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Weight gain after 40 smg template

Are you age 40 years or older and finding it difficult to lose weight? Learn how your age, menopause and hormones can affect weight loss. Find out about strategies that can help you maintain a healthy weight.

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WEIGHT GAIN AFTER 40
          Presented by:
        Ronna Sherman MD
        November 29, 2012
Weight gain after 40 smg template
MIDLIFE WEIGHT CRISIS
     WEIGHT GAIN IN MID LIFE
    IS MENOPAUSE TO BLAME?


WHAT ARE THE EFFECTS OF WEIGHT GAIN

       WHAT CAN YOU DO
WHAT IS MIDLIFE WEIGHT GAIN
             DUE TO?
• Ovarian aging = menopause

• Chronological aging
AGING



        Cortisol
        Epinephrine
        Insulin
Effects of Aging
Thyroid               Metabolism declines
Parathyroid           Osteoporosis
Insulin
                      Increased blood glucose levels
Adrenal gland:
                      Orthostatic hypotension
   Aldosterone
   Cortisol           Cortisol blood levels stay same
   DHEA               DHEA levels decrease
   Epinephrine
Ovaries & Testes      Testosterone and estrogen

                      levels decline

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Weight gain after 40 smg template

  • 1. WEIGHT GAIN AFTER 40 Presented by: Ronna Sherman MD November 29, 2012
  • 3. MIDLIFE WEIGHT CRISIS WEIGHT GAIN IN MID LIFE IS MENOPAUSE TO BLAME? WHAT ARE THE EFFECTS OF WEIGHT GAIN WHAT CAN YOU DO
  • 4. WHAT IS MIDLIFE WEIGHT GAIN DUE TO? • Ovarian aging = menopause • Chronological aging
  • 5. AGING Cortisol Epinephrine Insulin
  • 6. Effects of Aging Thyroid Metabolism declines Parathyroid Osteoporosis Insulin Increased blood glucose levels Adrenal gland: Orthostatic hypotension Aldosterone Cortisol Cortisol blood levels stay same DHEA DHEA levels decrease Epinephrine Ovaries & Testes Testosterone and estrogen levels decline
  • 8. Transition to Menopause Estrogen Testosterone 4 years prior 2 years prior Menopause to menopause to menopause
  • 11. WHAT HAPPENS DURING THE TRANSITION TO MENOPAUSE Weight gain Muscle mass Fat mass
  • 12. BODY WEIGHT AND FAT MASS Majority of weight gain and increase in fat mass occurs during perimenopause After menopause There is a “shift” in fat (adipose) tissue
  • 13. FAT RE-DISTRIBUTION PEAR and APPLE PREMENOPAUSE: greater fat in gluteal and femoral region POSTMENOPAUSE: greater fat accumulation in abdominal and visceral region
  • 15. WHAT’S WRONG WITH ABDOMINAL FAT? • Hormone production • Inflammatory • Colorectal cancer • Hypertension • Diabetes • Impaired memory
  • 18. WHO’S TO BLAME ESTROGEN More precisely Lack of Estrogen LIPOPROTEIN LIPASE - LPL Estrogen controls the activity of this enzyme
  • 19. WHAT IF WE GIVE WOMEN ESTROGEN? It does not shift where the greatest activity occurs WHAT IF YOU SURGICALLY REMOVE FAT? It doesn’t work
  • 20. CONCLUSION • MOST WEIGHT GAIN OCCURS DURING PERIMENOPAUSE • HORMONAL CHANGES SHIFT FAT DISTRIBUTION • MUSCLE MASS WITH MENOPAUSE • MUSCLE DETERMINES METABOLIC RATE AND CALORIC REQUIREMENT
  • 21. Average woman gains 1 lb/yr after age 40 15 calories/day leads to gain of 1½ lb/yr Average glass of wine is 150 calories
  • 22. CAN YOU CHANGE YOUR FATE If everything remains the same : 150 calories per day …… 15 pounds / year After menopause: 200 calories less/day ….. Maintain current weight 200 calories less /day + moderate exercise min 150 min/week… LOSE Exercise : expends calories Strength training increases muscle mass
  • 23. GAME PLAN 1. Cut your calories – but not too much
  • 27. Add 200 calories for every cup of steamed rice that you eat http://www.cspinet.org/nah/chinese.html
  • 28. GAME PLAN 1. Cut your calories – but not too much 2. Exercise – duration intensity strength training
  • 29. STRRIDE (Studies of Targeted Risk Reduction Interventions through Defined Exercise) No exercise: women 11.6 % increase visceral fat more than 2x that of men + Exercise: 12 miles/week – no gain in fat 20 miles/week – lost visceral fat Inactivity, exercise, and visceral fat. STRRIDE: a randomized, controlled study of exercise intensity and amount Cris Slentz et al. + Journal of Applied Physiology October 1, 2005 vol. 99 no. 4 1613-1618
  • 30. Why It’s So Difficult to Maintain Your Weight  Loss of sex hormones  Disruption of normal insulin function  Adipose tissue is self preserving
  • 31. Biologic Mechanisms Protecting Adipose Tissue Mass
  • 32. Hormones produced by Adipose Leptin Stimulates energy expenditure Inhibits food intake Restores euglycemia Adiponectin Increased insulin sensitivity Energy expenditure Reduced production of glucose by liver Obesity is associated with Leptin Resistance
  • 33. Color-Enhanced Scanning Electron Micrograph of Adipose Tissue, Showing Adipocytes. Apovian CM. N Engl J Med 2006;354:1101-1102.
  • 35. Obesity and Inflammation Adipose (fat) is site of energy storage As fat cells grow :  Invaded by Macrophages  TNF α and IL-6  Blocks insulin  Cause inflammation  Decrease in production of Adiponectin
  • 36. OBESITY AND HOT FLASHES • Fat cells metabolize testosterone into estrogen • It was previously thought that women who were fatter had less hot flashes Opposite is true : fat acts as an insulator

