Weight gain in middle age is challenging and very common.

I see many women over the age of 40 that are frustrated with their weight. They are eating healthy and exercising, but the extra weight just won’t come off! Some women even decide to “clean up” their diet and hit the gym even harder but still…no change. Weight gain has been said to be nothing more than your body’s chemical reaction to foods. It’s not that you’re eating too many calories or not exercising enough. It comes down to 2 things: hormones and inflammation.

As women go through their middle years, their body composition changes in proportion to fat.

The proportion of fat to body weight tends to increase (more than men), and fat storage begins favoring the upper body over the hips and thighs. In other words, your waistline starts to grow in inches as visceral fat (the fat that wraps around your abdominal organs) pushing out against the abdominal wall.

What we have learned since the mid-1990’s, is that the fat cell is an endocrine organ, secreting hormones and other molecules that have far-reaching effects on other tissues. There are a host of chemicals that link visceral fat to a wide variety of diseases.

While subcutaneous fat produces a higher proportion of beneficial chemicals, visceral fat produces chemicals that are far more harmful. Visceral fat makes more of the proteins called cytokines, which triggers low lying inflammation and is a risk factor for heart disease and other chronic conditions. It also produces a precursor to angiotensin, a protein that causes high blood pressure.

We know that there is a hormonal mechanism that perpetuates middle age weight gain (obesity) through eating high glycemic foods. Foods that have a high glycemic index pack alot of sugar into a small package. High glycemic foods cause a fast rise in blood sugar resulting in insulin release. Highly processed refined carbohydrates are absorbed quickly, increasing insulin levels that can result in rebound hypoglycemia and insulin resistance. These mechanisms increase insulin sensitivity in adipose tissue but create insulin resistance in muscle and brain. Over time, fat accumulates viscerally while less is taken up in the muscle. Your body continues to make more and more insulin which leads to metabolic dysfunction, inflammation, weight gain, fatty liver and plaque development.

Other research by Mengeste and colleagues describes the characteristics of muscle between obese and lean people.

The obese muscle changes its composition to a muscle fiber (type 2) that is less able to utilize sugar for energy. This is because the number and function of mitochondria decline. These muscle fibers fatigue more easily than the dominant type 1 found in lean people. This is where exercise is so important but initially will not result in quick weight loss because the muscles are less able to absorb and burn energy.

What Does This Mean and What Can We Do?

All calories are not the same. Carbohydrates that are refined and have less fiber get absorbed very quickly and trigger hormones that allow the accumulation of fat. This changes muscle fibers and its function, making weight loss and exercise more challenging. So eating less and exercising more just doesn’t work…especially in middle age. High quality food is key.

So what can we do after age 40 (or even after age 35!)

1. Eat more multicolored fiber-rich whole foods
2. Eat more fiber and protein with a carbohydrate to slow absorption
3. Drink a glass of water with 1 tsp of psyllium husks (or any soluble fiber) before meals to help reduce the glycemic index of a meal. Here is a patient handout on glycemic index/load.
4. Do not use artificial sweeteners. They can actually exacerbate obesity
5. Try to sustain good nutritional and exercise habits over time to increase type 1 muscle fibers. These muscle fibers have more mitochondria to help burn sugar and fat while increasing muscle endurance.

 

References

1. 1. Ludwig DS, Aronne LJ, Astrup A, et al. The carbohydrate-insulin model: a physiological perspective on the obesity pandemic. Am J Clin Nutr. 2021 Sep 13. doi: 10.1093/ajcn/nqab270. Online ahead of print. https://academic.oup.com/ajcn/advance-article/doi/10.1093/ajcn/nqab270/6369073
   2. Mengeste AM, Rustan AC, Lund J. Skeletal muscle energy metabolism in obesity. Obesity. 2021;29(10):1582-1595 https://onlinelibrary.wiley.com/doi/10.1002/oby.23227
   3.  Jovanovski E, Khayyat R, Zurbau A, et al. Should Viscous Fiber Supplements Be Considered in Diabetes Control? Results From a Systematic Review and Meta-analysis of Randomized Controlled Trials. Diabetes Care. 2019;42(5):755-766. https://care.diabetesjournals.org/content/42/5/755.long

 

People that had SARS-CoV-2 infections may think that they have “natural immunity” and are protected from getting re-infected from this COVID-19 virus. But there are 2 new studies showing evidence that vaccination generates a more vigorous B and T cell (immune memory cells) response than does natural infection. It shows that vaccination is particularly stronger in people with previous SARS-CoV-2 infections.

