BOOK EXCERPT

Can’t lose weight? Blame it on middle age and your hormones

A new book explains why the science behind why weight loss is so difficult.

Ariana Green was an ambitious forty-five-year-old realtor in San Francisco. She was new to the business, which meant working seven days a week to build her reputation and client list. She was up for the challenge, though, and over time, her business grew. Ariana was also a beautiful woman who stood five feet ten and had blond hair, blue eyes, and high cheekbones. Her mother was a fashion model and Ariana inherited her good looks, which certainly had its advantages.

As Ariana marched through her late forties, she started gaining weight. At first she attributed this to the stresses and erratic eating habits that came with the new career. Then came a knee injury that slowed her down for a while. In the past, she’d always been able to shed weight easily. However, this time was different. Now fat appeared out of nowhere and seemed determined to stay. Her clothes became snug so she would go to a bigger size, and then it would happen again six months later. She was putting on weight like never before, and feeling depressed and confused about it. Finally, at fifty, something happened that shocked her: Ariana saw a snapshot of herself standing in the water in Cancun.

“I was absolutely obese,” she says. “I hadn’t realized it had gotten this far.”

On a different continent but also in the same physical predicament was Mike Hanson, a forty-eight-year-old software engineer living in Sydney. His job was demanding and entailed traveling from Australia to northern California and China. Mike was no stranger to hard work. He had competed with Silicon Valley tech jocks for years and could hold his own. But now, in middle age, things seemed different. He was getting a spare tire around his waist and feeling sluggish. The punishingwork schedule was bad enough, but when Mike turned fifty, his wife left him. His stress level shot through the roof. Suddenly, he was in a depression, and the spare tire was joined by fat elsewhere on his body.

What were Mike and Ariana doing wrong? They made the mistake of aging.

With age comes hormone decline and stress, and our bodies change in many ways. Among the most frustrating is that we accumulate fat more easily, and lose it only with difficulty. Worst of all, fat begins to appear in new and strange locations that we never had to worry about before.


Fat takes on different responsibilities at different ages. The younger we are, the better our fat behaves. When we are infants, a good proportion of our fat is the brown type, which burns calories and produces heat. At this stage, fat’s primary functions are to keep us warm and safe as we leave the womb and enter an uncertain world. Babies have more brown fat, percentage-wise, than any other age group. Baby fat also serves to cushion us from falls and injuries. As we grow out of infancy, the proportion of brown fat decreases and white fat increases.

In our teenage years, fat changes function again and plays a key role in sexual maturation. It helps trigger puberty by telling the brain that we are sufficiently well fed to bring offspring into the world. Without the proper level of body fat, sexual development is delayed. One way fat controls maturity is by secreting leptin, which aids in producing menstruation in girls. Another way fat regulates puberty is by producing estrogen, also critical for development. As their bodies get ready to bear children, girls will start to pack on more fat compared to boys.

Once the childbearing years arrive, it is baby fat, part two. Fat and the estrogen it produces are needed for women to get pregnant. Females must have the right amount of fat—not too much or too little. They will continue to gain fat in pregnancy, some of which will be used to produce milk for lactation. For nursing mothers, fat is used to foster the next generation.

Fat-wise, at this stage all seems right in the world. Then we hit middle age. And everything changes. As we approach our forties, production of the three sex hormones—estrogen, testosterone, and progesterone—which have heretofore been plentiful in our bodies, begins to wane. And, not coincidentally, our body fat suddenly becomes troublesome.

It begins to shift from places where it once seemed so appealing to locations where it is anything but.

In men, it now accumulates in the belly, the lower back, the nape of the neck. Women’s fat settles in the belly, too, and on the thighs, buttocks, and breasts.

As we age, our fat mass peaks. Between fifty and sixty, we are typically at our heaviest and have the most difficult time keeping fat in check. Many people who were thin since childhood suddenly struggle with weight. “What is going on?” they ask.

We know that fat can talk. It sends out messengers in the form of chemical signals like leptin to our brains, bones, and reproductive system.

But just as fat can talk, it can also listen. This extraordinary property of fat was actually noticed decades before researchers knew it could talk.

In 1969, Dr. Pedro Cuatrecasas at the National Institutes of Health ran experiments in which he combined fat cells and insulin and noticed that the insulin made fat cells act differently. When insulin was present, fat cells would increase their conversion of glucose to fat.

Cuatrecasas refined his experiments to understand how insulin was having such an effect. After some searching, he determined that fat cells had receptors on their surface that were uniquely designed to bind to insulin. And once insulin was bound to a receptor, the behavior of fat cells would change to produce more fat. Receptors are like “ears” on the cell’s surface that pick up incoming messages from the body. They are part of a two-way communication path whereby fat talks to the body (by emitting hormones such as leptin and adiponectin), and the body talks back to fat (by sending hormones to fat). In the case of the insulin receptors on fat cells, these “ears” would “hear” insulin (coming from the pancreas) on the cell’s surface and signal to fat cells to absorb more glucose and produce more fat.

Soon, other receptors were located as well. Dr Thomas Burns at the University of Missouri School of Medicine and his team found that fat cells also had receptors that could bind adrenaline, which communicates to adipocytes to release fat into the system for energy. If you see a bear, adrenaline tells your fat: “Don’t hoard energy for later. Use it now! Run!” Fat hears that signal and starts to release free fatty acids into the system for energy.

In the decades to come, it was discovered that fat has receptors for our most potent hormones – thyroid hormone, growth hormone, estrogen, testosterone, and progesterone. All these hormones tell fat when it is time to liquidate and release energy into the system.

When we are young, we have an abundance of these hormones. They work to grow our tissues, activate our reproductive systems, and keep our energy and metabolism high, which helps young people lose weight faster and keep it off more easily. But when we approach middle age we no longer need to activate our reproductive systems. Biologically speaking, we’ve outlived our usefulness. At this point, the production of most of those hormones decreases, which means the messages to our fat to dissolve itself are less powerful. With our bodies burning less adipose tissue through hormonal messaging, we inevitably get fatter.

At the same time, another hormone, cortisol, increases with stress and age. Cortisol is released from the adrenal glands in response to ongoing stress and is correlated with higher abdominal fat. All these hormonal changes together make it easier for fat to grow. We see it happen before our eyes; even though we may not be eating more than when we were young, fat now sticks to us more easily.

Women especially experience this weight gain as they approach menopause. During this period their hormone levels plunge as their ovaries head for retirement and produce less estrogen, progesterone, and testosterone. Lower estrogen levels cause increased appetite, reduced fat burning, and a redistribution of fat to the belly area, not to mention hot flashes and decreased energy. Furthermore, as the ovaries produce less estrogen, the body begins to rely more on fat’s ability to manufacture the hormone. Fat becomes a dominant source of estrogen in postmenopausal women.

It is hypothesized that this dependence is one reason women have a more challenging time reducing their fat compared to men.

Progesterone also declines significantly, altering the progesterone-to-estrogen ratio and causing a condition known as “estrogen dominance.” This can lead to irritability, depression, sleep problems, water retention, a bigger appetite, and sugar cravings. It’s like premenstrual syndrome, except that it lasts for years.

Testosterone, which is critical for both sexes, also decreases, causing a reduction in lean body mass and energy, ultimately leading to slower metabolism. Though we tend to think of testosterone as the male hormone, there is more of it in a woman’s body than estrogen at most times of the month, and certainly during the perimenopausal or postmenopausal years.

Excerpted with permission from The Secret Life of Fat: The Groundbreaking Science On Why Weight Loss is So Difficult, Sylvia Tara, Aleph Book Company.

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.