Editor's Notes

  1. I will never forget the first time I learnt about the weight trap that women fall into after they turn 40. I was in my early 20s at the gym and I ran into one of my cousin ’s friend who was in her mid 40s. She exercised on a daily basis as I did and she was in pretty good shape. I told her how great she looked and she said you have no idea how hard I work to look like this. Just wait , you’ll see. I shelved it in the back of my mind. Thirty years ago exercising on a daily basis was not the norm. Cardiovascular health was of minor concern for women and all the things we know today about ideal body weight and prevention of heart disease in woman was undiscovered. In the late 1990s I took part in a clinical trial for a weight loss drug that is was first marketed as xenical. I was responsible for following all the participants in the trial and I started to notice a trend. The women had a much harder time than the men losing weight. I heard the same story over and over again. I never had a weight problem till I went through menopause. So I became curious. Is this a fait accompli? Last year I did a lecture on hormones and how they affect weight gain and emotions. But this year I decided to focus on the how and why we gain weight as we get older Is it age or change in hormones. So lets explore a little ………
  2. So why do we gain weight. After the birth of my first child I was having a difficulty losing the weight I had gained. I remember asking my gynecologist what was going on and her answer was “ you are getting older” . I said I am only 9 months older. You have to be kidding! Do we gain weight because of age of is it the decrease in ovarian production of estrogen (previously identified as our fountain of youth).
  3. I am going to start off with an explanation of what happens as we age. Obviously as we age, the tissues and organs in the body also age. It would stand to reason that the hormones produced by these organs are also affected This happens to both men and women Hormonal therapy of intrinsic aging. Zouboulis CC, Makrantonaki E. Source Department of Dermatology, Dessau Medical Center, Dessau, Germany. christos.zouboulis@klinikum-dessau.de Abstract Intrinsic skin aging represents the biological clock of the skin cells per se and reflects the reduction processes that are common in internal organs. The reduced secretion of the pituitary, adrenal glands, and the gonads contributes to characteristic aging -associated body and skin phenotypes as well as behavior patterns. Our knowledge of whether there is a direct or indirect connection between hormonal deficiency and skin aging still remains limited. In females, serum levels of 17β-estradiol, dehydroepiandrosterone, progesterone, growth hormone (GH), and its downstream hormone insulin-like growth factor I (IGF-I) are significantly decreased with increasing age. In males, serum levels of GH and IGF-I decrease significantly , whereas it can decrease in late age in a part of the population. Hormones have been shown to influence skin morphology and functions, skin permeability, wound healing, sebaceous lipogenesis, and the metabolism of skin cells. Prevention of skin aging by estrogen/progesterone replacement therapy is effective if administered early after menopause and influences intrinsically aged skin only. Vitamin D substitution and antioxidant treatment may also be beneficial. Replacement therapy with androgens, GH, IGF-I, progesterone, melatonin, cortisol, and thyroid hormones still remains controversial. PMID: 22533363 [PubMed - in process]
  4. It is not just coincidence that our health declines as we age. Our body is a fine tuned machine that is kept in balance by the hormones that are produced by the organs and glands in our body. Our thyroid for example controls the function of almost everything our body does including metabolism. It control bone health, heart function and metabolism. As we age, its function declines and so does it affect Our sex organs are one of the few that have a limited life span and actually stops working . This is what we call menopause
