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Why You’re Not Losing Weight

Despite what we’ve long been told, and the pervasive amount of food- and fat-shaming in our culture, the number on the scale isn’t always a simple reflection of the number of calories we consume vs. the number we burn. In fact, the stress brought on by extreme diets and exercise can undermine them entirely—and actually cause weight gain. Often the real key to losing what may be unwanted belly fat, and gaining energy, clarity, and a better mood lies with your hormones, according to Bay Area-based Dr. Sara Gottfried, the New York Times bestselling author of The Hormone Reset Diet and Younger (which comes out this March), among other books on women’s health.

In her twenty-five year-long gynecology and functional medicine practice, Gottfried has found that weight loss resistance is nearly always hormonally based in women. Here, she explains the hormone imbalances that have the greatest effect on our weight—not to mention our mood and happiness—along with what to do if hormones are out of whack, how to reset your metabolism, break painful food addictions without self-blame, and the most important things we all should know about hormones—regardless of what we may weigh.


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A Q&A with Dr. Sara Gottfried

Q

Sometimes diet and efforts at the gym just don’t pay off on the scale—do you believe that weight loss comes down to one calorie in, one calorie out?

A

Ah, I’ve totally been there, feeling like nothing works. I struggled with weight loss after the birth of my daughters. At age thirty-eight, I went to my doctor, who smugly told me that weight loss is just a case of simple math—that all it takes is to “eat less and exercise more.” At first I was humiliated, but then I got angry, as I considered that millions of women are made to feel bad by this common misperception, i.e., that they just need more self-control when it comes to weight loss. Which is totally wrong.

I left his office and went to the lab to test my hormones myself, thinking that they were off. I was stunned, though, to find that my cortisol, the main stress hormone, was three times what it should be: Cortisol causes belly fat deposits, PMS, and a short fuse. My insulin was too high, which made my blood sugar high (insulin wasn’t doing its main job, which is driving glucose into cells). My leptin was blocked too, causing me to be ravenous. My thyroid was borderline slow, leading to hair loss and fluid retention. The list went on.

So the solution was to fix my hormones—and when I did, something awesome happened: I not only lost weight more easily, my mood improved. I was more generous and patient with my kids. I wanted to go to yoga at night instead of the wine bar. I graduated from couple’s therapy! I connected again to my essential nature of joy. My daily outlook was no longer determined by the bathroom scale and my battle of the bulge; I had more energy for bigger things.

“I discovered that the calorie-in/calorie-out hypothesis has been widely disproven and remains the greatest misconception people have about diet and weight loss. Calories matter, more to some people than others, but hormones matter more.”

After digging into the research, I learned that 99 percent of weight loss resistance is hormonal. I discovered that the calorie-in/calorie-out hypothesis has been widely disproven and remains the greatest misconception people have about diet and weight loss. Calories matter, more to some people than others, but hormones matter more. Almost anyone who struggles with weight also battles a hormone imbalance. It amazes me how easy weight loss becomes once hormones are back in their sweet spot. Hormones control how efficiently a calorie makes you fat.

Most diets don’t work for women, because they fail to address the hormonal root causes that are the most common reasons for weight loss resistance, like excess cortisol, insulin and/or leptin blockage, estrogen dominance, a sluggish thyroid, low testosterone, and problems with the HPA (hypothalamic–pituitary–adrenal) control system. I struggled with every single one of these hormonal misfires, and learned through trial and error how to fix them rapidly with functional medicine: I developed a three-step protocol, starting first with lifestyle redesign and filling nutrient deficiencies (step 1), administering herbal therapies if symptoms don’t resolve (step 2), and finally adding bioidentical hormones if imbalances still exist (step 3), but in the lowest doses and for the shortest duration possible.

Q

What is the typical hormonal imbalance that causes us to hold onto, or have trouble relinquishing weight?

A

Ninety percent of the time, I find that the main hormone that’s out of whack is cortisol (which ends up disrupting other hormones, too). Your body makes cortisol in response to stress, but most of us run around stressed too much of the time, and our cortisol is off as a result. High or dysregulated cortisol levels wreak havoc over time, depleting your happy brain chemicals like serotonin, robbing your sleep, and making you store fat—especially in your belly. High cortisol is likewise linked to depression, food addiction, and sugar cravings.

