Introduction: Warning! A little heavy on the science but this group can handle it.
Since our blogs are about beauty and many of us consider beauty as an inside job let’s take the literal insides.
Have you started dressing up for an occasion and feel a little uncomfortable about the dress you are wearing?
Your try on 10 dresses before you find something that will comfortably cover the layers of fat that bother you?
You look at your side profile then front and feel you look too fat particularly in the mid-section?
Everything fits well except around the thighs and hips?
This makes dressing up so difficult especially if you are aware of this and are conscious of this.
This is a common South Asian problem. In some cultures a full figured woman is beautiful in others not so.
However it is the beauty inside that allows us to age gracefully and this blog is about the awareness of how we age and why metabolic syndrome is so difficult to overcome.
I will close with some simple practical steps to begin the journey to great vascular health and graceful aging.
Women who have a full figure look awesome in the traditional Indian garb, the saree, particularly when they have this “safety belt”- hips and thighs that are fuller.
So before we whine about this, let me tell you it does 2 important things:
- Women who have subcutaneous fat have more intelligent children as it is supposed to provide omega 3 to the growing fetus.( may explain why we have such brilliant prodigies in the community)
- Subcutaneous fat is not associated with inflammatory markers as are visceral fat so do not pose a health risk.
In this blog I will breakdown from a functional medical aspect on how to address this particular issue of visceral fat and its implications in our health and probably give you a different way of thinking.
South Asians are from the territories of Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, India, Pakistan, and Sri Lanka.
Let’s first delve into the five reasons why South Asian women tend to have a lot of difficulty building muscle and losing belly fat.
It all starts with the interaction of genes and environment (the epigenetics)
How your mother and father were health wise pre determines your response to your environment. Many of the ancestors of South Asian origin live under some very stressful circumstances in these regions.
If they had very stressful lives, your cells (inherited vertically) are programmed to have the response to stress that is already coded.
The theory is that cortisol responses are sharper, particularly in the morning. Cortisol is a fat storing hormone and particularly in the mid-section.
How do you know if this is an issue if you do not have a weight issue?
Morning blood sugars can be high.
Yes both mother and father’s stress impacts your cells responses.
Here is a study that showed in mice of course that paternal stressors are important in morning sugars in mice.
Delving a little deeper into the hormonal issues causes of increased abdominal fat:
There are four main hormonal imbalances noted in the South Asian Population:
- Insulin resistance which are of many kinds (Receptor level, fat stores, gut issues etc.)
- Estrogen overload.
- Poor activation of the T4 to T3 ( thyroid)
- Stress( cortisol)
The hormonal imbalances of significance are depicted as accumulation of fat cells that actually promote inflammation.( visceral )
Abdominal fat does not always signify poor health even though psychologically it signifies poor self-image.
The more important health risk in South Asians are that the inflammatory markers are very high with abdominal fat (visceral). This is seen more in the male population.
Important: Ketogenic diets may help with weight loss but the hs-CRP (high sensitive C reactive protein), goes up therefore actually increasing the risk for cardiovascular disease in many.
The inflammatory markers we look into
Below is a snapshot of the Apo E genetic marker of metabolism of lipid
Vitamin deficiencies that impact our metabolic health.
Almost universally high is the hs-CRP. This is due to cytokines produced by visceral fat that carries more inflammation.
Visceral fat is the fat that surrounds our organs. This acts as an endocrine gland and produces a lot of the inflammatory markers and hormones, particularly leptin and adiponectin.
The key to losing weight that is inflammatory are the following:
- Management of stress- cortisol
- Reducing fatty liver
- Enhancing metabolism of estrogens
- Optimizing thyroid function
The response of cortisol begins with the previous generation possibly as explained earlier.
If parents were exposed to stressful environment the response to cortisol is heightened in the offspring.
This is manifested as high blood sugars in the morning.
How to monitor?
I would highly recommend getting yourself a continuous glucose monitor and this will help you understand your blood sugar excursions. Even if you are not a diabetic. (You can get the G6 or Liber for your office)
A very important habit to develop for busy moms and career women, is taking time to meditate. This clearly has shown to bring down cortisol levels and organize the brain activity reducing the impact of stress.