  5. For close to half of our life the ovaries are active and produce hormones that regulate the menstrual cycle. While that in itself causes its own problems (emotional swings, water retention, cramps and discomfort) these hormones are thought to be keeping us young During the first part of the menstrual cycle, estrogen is produced Midcycle ovulation occurs and estrogen production peaks and starts to decline. Of interest, this is the point where testosterone levels also peak and produce an increase in libido . (natures way to ensure that women will be hormonally excited at time when she is most fertile). The next 2 weeks are marked by formation of corpus luteum which produces progesterone. (progesterone prepares the lining of uterus for pregnancy) If pregnancy does not occur the levels of both estrogen and progesterone decline and the lining of the uterus is shed --- period. Estrogen activates the brain and has shown to have an excitatory role on neurons in brain. While progesterone has a calming effect on the brain. Estrogen modulate molecular pathways involved in monoaminergic neurotransmission (serotonin [5-hydroxy-tryptamine receptors or 5-HT], norepinephrine [NE]); these systems are critical for mood and behavior regulation. Women with PMS or PMDD (premenstrual dysphoric disorder) have been noted to have lower levels of serotonin during the latter phase (luteal) (although their level of hormone production is similar to normal indiv) The hypothesis is that these women have an underlying vulnerability to the normal fluctuations in hormone levels during the menstrual cycle. It is how these women respond to these cyclical variation that is the key. Hence SSRIs are considered the first line therapy for treatment of confirmed PMDD in women more than 18 years of age After behavior management : Reduction of sodium, sugar, alcohol, and caffeine can minimize somatic symptoms and bloating, and exercise
  6. This is a simplistic model of what happens as we age. I did not want to make this lecture about the changes that occur during menopause but it is impossible to talk about weight without explaining what is going on inside the body
  7. The average age of menopause in the US is 51 (50 for smokers). Menopause is defined by the absence of a menstrual period for 12 consecutive months Perimenopause is the 3-8 years prior so Its safe to say that the menopausal transition begins sometime in the mid to late 40s. Perimenopause is associated with fluctuations in estradiol and progesterone levels. During this time the FSH level is consistently increases and when the FSH level is >30 this is equivalent to menopause The fluctuations in hormone levels associated with perimenopause are like a roller coaster ride, That is why any individual measurement of hormone levels is not a good representation of what is going on.
  8. The Journal of Clinical Endocrinology & Metabolism April 1, 2004 vol. 89 no. 4 1869-1878 A key study published in the Journal of Metabolism followed women between the ages of 42 and 50 and monitored their weight over a period of 3 years. Women were categorized as premenopausal, perimenopausal or menopausal SUPRISINGLY The conclusion was there was no association with menopause and weight gain. weight gain was not associated with menopause However, Fat mass and distribution are correlated with menopause What they did find was that as women transiition into menopause muscle mass decreases skeletal mass declines – resulting from the loss of estrogen fat mass increases BODY COMPOSITION changes with the loss of estrogen Estrogen promotes the typical female type of fat distribution characterized by accumulation of fat below the skin, (subcutaneous fat ) with only modest accumulation of adipose tissue intraabdominally 
 lipolysis is controlled through the balanced control of lipolytic β-adrenergic receptors and α2A-adrenergic receptor-mediated antilipolysis visceral adipocytes, epinephrine stimulates lipolysis (high β- to α2-adrenergic ratio), whereas it inhibits lipolysis in sc adipocytes (high α2- to β-adrenergic ratio) adipocytes from premenopausal women possess a higher α2-adrenergic receptor density than those from men Estradiol might also affect lipoprotein lipase (LPL) activity. LPL is important for the uptake of fat into the adipocytes, and it has been shown that the promoter region of the LPL gene contains a unique estrogen response element that is responsible for the inhibitory effect of estradiol on the LPL mRNA expression in 3T3-preadipocytes (10). A recent study in humans found reduced LPL activity in adipose tissue beneath a 17β-estradiol patch applied to the skin (11). Thus, estradiol might also affect uptake of fat in human adipose tissue.
  9. SWAN study- study of women across the nation Showed similar results with one difference Looked at 540 perimenopausal women (going thru menopause) over a 6 year period What they found was that the majority of weight gain occurred during the perimenopausal transition and after menopause the major change is fat redistribution. Fat mass increases at a consistent rate during perimenopause and then stabalizes after menopause What can we take away from these studies: We can say that PERIMENOPAUSE is the critical time to be focusing on making changes If you want to prevent a large increase in body fat and weight you need to start before menopause occurs. That doesn ’t mean that you are doomed if you are already in menopause. It just resets your expectations a little. What you historically did to lose weight is not going to work. Not only is aging a factor that is working against you , but the accumulation of fat in the abdominal region is a new challenge that requires a more committed approach and consistency is the area you need to focus on.