Researchers evaluated people who were vaccinated with the mRNA vaccine after natural infection and people who were vaccinated but had no prior infection. Memory B cells against SARS CoV-2 were 5-10-fold higher when vaccination followed natural infection than after natural infection or vaccination alone. The most surprising result was that in people who were vaccinated after natural infections, neutralizing antibodies against the beta variant were higher. They were 25 times higher than after vaccines alone and 100 times higher than after natural infection alone. This was amazing since natural infections were almost never with the beta variant and that vaccines don’t target the beta variant spike protein.

Other studies as well have shown similar results. A study in the CDC (Centers for Disease Control and Prevention) Morbidity and Mortality Weekly report shows 2.3 times the number of reinfections with natural immunity compared to breakthrough infections in those who are vaccinated. It is unclear how effective natural infection is against other variants, particularly the Delta variant. This new variant, as well as the lambda variant, may weaken the protection provided by having been previously infected by SARS-CoV-2.

People who have had COVID-19 are advised to be vaccinated. It will very likely offer better protection against symptomatic reinfections, even with the Delta and future variants.

References: Diamond, F. Kavanagh, K. Get vaccinated even if you’ve gotten COVID-19, study suggests. Infection Control Today 2021, Aug 8.

Stamatatos, L et al. mRNA vaccination boosts cross-variant neutralizing antibodies elicited by SARS-CoV-2 infection. Science 2021 Mar 25; 372: 1413.

 

Deepti Gurdasani is a British-Indian epidemiologist who is a public researcher at the Queen Mary University of London. This is a part of a thread in which she discusses Long COVID and the implications in the community.

 

Several studies have put the overall incidence of long COVID between 10-50% of those infected. Scientific consensus is that Long COVID is not just a respiratory disease but a “real” multi-system syndrome that occurs in those infected- predominantly impacting the young. The Office of National Statistics (ONS) data and REACT-1 data compares symptoms post infection among those infected with control groups of those confirmed not to have infection. These are some of the most robust data on Long COVID based on PCR tests through random nationally representative surveys of thousands of people (ONS data 313, 216, and REACT-1 data 508,707 samples).

Here are some highlights:

Most people present with a combination of symptoms and of the 1 million people affected, 2/3rds said it impacted their day-to-day activity. About 400,000 have had persistent symptoms for over 1 year. Sadly this included 9000 children who have been affected for more than a year. Those with the highest risk factors were women, increasing age, smoking, and low income.  There is strong evidence that even those with mild symptoms can have long-term structural brain changes including thinning of grey matter in brain areas related to smell, taste, memory and emotion. The risk of organ dysfunction was 38.9% in those aged 19-49 years. This clearly impacts a large proportion of young people.

So to summarize, long COVID is common- even in young children with mild infection. It usually includes multiple symptoms, that in many, affects day-to-day lives. Remember that children under the age of 12 cannot get vaccinated. Let’s do our part and get fully vaccinated for ourselves, our families (and children) and our community.

Follow the full thread at @dgurdasani1. Other links are Post Acute COVID-19 Syndrome and Survivor Corps

 

 

Electronic health records were studied at multiple institutions in the U.K. Researchers estimated the incidence of neurological or psychiatric sequela in 236,000 people with COVID-19 infection. During the 6 month follow-up, 13% were diagnosed for the first time with either a neurological or psychiatric condition with no prior history of these conditions. Another 21% of patients who had prior conditions developed new conditions.

These rates were compared with rates in 342,000 people with influenza and other respiratory tract infections. The incidence of neurological and psychiatric diagnoses were significantly higher in COVID- 19 patients. The most common diagnoses were anxiety (17.4%), psychotic disorder (2.8%), ischemic stroke (2.1%), dementia (0.7%) and intracranial hemorrhage (0.6%).

The most concerning were those whose acute COVID-19 infection caused encephalopathy (defined as delirium or other altered mental states). In those with encephalopathy, the chances of developing mood disorder were 22%, anxiety disorder 22%, ischemic stroke 9%, psychosis 7% and dementia 5%.

This large study demonstrates that various psychiatric and neurological conditions develop with a relatively high incidence in 6 months following acute COVID-19 infection in people with or without previous disorders. We need to look for interventions to address these sequela for post COVID patients. It is not just about surviving this infection, but hoping that you don’t fall into the long-hauler conditions that are so debilitating. One site connecting people with these symptoms that provides support and resources is survivor corps.

It is unknown whether the post COVID mood and anxiety disorders are due to the psychological stress of the illness, or that they are triggered by neuro-inflammation caused by the infection. Regardless of whether it’s the “chicken or the egg”, these symptoms are real and thus far unpredictable as to how long they may last.

Reference: Taquet M et al. Six month neurological and psychiatric outcomes in 236379 survivors of COVID-19; A retrospective cohort study using electronic health records. Lancet Psychiatry 2021 April 8:416.