E20: 7 Domains After Weight Loss

There are jillions of websites with advice about how to lose weight. And jillions isn't a regular real number, but you get the point. But that's not what we're going to talk about here. We're going to talk about the 7 Domains after weight loss.

What are the changes in your life that might come after a significant weight loss? Now, the reason for weight loss and the manner in which you might have achieved it will be different. Some women will have lost significant weight loss the old-fashioned way, diet and exercise. Some will have lost weight through bariatric surgery, surgery that changes how your body absorbs food or how full you feel. And this is increasingly used because it's very successful in keeping weight off. And some will have lost a lot of weight because of a health problem. And maybe their health problem is better now, but they find themselves with a new body.

Now, losing lots of weight could cause changes in your mind and your body. We're going to go through some of these changes in the 7 Domains. So let's dive right in and talk about the physical domain.

You could stop getting your period. We evolved starving. So if you go back 100,000 years ago when we were becoming humans, we had periods potential. We had the potential for periods once a month. But usually, we didn't have periods because we were starving. We held on to calories really hard. And especially if we were trying to be pregnant, we would hold on to calories to try to grow a baby. We aren't so good at trying to figure out what to do when we're in a situation where calories are everywhere.

But we still think that we're starving when we lose weight. We think that, "Oh, hard time has come. There's a famine. There's drought on the land. We shouldn't get pregnant." And it's one of the adaptive mechanisms that women have to stop having their periods when they've lost a lot of weight, because the body doesn't know the biochemical mechanisms are to protect you from getting pregnant when you are starving.

It doesn't always work. We certainly know many women in refugee camps who are starving, have low food supplies, still get pregnant. But it's common in women who lose more than 35 pounds, especially if weight loss is rapid, for women to lose their periods.

Conversely, for women who were very obese and had irregular periods associated with that problem of being overweight, and that could be a condition called polycystic ovary syndrome, we know that those women, after they lose weight, may actually start having regular periods.

So for women who are overweight with polycystic ovary syndrome, 10% weight loss may actually renew women's cyclicity, or their regular periods. That's a great thing if you're trying to get pregnant. But if you think you can't get pregnant because your periods are irregular and then you lose weight, you may find that now you're more fertile.

So certainly, massive weight loss can cause a disruption in what your pattern is. If you were regular, you may actually have periods of amenorrhea. And if you were irregular, you may become more regular.

Another thing that can happen is you can have significant hair loss. Your body needs nutrition to make extra things like hair. And we know that sudden weight loss is a significant stress, and many women will notice their hair is getting thinner. That's not unlike the kind of hair loss that is associated with the birth of a child or is associated with general anesthesia.

There's something called telogen effluvium. When there's a shock to the system, and sudden weight loss is indeed a shock to the system, you can lose a lot of your hair at once and then the hair grows back at once.

If you've had your weight loss by bariatric surgery and you're not absorbing enough nutrients, then you may not have your hair grow back unless you're very careful about making sure that you're getting enough protein, vitamins, vitamin D, and biotin. So we know that weight loss makes changes in your hair as well.

Well, you might feel colder. Now, there are two reasons to feel colder if you've lost a lot of weight. You've lost your puffy coat that you wore around with you, but also your metabolism changes. And those changes in your metabolic rate are another protective mechanism. The body doesn't want to burn as many calories because it thinks that you're in a starvation time and doesn't think that this is something you've done for your health.

And it's not uncommon for people who have had very significant weight loss to experience feeling more chilly, more cold. Sometimes, it's important just to get up and move more because that can increase your metabolic rate and make you feel a little warmer.

You might have difficulty sleeping. And you might have noticed this during your weight loss when you weren't eating very much. So carbs help make a certain kind of hormone in the brain that can help you feel sleepy and go to sleep. And if you're hungry when you go to bed, it's difficult to actually fall asleep. Some people who've had a lot of weight loss and are still really restricting their calories and go to bed hungry may find that it's harder to go to sleep.

And so hormones that affect sleep and molecules and proteins like tryptophan may actually improve your sleep. So it wouldn't be a bad idea if you budget in your calories a little carbs and a little protein before you go to bed. And that may be milk. Milk has protein and calories, and it can help you go to sleep at bedtime.

Of course, big weight loss will change how your body looks, and it's going to change your body composition. We know that big weight loss causes people to lose muscle mass. But hopefully, they've lost a lot more fat mass and maintain some of their muscle mass. But it changes your fundamental biochemistry. And it may change some of your neurochemistry, the way you feel.

So the physical domain, let's talk about sagging skin. All of us who have been moms know that our skin could stretch way out when we become pregnant and the skin can stretch pretty amazingly. But it doesn't bounce back quite as well.

Now, when you're younger and some people with genetic resilience in their skin, it can make their skin go back. You know those women who had eight-pound babies and they don't have a single stretch mark. But for people who have lost a lot of weight, loose and sagging skin can be a significant physical problem and they may choose to have surgery for skin reduction. This can be in their arms, in their tummy.