  10. PREMENOPAUSE: Typical female shape is greater fat in gluteal and femoral region POSTMENOPAUSE: greater fat accumulation in abdominal and visceral region What is the mechanism for this redistribution ESTROGEN What is the significance : abdominal adiposity is associated with several interesting changes 6 months after menopause there is a significant change in lipid levels LDL increases HDL decreases TG spike This is what increases our risk for heart disease Some researchers suspect that the drop in estrogen levels at menopause is also linked to increased levels of cortisol, a stress hormone that promotes the accumulation of abdominal fat.
  11. http://www.health.harvard.edu/newsweek/Abdominal-fat-and-what-to-do-about-it.htm We used to think that abdominal fat was nothing more than an blob of fat waiting patiently to be used for fuel. We now know the this collection of fat actually acts like an organ that produces chemicals and hormones that negatively impact our health. It produces hormones such as leptin and adiponectin which influence appetite and hunger and affects how cells respond to insulin ( that is why diabetes is more common in overweight men and women ) It also produces inflammatory chemicals that increase our risk for CV disease This fat depot is lying close to the blood vessel that carries blood to the liver. This fat store is rich in fatty acids that are transported to the liver and increase production of cholesterol But that’ s not all. Recent studies have shown that people with increased waist to hip ratio (waist circumference) are at a 50% increase risk of colorectal cancer and hypertension a study presented at the 2005 annual meeting of the Society for Neuroscience found that older people with bigger bellies had worse memory and less verbal fluency,
  12. I know this picture is confusing. I don ’t expect you to remember this but it highlights your options. When we absorb fat from the diet (TG) it travels in the bloodstream in the large cells called chylomicrons. It travels around looking for an invitation to take up residence. If you happen to be exercising your muscle will invite the TG in. But in most cases the TG is attracted to the enzyme lipoprotein lipase on the adipose / fat cells and it breaks it into free fatty acids which are taken up and stored in the fat tissue. The fact that the abdominal fat now has an abundance of LPL makes it an attractive place for the TG to be stored This is important: these fatty acids can go to one of 2 places (for simplist sake) It can be stored as fat or go to muscle to be used for energy. The story is slightly more complicated than this because we can make fatty acids from carbohydrates ( insulin promotes fat storage and is related to carbohydrate intake) but lets keep it simple. When you exercise your body initially uses sugar in the bloodstream for energy. The next source is sugar stores called glycogen . It is not until 20 minutes later that your body will signal your fat cells for energy use. .
  13. Why does this shift of body fat occur Estrogen ; lack thereof Lipoprotien lipase is the enzyme that breaks down fat in the form of triglycerides into fatty acids. Fatty acids pass into cells either to be stored or used for energy ( remember this because we will come back to this point) LPL activity is more active in the gluteal femoral region in premenopausal women After menopause: there is a decrease activity in this enzyme in the gluteal regiona and an increase in the enzyme activity in the abdominal area Men consistently have greater LPL activity in abdomen and visceral compartment There is only one other time in woman ’s life when this shift in LPL activity occurs ….. Pregnancy and this is to allow for the carrying and feeding of the fetus
  14. Estrogen may increase the activity of LpL but doesn ’t change where it is active. dieting and liposuction both reduce fat tissue in the abdomen but only dieting reduces fat in visceral organs and muscle. Indeed, earlier studies of animals show that surgical removal of visceral fat eases insulin resistance, whereas removing abdominal fat doesn't.