The root cause of cortisol imbalance is usually a dysregulated HPA (hypothalamic-pituitary-adrenal) axis, which is the boss of all of your hormones:

When the HPA is up-regulated, you churn out too much cortisol, like I did. Result? Muffin top, feeling like you’re constantly racing from task to task, feeling wired but tired, quickness to anger and irritability, rapid weight gain.

Over time, the HPA can get burned out and become down-regulated. Then you feel a lack of stamina, have a tendency to hold a negative point of view, catch colds frequently, and you may experience thyroid problems that improve briefly before you crash again.

Since the root cause is usually the HPA, the key is to reset it, starting with cortisol. Any other attempts at fixing the hormones will likely fail in the long-term if the wayward HPA is not addressed. Here is my (simplified) protocol for becoming more objective about your stressors and balancing cortisol in women (all suggestions that are proven in randomized trials, the best evidence we have):

  • Talk through what’s stressing you with a girlfriend.

  • Practice some form of “witness” consciousness like meditation or yoga.

  • Add B vitamins and omega-3s if you’re deficient.

  • Take phosphatidyl serine until you perceive less stress and your HPA is no longer hypervigilant.

  • Get a massage once or twice per month.

  • Limit alcohol and coffee, or ideally switch to green tea, which contains L-theanine, an amino acid that reduces stress without sedation.

  • Eat extra dark chocolate (80 percent cacao or higher).

  • If your symptoms don’t resolve, add plant medicine. Ashwagandha is my favorite adaptogen that helps to reset cortisol, so it’s not too high nor too low during the day. If it doesn’t work for you, try rhodiola.

Q

Can you break down the other hormones that are problematic for people?

A

INSULIN: Insulin is a fat-storage hormone. Insulin resistance or block means your cells can’t absorb the extra blood glucose your body generates from the food you eat—when that happens, your liver converts the glucose into fat. Insulin resistance usually causes weight gain and sugar addiction.

LEPTIN: High leptin causes weight gain and excessive hunger. Leptin is nature’s appetite suppressant. When you’ve had enough to eat, leptin signals your brain to stop eating. When you are overweight, your fat cells produce excess leptin. When your brain gets bombarded with leptin signals from too many fat cells, it shuts down; leptin levels keep rising, receptors stop functioning, your body doesn’t get the leptin signal, and you don’t feel full. You keep eating the wrong foods in an addictive pattern, and you keep gaining weight.

ESTROGEN: Estrogen dominance is when you have too much estrogen compared with its counter-hormone, progesterone. Having too much estrogen in the body causes a number of symptoms, including weight loss resistance, moodiness, PMS, and heavy periods.

THYROID: Your thyroid acts as the gas pedal of your metabolism, managing how fast or slow you burn calories. When the thyroid is sluggish, it can cause weight gain, fluid retention, hair loss or thinning, depression, and constipation, among other problems.

Q

Can emotional factors affect hormone levels and thus weight?

A

Yes, absolutely. We tend to think first of the physical aspects of weight loss resistance, like diet and exercise, yet the emotional, mental, social, and spiritual factors may be even more important. I believe hormones affect all of these domains. Ancient systems like Ayurveda and traditional Chinese medicine get it right in considering these factors in aggregate in their general concept of wellness. In modern medicine, “stress” is often a catchall for emotions; and it is the overactivated stress response that can often lead to weight loss resistance.

In twenty-five years of working as a gynecologist, I’ve seen that about 80 percent of my patients have mental and emotional obstacles, beliefs, and attitudes that sabotage their weight loss. Emotional backtalk, or what scientists call “internal disinhibition,” are the thoughts and feelings that derail you from eating the best fuel possible and making other wise choices. Being reactive, or triggered emotionally like a cornered animal, feels bad and sidelines your ability to tap into more advanced emotional resources. Unprocessed and/or troublesome emotions can lead to overeating, drinking too much alcohol, binge-watching TV, maybe even using shopping as a balm…generally, to self-medicate.