People who have lost hundreds of pounds have skin that adapted to that body size, and now the skin is still there, but the fat is gone. That's a big deal, and there are options for body re-sculpting, and there are people like Dr. Agarwal who can help.

Dr. Jones: Dr. Agarwal is a plastic surgeon with a particular interest in reconstructive and aesthetic surgery, who really has helped women try to find the bodies they're looking for. And this is her specialty. So welcome to the "7 Domains," Dr. Agarwal.

Dr. Agarwal: Thanks so much for inviting me.

Dr. Jones: So I've been thinking a lot in terms of partly the emotional domain. I've been thinking about people who've been obese since childhood, and maybe their obesity itself may have changed the way their bodies would have matured through their teens.

And now, they're in their mid-20s, and they've always been round. They've never been particularly curvy. And now, they have comorbidities. They have diabetes. They may have osteoarthritis. They have been approved for bariatric surgery, and they've been successful, and they've lost their 150 or 200 pounds. But they don't even know how to go back to a body that they never really had. How do you begin to talk to them about what they're looking for?

Dr. Agarwal: I think this is a really interesting topic and it's really important. As you say, there are more young adults being approved for this kind of surgery and are successful in this surgery.

And I'll say that it's a very personal conversation. I think a lot of these individuals who have been obese since childhood have a lot of just fear around even being examined and even talking about their bodies. And they, in some cases, have been hiding their bodies, maybe avoiding the gym, avoiding relationships. It's not as easy always to talk to someone about their bodies when they have maybe shame around them. And even though they're feeling better and healthier, like you said, they haven't really lived in their body in a healthy way or necessarily relationships.

Part of the conversation is really just getting to know them and talk about what would be realistic and what are they hoping for. And that can take a little bit of time. I think it takes time, and support, and surgery . . .

Dr. Jones: And surgery, absolutely.

Dr. Agarwal: . . . to allow them to really feel free. I don't think people talk about that as much when they start having the process of bariatric surgery. They don't really realize that when they walk . . . I mean, this might be sort of shocking, but when they walk, they might hear flapping of skin against skin on their thighs or their belly. And it's embarrassing. And sometimes there are odors. I don't think this is discussed as much. We sure try to introduce this to them.

But it can be this disappointment after this great weight success. They've reached their number and they're so happy, but there can be a . . . not a disappointment, but a realization that they still have ways to go before they're going to really feel confident and have the body that they hoped for.

Dr. Jones: I'm thinking of how successful group therapy has been for other chronic conditions, whether it's polycystic ovary syndrome, or whether it's diabetes, or whether it's cancer. Are there any places where people who are going through this process can meet up with people who've been in this process and have a conversation with people and they can share, and laugh, and giggle with things that someone else who's been perfectly formed all their life may not feel like they can talk to someone about their anxieties about it?

Dr. Agarwal: Yeah. I have some very mixed feelings about that. Absolutely, there are support groups. The concern is that these are, on the internet, groups that they find on their own often. And some of the stories that are shared back and forth might be infiltrated with some misinformation.

Dr. Jones: Oh, yeah.

Dr. Agarwal: I think there are things that are shared that someone will come in and share with me and show a picture of someone else who had this done. And I say, "Well, that's not realistic for you." So I think as much as there is support, I think the bariatric program at The U will be able to direct patients towards proper support groups that have maybe, I guess, some guidance from professionals.

But there's as much good information and good support as there is bad information and kind of fear mongering a little bit. So I would guide people to take all the internet, as we all should, with a grain of salt. But I know there are good support groups out there. I would just caution people to maybe do some homework first.

Dr. Jones: Well, I think the issue is that during the COVID times, we didn't meet in-person. But when it comes to a moderated, meaning with a professional, maybe someone like a behavioral psychologist who does bariatric work, offering post-bariatric support, having someone moderate that. Often people who go online have an agenda, and they have their own personal experience, that maybe the people are not real, or these people, the so-called influencers. And that makes me very uneasy. I'd much rather be in a room with other women, in this case, talking about where we are right now with a pro in the room.

Dr. Agarwal: Absolutely.

Dr. Jones: Meaning a pro who's actually seen a whole lot of patients with a lot of different issues. And it can really normalize what people are experiencing and can keep some issues maybe down a little if it seems to be too personal for one person.

I have a story about a patient that I met when I was a resident who was a young woman who had been obese since childhood and really never had a period. She had kind of an interesting endocrine problem. She weighed about 400 pounds, and her mother did everything for her. She never left the house. And then her mother died. And in the process of not having anyone to feed her or to cook for her, she actually lost a lot of weight.

Well, the long and short of it, she actually got out into the world and she met a wonderful guy in her 30s. And she got married and she got pregnant. But she wouldn't come into the hospital because she didn't want anybody to see her body. And helping her realize that we had no judgments about her . . . We only wanted her to have a healthy baby that she had worked so hard for.

For me, I had never really thought about what it meant to be really isolated all one's life and now have to be out in the world with a body that is different than other people's bodies because she'd lost so much.