Even dedicating 5 minutes a day helps. You can start your day that way or even meditate when driving (yes there is an app for that too).
Given that I have a Functional medical practice we start our morning huddle with a meditation, patients are invited to this so we all get this in.
See this video for explanation of the impact of fatty liver
Fatty liver is becoming an increasing problem due to change in our food and sometimes how we are wired. (Genetics)
The liver is our main detox organ and when it is accumulating fat and inflammation the hormones do not metabolize and the chemicals we get exposed to act as endocrine disruptors as they are not effectively removed.
Today we have access to genetic markers that tell you that you have a predisposition to accumulate inflammation in the liver.
Here is an example of a patient who has multiple family members have cirrhosis of the liver and history of liver cancer with no hepatitis C or alcohol history: They all lacked the glutathione transferase enzyme and this led to poor detoxification:
How can you tell if you have a problem with fatty liver?
2 main clinical features of a fatty liver:
- Widening hairline
- Dark eyes and eye bags.( also seen with chronic stress)
NAFLD is also seen in people deficient in choline found in eggs and fish. So being vegetarian can be the epigenetic trigger that predisposes you to this.
Overcoming some of the predisposition of this risk for fatty liver is by introducing plant based omega -3 from algae preparations. Adding glutathione as a supplement. Adding choline to the diet
A common misconception is that fruits are good. Fruits are good when in season.
When we have fruits all through the year the fructose in fruits can actually cause an increase in liver inflammatory marker which is ferritin.
Fruits and sugars (naturally and synthetic fructose) are an important cause of fatty liver disease that can progress to non-alcoholic fatty liver and nonalcoholic hepatic steatosis and cirrhosis, if not cirrhosis hepatocellular cancer.
This can be due to insulin resistance or due to a genetic predisposition.
Estrogens are hormones that get broken down in the liver. The metabolites need to be cleared. Genetic predisposition to high estrogen states are present in many in the South Asian population.
The 4 main genes that have mutations or SNP’s are:
Mutations of these genes result in accumulation of estrogen metabolites leading to heavy periods unless the progesterone is given to balance the overproduction of estrogen.
Clearing of the estrogen metabolites can also be done today with appropriate supplements and dietary changes.
Unfortunately, the current approach is a little behind the times with the removal of the uterus, a very common practice leading to weight gain with the loss of the hormones.
Here are genetics you can easily get tested for.
Estrogen metabolites can be measured in the urine and estrogen in the saliva. Genetic markers for metabolism of estrogen also can be assessed.
If any of these defects are present then enhancing metabolism of estrogens can be done with supplements and to some degree time restricted feeding.
High insulin state causes fat cell accumulation just as does high cortisol, and disables lipase enzymes. In these fat cells are the aromatase enzymes leading to increased aromatization of testosterone leading to increased estrogen states.
Thyroid dysfunction usually occurs after pregnancy characterized by weight gain, thinning of hair, apathy, feeling cold and dry skin. Blood tests can be normal but with every pregnancy the thyroid is inflamed leading to increased risk of thyroiditis that can become autoimmune.
Thyroid function requires multiple vitamins and minerals.
It also requires that the liver is functioning well and is not fatty.
As the conversion of the T4 predominant hormone produced by the thyroid has to be converted to the more potent T3 in the liver. So a fatty liver is also associated with symptoms of low thyroid.( one of which is weight gain )
Commonly deficiencies seen in the South Asian population are:
- Iron ( heavy periods from his estrogen and low progesterone state)
- Vitamin A is ( this is a receptor defect)
There is also a dietary increase in thiocyanates (cassava, cabbage, turnips, broccoli, Brussels sprouts, and cauliflower), in the food of the Asian population that competes with the influx of iodine.
These foods are actually very good for the liver so should not be avoided even if a thyroid problem is present. Instead by increasing high iodine containing foods (seaweed, spirulina or chlorella) this competition with iodine can be overcome.
Assessing these and replacing with food and supplements is a personalized intervention.
Clinical signs of insulin resistance:
Hyperpigmentation sides of the cheek bones, elbows and nape of the neck
Skin tags. Melisma ( high estrogen state and insulin resistance)
Insulin resistance manifests itself initially as Leptin resistance first and then reduction in adiponectin both produced by the visceral fat cells.