“A daily battle with the bathroom scale can cause shame, judgment, suffering, and obsession with weight—contributing further to weight loss resistance.”

Even worse, the drill-sergeant approach of restricted eating and harsh exercise can escalate hormonal and emotional problems. A daily battle with the bathroom scale can cause shame, judgment, suffering, and obsession with weight—contributing further to weight loss resistance. When meals are accompanied by guilt, suffering, or anxiety about our food or our bodies (for example, when you’re telling yourself, “I shouldn’t be eating this,” or “I’m blowing it again,”) a physiologic stress response is activated, triggering a fight-or-flight reaction and raising cortisol.

Q

How do you “reset” your hormones, or jump-start your metabolism? Can you do it through diet alone?

A

The best way to get your hormones back on track and reinstate a healthy weight is to correct hormonal misfires with changes to the way you eat, move, think, and supplement. Start with diet: In my experience, 80 percent of weight loss is determined by the hormone/food interaction, so you want to eat in a way that optimizes your hormones. Here’s my priority list:

CHANGE THE WAY YOU EAT AND DRINK. Remove processed foods, refined carbohydrates, sugars and sugar substitutes from your diet. Eliminate alcohol for 21 days (even a single serving can reduce a woman’s metabolism by more than 70 percent—it’s a temporary effect, but can add up over time if you drink most nights).

TARGETED EXERCISE. Make sure to keep moving, and choose forms of movement that you love, but exercise smart. Avoid chronic cardio (more on why coming). Burst training and adaptive exercise (i.e. Pilates) are more likely to stabilize cortisol than running a half marathon. Burst training involves short periods of high intensity exercise with moderate-level exercise as recovery. It is incredibly efficient and comes without the cortisol-raising side effect of a long run. Not only that, but it is extremely effective at raising growth hormone, the growth-and-repair hormone that maintains your lean body mass, a crucial indicator of how your body is biologically aging. My suggestions:

  • For adaptive exercise (especially important if you have cortisol or thyroid problems): yoga, Pilates, and dance class. I regularly attend barre classes since they utilize small weights and body resistance, which are great for the HPA and preventing injuries.

  • Cross train: Lift light weights twice a week at a minimum to prevent osteoporosis.

  • Walk or hike briskly at an effort level of 9 to 10 (out of 10) for 3 minutes, alternating with an effort level of 6 to 7 for 3 minutes, for a total of 30 minutes—a protocol shown to foster weight loss.

  • Try chi walking or running, a combination of walking or running with tai chi.

  • I also love (regular) tai chi and most spin classes.

TAKE SUPPLEMENTS TO IMPROVE YOUR HORMONE LEVELS. Here are a few of my favorites:

  • Cortisol Manager: You need 7 to 8.5 hours of sleep to break through weight loss resistance. My favorite supplement for improved sleep—and less stress—is called Cortisol Manager, a combination of phosphatidyl serine and ashwagandha. It dials down the HPA so that you don’t feel stressed and can wind down for a good night of sleep. Too much cortisol raises blood sugar and deposits fat at night. Take one tablet at bedtime.

  • Berberine is the most proven supplement to reset insulin and support weight loss in women. It activates an important enzyme called adenosine monophosphate-activated protein kinase, or AMP, nicknamed the “metabolic master switch.” Take 300 to 500 milligrams one to three times per day. It works better when combined with milk thistle.

  • Di-Indole Methane (DIM): I know it doesn’t sound appetizing, but it’s very good for you. This supplement is akin to eating 25 pounds of steamed broccoli. Many women with weight loss resistance have estrogen dominance, a problem that affects 75 to 80 percent of women over thirty-five. Specifically, DIM reduces 2-hydroxy-estrone and 2-hydroxy-estradiol, so that you have more protective estrogens and fewer bad estrogens. Dose is typically 200 mg/day but must be adjusted to the individual. (Alternatively: Eat more lightly steamed cruciferous vegetables, which can improve your good-to-bad estrogen ratio by 30 percent.)

