Episode 105: October 17, 2012
by Sanaz Majd, MD
Unintended weight gain is a big topic of conversation at the doctor’s office. I see patients on a daily basis who complain about their weight and the difficulty of shedding those extra pounds. Most of the time, it has a lot to do with our poor nutritional habits and lack of activity, and less to do with a medical condition causing it. As we all know, the U.S. is facing an obesity epidemic. Our busy lifestyles leave us little free time to exercise or prepare our own meals, which makes it so easy to head through the local fast food drive-thru.
That’s why I’m rarely surprised when I see patients reporting difficulty with weight gain. However, as a doctor, I still need to investigate all the possible medical causes of weight gain when faced with this common health complaint. Today, I’d like to talk about a case in which I was truly surprised and that’s why it is this week’s mystery diagnosis.
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Wendy is a 38-year-old gal who came to see me in the clinic 6 months after giving birth to a beautiful and healthy baby girl. She had gained 65 pounds with her pregnancy, and still had 35 pounds to lose.
“I’m here because I want a prescription for a weight loss medication,” she said. I heard the desperation in her voice. Wendy told me that she had been trying to lose weight for the past 3 months without any success. In fact, she was gaining instead of losing. “I can’t believe it – I’ve gained 5 pounds in the last 2 months, and I’m trying so hard.” She revealed that her self-esteem was so low that she wasn’t able to be intimate with her husband any longer and that it was affecting their relationship as a result.
Patients often tell me they’ve been trying to lose weight, but upon dissecting the details, I often find that there is some room for improvement. So I got down to the nitty gritty with Wendy’s weight loss regimen. I started with her activity level -- she revealed that she was using the treadmill and elliptical machine for 1 to 1.5 hours per day, five days a week. Okay, so there’s no problem there. Wendy is getting enough physical exercise.
I thought to myself that this must be a nutritional issue. Yes, let’s ask her about that. “I eat half a piece of pita bread with my meals for my carbohydrate portion, and the rest of my plate is either a lean protein like turkey or chicken without the skin and half of my plate is comprised of vegetables.”
It must be her drinks then. Yes, our liquid intake is often a great source of our calories. “Nope, I only drink water with a squeeze of lemon.” How about her snacking, you may be wondering? “I snack on carrot and celery sticks and dip them into nonfat yogurt.” Goodness, Wendy was eating a very well-balanced diet, and exercising plenty. She was obviously very determined to lose weight, so it didn’t make any sense to me.
She had a normal pregnancy, nothing out of the ordinary. She delivered vaginally, and her postpartum health was uneventful. She stopped breastfeeding 2 months ago since she started her weight loss regimen and her periods still have not returned.
Upon examining Wendy, she appeared overweight but not out of the ordinary for someone who had just had a baby. She had an otherwise normal physical exam.
The Differential Diagnosis
Whether or not the patient’s diet and activity clearly reveal the potential cause of weight gain, I always think through this list of potential causes of weight gain for every single patient:
Thyroid Disorder: A medical condition called “hypothyroidism” occurs when our thyroid gland, the gland that helps regulate our metabolism, pumps out too little thyroid hormone. When this occurs, our metabolism slows down, and besides hair loss, constipation, and fatigue, it can cause weight gain as well. A simple blood test ruled this out for Wendy, who had normal thyroid levels.
Diabetes: Patients with Type 2 Diabetes tend to have more difficulty losing weight. They suffer from a phenomenon called “insulin resistance,” in which the body does not react the way it should to insulin. This slows down the metabolism and patients often gain weight in the mid-section. Diabetes is thought to be underestimated since many patients can be diabetic but experience no symptoms. Thankfully, Wendy’s test for diabetes was also normal.
Medications: Certain medications can cause weight gain, including some antidepressants, antipsychotics, steroids, and diabetes medications. Wendy is a healthy young lady who is not taking any medications.
Stress: Certainly, those patients with elevated stress levels can cause weight gain indirectly. When patients are stressed out, they may not pay attention to their nutritional intake, forgo exercise, or neglect to take care of themselves like they should. Many use food as a soother, and heavy comfort foods may be the first thing they reach for. Having a baby can certainly be stressful, and no one would fault Wendy for that. However, she is adamant about maintaining her diet and exercise regimen despite this stressful situation.
Menopause: When estrogen levels decline, our metabolism tends to slow down. Some women nearing menopause tend to start gaining weight, especially in the mid-section. It can be caused by mood changes or lack of sleep that trigger high-carb snacking or the decline in estrogen itself, both of these cause a physiologic change in fat deposition. Wendy was only 38-years-old, and nowhere near menopause. The average age for starting menopause is 51 in the U.S.
So what could possibly be causing Wendy’s weight gain? She didn’t seem to fit the profile of any of my top causes of weight gain. She was eating right, exercising enough. She told me that she was not having intercourse, so she can’t be pregnant.
But when I sent her to the lab for thyroid and diabetes tests, I added one more test – a pregnancy test – just to be on the safe side. And sure enough, she was pregnant! I called Wendy to tell her the news. Needless to say, she was totally surprised. “But I have had relations with my husband maybe once, at the most twice, since my baby was born!”
This was a good case to remind me of two lessons:
All it takes is once to get pregnant.
Pregnancy is possible even if your periods are irregular or not yet returned due to breastfeeding. Women may ovulate, even though they are not menstruating.
Wendy was quite shocked, but was truly happy once the news settled. She was also relieved to know that there was a reason for her unintended weight gain. She went on to deliver a healthy baby boy.
How did you deal with unintended weight gain? How did you shed those extra pounds? Share it with us on the House Call Doctor’s Facebook and Twitter pages!
Please note that all content here is strictly for informational purposes only. This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your own personal health provider. Please always seek a licensed physician in your area regarding all health related questions and issues.