  15. Slowing metabolic rate Increased tendency to gain weight Loss of muscle tissue also leads to lower metabolic rate I am sure that you are saying to yourself , terrific I came here to find out that I am having a hard time losing weight. I knew that already. I know But I think it is important for you to understand why so you don ’t simply say what I did before isn’t working so nothing will because That is not true. You need to do something different. And you cannot try the diet that is working for your husband or your co worker who is in her 30s.
  16. What is the bottom line- lets look at the same facts with a different slant if all it requires to gain 1-2 pounds per year is an extra 15 calories per day then the reverse is also true. 15 x 365 is 5,475 Lets take something significant 150 calories per day ……. 54,750 calories / year Each pound is 3500 calories That ’s 15 pounds a year if all else remains equal ( no loss of muscle tissue and no decrease in metabolism) Unfortunately this is not the case Once you hit 40 your metabolism slows as a natural part of aging There is a further decline in metabolism from loss of hormone production and the effect this loss has on muscle mass In essence we get hit from all sides. So the calorie reduction will work only if you are maintaining your muscle mass If you are not exercising, even if you don ’t change your eating habits at all you can expect to gain weight
  17. Smaller portions; your body can only metabolize a limited number of calories at one time There is a major difference between eating 300 and 600 calories for a meal. The smaller meal is more likely to be used for energy and the larger is more likely to be stored. Now what you are eating for those calories is important. Simple carbohydrates are easily digested and enter the bloodstream looking for a place to go. But remember that is you cut your calories too low you force your body into starvation mode and it will store fat more efficiently than before you started the diet Although calories are important the key component to losing abdominal fat is ….exercise Researchers at Duke University Medical Center found that people who did not exercise gained an average of 9% of visceral fat while those who exercised the equivalent of walking or jogging 12 miles per week gained no visceral fat and those who exercised the equivalent of 20 miles per week lost visceral and subQ fat A Univeristy of Pennsylvania study found that strength training also helped to fight visceral fat. They studied overweight and obese women ages 24-44 for two years. Those who added 1 hour of strength training twice a week saw a 4% decrease in body fat and did not gain visceral fat. Spot exercising will strengthen abdominal muscles but does not decrease abdominal fat ( SHOW PICTURE OF WHERE ABDOMINAL FAT IS) Nor will liposuction Exercise: AHA recommends 60-90 minutes of moderate exercise on 7 days of the week to lose weight and
  18. Smaller portions; your body can only metabolize a limited number of calories at one time There is a major difference between eating 300 and 600 calories for a meal. The smaller meal is more likely to be used for energy and the larger is more likely to be stored. Now what you are eating for those calories is important. Simple carbohydrates are easily digested and enter the bloodstream looking for a place to go. But remember that is you cut your calories too low you force your body into starvation mode and it will store fat more efficiently than before you started the diet Although calories are important the key component to losing abdominal fat is ….exercise Researchers at Duke University Medical Center found that people who did not exercise gained an average of 9% of visceral fat while those who exercised the equivalent of walking or jogging 12 miles per week gained no visceral fat and those who exercised the equivalent of 20 miles per week lost visceral and subQ fat A Univeristy of Pennsylvania study found that strength training also helped to fight visceral fat. They studied overweight and obese women ages 24-44 for two years. Those who added 1 hour of strength training twice a week saw a 4% decrease in body fat and did not gain visceral fat. Spot exercising will strengthen abdominal muscles but does not decrease abdominal fat ( SHOW PICTURE OF WHERE ABDOMINAL FAT IS) Nor will liposuction Exercise: AHA recommends 60-90 minutes of moderate exercise on 7 days of the week to lose weight and
  19. Division of Cardiology, Dept. of Medicine, PO Box 3327, Duke Univ. Medical Center, Durham, NC The study conducted by Duke University followed men and women ages 45-75 no exercise, low dose/moderate intensity (equivalent of 11 miles of walking per week), low dose/vigorous intensity (11 miles of jogging per week) or high dose/vigorous intensity (17 miles of jogging per week). There was no difference in total fat or visceral fat in the low dose group in men or women but it was sufficient enough not to increase fat stores. What this showed was that the amount rather than the intensity was correleated with visceral fat loss