CONSIDER GENETIC TESTING. It can guide the best ways for you to eat, move, think, and supplement for hormonal harmony and weight loss. I started genetic testing for my patients (and myself) more than a decade ago, and it can truly help break through hormonal chaos and weight loss resistance. For example, changing your food strategy can reset the way certain genes are expressed: You can reduce your carbohydrate intake to reset the ADRB2 gene, which controls your weight changes in response to exercise. (I have the bad variant of this gene, which can cause weight loss to take twice as long as it would take a normal person. Exercise helps very little; it’s all about wrangling the mind to eat the right types and amounts of food with steady discipline. Gah!)

Q

What causes hormones to go haywire? Is it the natural aging process, stress, having babies…is there a primary culprit?

A

The main culprits of haywire hormones are:

  • Nutrient deficiencies. For instance, not enough vitamin C can lower your progesterone. Progesterone is nature’s Xanax, so a deficiency makes you feel overwhelmed and anxious.

  • Excess toxins. Bisphenol A is a good example: It can interfere with the estrogen, insulin, thyroid, and testosterone messages in your body.

  • Poor stress coping. I put myself in this category. Again, the root cause is that the alarm system in the body doesn’t turn off, so you make too much cortisol at the expense of other hormones.

  • Age. Women’s hormone levels change throughout their reproductive years and through perimenopause, menopause, and beyond. Common life events, such as menstruation and pregnancy, can throw your hormones off balance, as can medications like birth control pills.

  • Poor sleep. Only 3 percent of the population does well on less than 7 hours of sleep. Sleeping 7 to 8.5 hours every night keeps cortisol in check. Alcohol raises estrogen and cortisol levels, robs you of deep sleep, and lowers metabolism by more than 70 percent, as mentioned previously. I always suggest my patients get off alcohol completely for a minimum of two weeks, twice per year, to give the liver a break.

  • While exercise is an essential part of balancing your hormones, it can also throw them further out of whack if not managed properly. For women, I rarely advise CrossFit or Orangetheory unless your form and adrenals are impeccable. Some exercise (like running) place so much stress on the body that cortisol shoots sky-high. Think of a Tibetan monk versus a marathon runner. Who ages more rapidly? The runner, due to a higher load of cortisol, a wear-and-tear hormone. Additionally, running for women is very hard to get right in terms of form—I’m a runner and like many women, I’m plagued by knee and hip problems because of a wider pelvis compared with men. When I began running less, and more intelligently, and combined it with barre class, I lost weight. My advice is to stop exercising so hard in an obsessive desire to burn calories. Instead, practice yoga, meditation, or guided visualization several times a week and add more adaptive burst training to your routine.

    Q

    How can you tell if your hormones might be out of whack? Are there certain tests that you can ask your doctor to order, or is it something that people can handle on their own by addressing their diet?

    A

    When your hormones are in balance, neither too high nor too low, you look and feel your best. But when they are imbalanced, you feel miserable, with a range of symptoms that include fatigue, sugar cravings, weight loss resistance, bloating, belly fat, trouble sleeping, anxiety or irritability, and constant stress.

    You can assess your hormones with my free questionnaire. However, you won’t really know if your hormones are to blame for your symptoms until you get some basic blood work done. So, record your symptoms and check in with your physician to ask for blood work.

    Below is a list of the tests I most commonly recommend for my patients. Once you get the test results, you and your doctor can see the areas that need the most improvement.

    Blood panels to ask your doctor to order (for a morning test after an 8-to-12-hour fast):

    • Cortisol

    • TSH, free T3, reverse T3, free T4

    • DHEA

    • Testosterone: free, bioavailable, and total

    • Insulin

    • Leptin

    • Glucose

    • Hemoglobin A1C

    • ALT (to check the liver)

    • If overweight: leptin, IGF-1 (growth hormone)

    • If you still have your period: Day 3 estradiol, Day 3 FSH, Day 21-23 progesterone

    • If menopausal: estradiol, FSH

    Urine testing. Consider the Complete Hormones profile test from Genova Diagnostics or the DUTCH test from Precision Analytics. Either will tell you about your adrenals (both short- and long-term function), and your estrogen metabolism, which can tell you if you have too much wear and tear from cortisol as well as if you have a modifiable tendency toward breast cancer or not, or a risk of osteoporosis. I suggest reviewing the results with an informed, functional medicine clinician.

