight, and this is what is observed.
Is there a solution? Possibly, and we’ll get to that.
Where does the set point reside?
How is this set point encoded and where does it reside in the body? Let’s consider two theories.
- Maybe there is a ponderstat–an actual sensor in the hypothalamus. Possibly more specifically, in the arcuate nucleus of the hypothalamus, where the major nuclei relevant to maintenance of weight reside. One theory is that specific astrocytes in the arcuate nucleus either sense changes in nutrition or somehow are attuned to loss of weight, possibly in relation to leptin levels. As a result, they are activated in a process known as reactive gliosis.[i] Other epigenetic changes are encoded in various parts of the brain and body as a consequence of weight loss leading to the defended phenotype. The symptoms of this condition are excess hunger and reduced satiety as compared to normal people. Nobody knows exactly what the thermostat is measuring. It could be circulating fat or leptin, it could be some factor related to fat free mass.
- Mitochondrial theory: our energy factories are irrevocably degraded by obesity, the oxidative stress of overnutrition damages them, reducing their effectiveness and their numbers. As a consequence, metabolism slows. Metabolism has been functionally reset because we are not using as much fuel. We cannot use it.
Bariatric surgery seems to evade some of the post-weight loss changes related to a set point, but only for a time and then not completely. The commonly performed surgeries change the composition and concentration of bile-acids, which are important signals of satiety. Also, because of structural changes in the gut, more nutrition passes to the distal part of the intestine causing increases in anorexigenic hormones such as GLP1 and PYY (hindgut hypothesis). There may also be changes in direct signaling to the CNS. Then the mechanical issues: the stomach is smaller, there is a fear of dumping syndrome if you eat too fast, etc. All of these factors contribute to a functional reduction in the set point, at least temporarily. Many people who achieve weight loss after bariatric surgery subsequently regain much of the weight.
But then how do we keep the weight off?
- Pacing. One basic principle is that if you must lose large amounts of weight, then do it slowly so that the body gradually adjusts to a lower set point. Losing weight more deliberately and pausing between plateaus seems to help people evade the set point phenomenon and thus maintain reduced body weight,[ii] though to be clear, this finding is anecdotal, controversial and lacks experimental proof.
- Muscle. When you lose weight, you lose both fat and fat free mass. Fat free mass includes the weight of organs and other tissues, but also muscle. When you regain the weight in the context of increased muscle mass, you will regain fewer pounds of fat. In other words, muscle mass will protect against fat regain. There are medications that should be used to mitigate the set point or even reset it. Ultimately, weight loss needs to be done in a controlled fashion with a plan, with frequent pauses to permit the body to catch up. Muscle mass facilitates this process.
- Dietary characteristics. I suggest a weight diet that is somewhat less palatable, with less sugar, salt, fat and calorie density, more fiber. The diet will be satiating but less rewarding. If you can stick to a diet like this for a few weeks, it will change the brain reward centers and alter how you defend adiposity.
- Mitochondria: theoretically increasing the health and number of mitochondria will increase resting energy expenditure and may reset an elevated set point for the rationale suggested above. This would be done by zone 2 exercise and a variety of supplements that support mitochondrial biogenesis. Also mitophagy inducers such as fasting and rapamycin. In the future, maybe mitochondrial transplantation will be possible.
- Rapamycin: speaking of the namesake mtor inhibitor, it has been shown in rats to durably reset the ponderstat by unknown mechanism.
- Finally, no discussion of weight is complete without a mention of exercise, sleep and stress management, the famous lifestyle triumvirate. Changing these often seems so inaccessible to people who are locked in patterns of work, parenting and life-responsibilities.