These can be easily obtained as a blood test: Leptin and adiponectin are the common hormones checked in the functional medical world to pick up early insulin resistance.
Low adiponectin is associated with metabolic syndrome very early, particularly in the “skinny fat men” (visceral fat)
Here is an image of the testing needed to determine insulin action along with A1 c and fasting sugar levels.
A good portion of insulin resistance can be due to
- Increased oils in cooking
- Gut microbiome
- Fructose in the diet
- Accumulation of visceral fat
Insulin resistance is the single most important reason for difficulty in weight loss in South Asians as the food rich in carbohydrates increases visceral fat. Here is what happens when you blood sugar increases.
Explanation of the above figure:
Under normal circumstances sugar becomes glycogen and stored,( that is why we do not have essential carbohydrates) if not used. The liver and muscle are the main storage sites for sugar.
However if they both get full as seen in insulin resistance the sugar is high despite high insulin.
So the way to overcome this is to utilize the glycogen and not try and push the sugar in.( avoid sulfonylureas).
Metformin, a biguanide made after the natural biguanide which was originally from the French lilac is a great way to help with this process. In fact the synthetic biguanides are currently being studied as an anti-aging drug. They seem to reduce the incidence of cancers in patients with insulin resistance.
So when most type II diabetics tend to feel a little fatigued and think their sugars are low, but their sugars are at 150 or above and they should actually exercise to empty their tanks and not eat.( which is a common mistake)
This is where CGM will help.
Other cause of insulin resistance in the South Asian population is the use of oils, particularly canola butter, ghee and vegetable.
Use of oils show dysfunction of HOMA-IR the marker of the insulin receptor.
The next important factor are the gut microbiome. When the bacteria are not of the right population they do not produce enough of the short chain fatty acids another key factor in weight issues. The future of weight loss is thought to be “poop” pills. As once again shown in experiments on mice, stools transferred from a thin mice to fat mice the fat mice tends to lose weight.
Summary of the clinical issues:
Look out for the following:
- If you have a history of gestational diabetes
- If you have difficulty losing weight
- Postpartum depression
- Irregular and heavy periods.
- Early thyroid symptoms( weight gain after first or second pregnancy and difficulty losing weight)
- Hyperpigmentation in the areas mentioned
- Widening hairline with thinning of hair
- Bags under the eyes or dark circles
- Midsection weight
- Early autoimmune disease or markers( hashimoto’s or ANA)
- Joint pains( inflammation)
Then you should get a complete assessment:
- Metabolic panel with inflammatory markers and lipoproteins
Work with someone who understands the systematic approach to breaking this down for you:
What can you do on your own?
- Monitor yourself. Today it is a day an age of wearables. (Soon it will be chips under our skin and apps on your phone.)
- Use a continuous glucose monitor (everyone should do this for one month) and see what foods raise your glucose.
- Focus on sleep. Sleep is essential. Setting bedtime routines. ( hot shower prior to bedtime)
- Use fasting as a tool ( time restricted window of feeding, that is eating usually when you are at work: early dinner and a real late break of fast giving yourself a 4 to 6 hour window of eating)
- High fiber whole foods to change the microbiome.
- Meditation and time off when stressed.
- Gums and teeth care ( avoid gingivitis-particularly if vegetarian as carbohydrates can case the cavity and gum inflammation and plaque formation)
- Regular exercise ( dance or tennis or walking- genetics can determine what exercise works for you)
- Change how you cook: using the least amount of oil but increasing whole fats like walnuts and adding fish or omega 3 from vegetarian sources. Ghee should be used after the cooking process 1/2 tsp for a whole dish to stimulate digestion never for cooking.
- Create a community that is supportive.
So if you struggle with weight loss issues it is usually stemming from a combination of genetic predisposition, inflammation due to emotional or physical environment and stress.
In today’s advances in lifestyle medicine and functional medicine none of us should truly struggle with weight issues or health issues.
It takes a systematic approach and willingness to prioritize your health and therefore your beauty by aging gracefully.