  20. To sum it all up: After you lose weight As we age, the level of sex hormones decline and our metabolism slows down Declining levels of hormones that suppress your appetite predispose you to gain the weight back Weight gain leads to disruption of normal insulin function leading to further difficulty utilizing energy -  wt gain Fat tissue is self preserving Adipose tissue also secretes hormones that make it difficult to lose weight and keep it off. What can you do: Avoid weight cycling Maintain modest weight loss
  21. Leptin is produced by fat cells, and ghrelin is produced by stomach. After you lose weight, , there is a reduction in adipocyte size and in circulating levels of leptin (our own natural appetite suppresant) and there is an Increase in ghrelin and reductions in glucagon-like peptide 1 (GLP-1) that signal the brain to increase caloric intake Once weight is stabalized, Insulin sensitivity improves which means glucose enters the cells to be stored as fat and Fat uptake into adipose tissue is enhanced and less likely to be taken up by muscle cells for fuel. (this has a negative impact on further weight loss ) The positive is that glucose and fatty acids (TG , chol) are no longer hanging around in the bloodstream causing problems
  22. Obesity is associated with high blood pressure, elevated cholesterol and diabetes Adipose tissue (especially postmenopausal abdominal adiposity) is inflammatory increasing risk for CVD Obesity itself is associated with increase risk for stroke, heart disease, diabetes and certain cancers. Obesity is associated with resistance to effects of insulin on the usage of glucose and fatty acids in the bloodstream. This leads to state called insulin reistance The resulting hyperglycemia, hyperlipidemia, hyperinsulinemia and adipokines lead to vascular inflammation, hypertension and the development of cardiovascular disease.
  23. Increase storage of fatty acids in a growing adipose tissue mass is associated with the development of insulin resistance. Adipose tissue is the body ’s largest source of fuel but it also is site of the production of hormones. At any given level of BMI, the risk of the development of cardiovascular disease in both men and women is increased by more abdominal fat (increased waist to hip ratio, WHR)
  24. As fat cells grow, they are invaded by macrophages . They secrete TNF alpha and IL 6 which are substances that block the action of insulin and cause inflamation. In addition this causes decrease production of Adiponection which is important for ________ Increased insulin sensitivity Energy expenditure Reduced production of glucose by liver Weight gain and increase in central body fat occur during transition to menopause. This has been postulated as contributing to the increase in CVD risk assoc with menopause.
  25. Fat cell metabolize testosterone into estradiol and estrone. In theory this should mean that the more fat women have the less hot flashes they would get The opposite is now thought to be true. Fat actually acts as an insulator keeping the excess heat in.
  26. Aging results in a number of bodily changes due to declining levels in many hormones (growth hormone, adrenal steroids and sex steroids). However, the sex hormones are the ones that make the most dramatic symptoms. You never really knew how important estrogen was to your overall wellbeing until you lose it. Puberty in reverse and in slow motion There are changes directly related to decline of female hormones, such as hot flashes, vaginal atrophy and dryness causing pain during intercourse, and then there are those changes that have nothing to do with sex hormones but are exacerbated by the lack of them. These include depression, osteoporosis, sleep disturbances and weight gain. Then there are other symptoms that are directly affected by the loss of estrogen. Many tissues in the body have estrogen reeptors. Skin, hair… and the estrogen deficiency leads to dryness of eyes, nose, mouth and vagina and the loss of skin elasticity is Skeletal bone mass peaks at age 30 and then declines. This decline is exacerbated by the loss of estrogen and after menopause women can lose up to 4-5% of their bone density each year. Hot flushes Night sweats Dyspareunia 2/2 vaginal atrophy occur fairly early on and are notable differences Disordered sleep Depression Osteoporosis are more insidous changes and are part of normal aging