    A genetic test like 23andMe. There are seven key genes that are important when it comes weight loss, hormone balance, and feeling younger; and they can all be tested via 23andMe (and interpreted with my new book, Younger.).

    Q

    Besides weight gain, or holding onto stubborn pounds, are there other ways imbalanced hormones impact the way we feel? Can you be at your target weight and still need a reset?

    A

    Yes. High levels of the main stress hormone, cortisol, will deplete your happy brain chemicals, such as serotonin and dopamine; 50 percent of people with depression have high cortisol. Past the age of thirty-five, disordered estrogen (excess or low) can cause depression and low libido. The resulting drop in serotonin can sometimes lead to depression or mood swings. Low thyroid levels can cause moodiness—approximately 20 percent of people with depression have low thyroid function or hypothyroidism.

    “To slow down aging, it’s important to maintain or improve your lean body mass, since aging begins in your muscles. So, yes, you can be at your target weight and still need a reset.”

    You can also be at your target weight but have too much fat, a phenomenon known as “skinny fat.” The problem here can be excess cortisol, insulin block, and/or low growth hormone. To slow down aging, it’s important to maintain or improve your lean body mass, since aging begins in your muscles. So, yes, you can be at your target weight and still need a reset.

    If this feels depressing: Eat a square of extra-dark chocolate (which has been proven to lower cortisol in randomized trials, as mentioned above).

    Q

    Any other tips on breaking food addictions?

    A

    The most common food addiction issues are sugar, flour, and quantity. There is also orthorexia, an unhealthy obsession with healthy food (a problem that I used to have). As a recovering food addict, I believe the root cause of food addiction is complex and multifactorial—so the solution requires nuance and feedback. Again, addressing wholeness rather than just the physical aspects is key. There aren’t really quick tips, but recovery and transformation do require baby steps in the right direction, and people can change their biochemistry and cravings through personalized, optimal nutrition. Put another way, you can manage your food addiction by resetting your biochemistry:

    • Crowd out the bad stuff with more nutrient-dense food. The amount of food you eat affects the balance of brain chemistry, hormones, and blood sugar levels. Over- and under eating creates unstable blood sugar, low functioning thyroid, food allergies, and amino acid and fatty acid deficiencies that can weaken neurotransmitter mechanisms. Your meals should contain enough essential fatty acids and amino acids to build sufficient serotonin and dopamine, both of which help you inhibit your food intake (particularly the intake of carbohydrates).

    • Reset your neurohormonal dashboard. Connect with your inner divinity; control your cravings by accessing the true you that’s in your mind and in your heart. How can you do this? Try a ten-minute morning meditation. Commit to a yoga class. Find a way to feed your soul in non-food ways. Close your eyes and focus on nothing but your breathing. If you can control stress with mindfulness and self-care, you have another tool to help break the habit of reaching for food when what you really need is to calm yourself.

    • Interrupt your pattern. Your biochemical urges will quiet down if you change up your routine and avoid slippery situations that directly lead to binge eating.

    The big takeaway: Hormones dictate what your body does with food. Address your hormones first, particularly cortisol, then match the right nutrient-dense food and the right quantity to your constitution.

    Sara Gottfried, M.D. is the New York Times bestselling author of Younger, The Hormone Reset Diet, and The Hormone Cure. She’s a graduate of Harvard Medical School and MIT. Dr. Gottfried’s online health programs can be accessed here. And you can see the goop vitamin/supplement protocol that she developed for women who feel like their metabolism might be slowing down, here.

    The views expressed in this article intend to highlight alternative studies and induce conversation. They are the views of the author and do not necessarily represent the views of goop, and are for informational purposes only, even if and to the extent that this article features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment, and should never be relied upon for specific medical advice.

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