Dr. Agarwal: When people come in to consult with us, it can be very sensitive to do an exam. This happens sort of across all groups, but particularly weight loss groups. Some people are very embarrassed to admit that they're having surgery to help their skin be removed, that they should somehow tough it out and get over it and live with it.

And a lot of times, I really just have to look them in the eyes, say, "A lot of people do this. There's nothing wrong with this. This skin won't go away on its own. It won't disappear on its own. A lot of people adapt and live with it. But if it's really making you miserable, surgery is a really reasonable thing to do."

Dr. Jones: Absolutely.

Dr. Agarwal: As long as you have the support and the help. And sometimes I need to talk them down from just being embarrassed to discuss it and say, "It's okay to do this. This is more reconstructive. We're trying to get rid of this skin that's holding you back."

Dr. Jones: Right, just being able to be mobile. Once again, it's being mobile. And when your body is going three directions at once just because skin is not attached to muscle anymore, if it ever was . . . but being able to move freely means that you have to have your skin appropriately tucked in places.

Dr. Agarwal: Unfortunately, we don't have a magic pill or magic laser that can tighten skin yet. If that ever happens, that would be great. But right now, surgery is really the only way to get rid of the real hanging skin.

Dr. Jones: There are many domains that change when you've had a really profound body change, like weight loss. The social domains can be significant. Your relationship, if your person that you're closest to, whether it's your sexual partner or your best friend, isn't with you in this weight loss journey and isn't supportive . . . or maybe you have become so obsessed with your weight loss that you don't have the emotional energy. All of your energy is going into your weight loss process and you don't have the emotional energy for your significant other.

It's not uncommon when any person makes a big change in their life, whether it's a physical change like weight loss, or a psychological change, or a treatment for depression, that the foundational relationship that they have also changes.

This is something worth talking about and saying, "I went through all this, and I'm not the same person that I was before emotionally, or physically, or socially. Can we talk about how you feel about my weight loss? I'm going to be continuing to be quite focused on maintaining my weight. Can you help me with this?" or, "Do you think now that I've reached my goal weight, that everything is going to go back the way it was? Because I really don't want it to go back the way it was. I'm not going to go out eating with you. I'm not going to go out drinking with you."

So this is a stress on some relationships, and trying to talk with your partner or maybe get some counseling together to make sure that you both are on the same page.

Dr. Agarwal: The one that's really coming to mind right now, I think, because I saw her more recently is someone who . . . she lost the weight all on her own. She was one of the ones who . . . she started with the bariatric program, but within their program, they have a nutritionist. A number of patients . . . I don't know the percentage, but I think it's the minority. But they're able to lose a substantial amount of weight just with help of the nutrition team and endocrine team, medically managed weight loss.

This woman was early 60s and had been obese her entire life. But what stands out to me is her husband was such a cheerleader for her to do this. I think that was so encouraging to have someone by your side.

And one thing that's always neat to hear is when the partners say, "I love you exactly how you are. You don't have to change a thing," and then the individual, the patient, is able to say, "I want this for me," and the partner is able to absolutely support it but they don't feel like they're doing it for their partner. I think that's a setup for just feeling bad about themselves.

Dr. Jones: Oh, yes.

Dr. Agarwal: But it was neat to see their relationship because she clearly wanted it for herself. And he clearly adored her no matter how much loose skin she had. He was so proud of her to see her come in each time wearing cuter clothes and telling me about how she wore a bathing suit for the first time in 20 years and going on vacations.

I do the operations, but when they come back for follow-ups one week, one month, three months, six months, you see them really blossom into the activities that they've always wanted to do but were held back. And that's really one of the joys of the job.

Dr. Jones: Right. They will show you their little selfies at the beach.

Dr. Agarwal: They do.

Dr. Jones: You get to see them outside your clinic being successful with their new bodies, in whatever life they're shaping for themselves. And often, their diabetes has gone away, and their hypertension has gone away, and their joints, which they thought they were going to need a knee replacement, and now they're feeling pretty good. It's really an amazing new birth. It's a rebirth of hope about what kind of life they can lead.

Dr. Agarwal: The transformation in just a short period of time relatively, say, over six months when everything is healed . . . In the very first visit when you have someone who's so just self-conscious, and you almost have to just pry the gown off to do a quick exam, and then to come back at six months and they're whipping off their clothes and saying, "Here, take my pictures." The confidence is so fun, to see that transformation in somebody.

Dr. Jones: All those things are important, and that's why we talk about the 7 Domains of any particular topic. It's the emotional domain. It's the environmental domain. Imagine being able to get on a plane and not take up more than your seat. That'd be great.

Dr. Agarwal: Right. These are things you don't necessarily think about unless you've been in that situation.

Dr. Jones: That is a new person with a new outlook and being able to give of themselves now that they are feeling strong.

In the emotional domain, we don't completely understand why a significant percent of people who have had very dramatic weight loss experience depression. Researchers in England observed 2,000 overweight adults for four years. And subjects who lost a significant amount of their body weight were 78% more likely to report depression.

And we don't know whether this is a neurochemical problem, the way your brain works when you're starving or when you've reset your body weight, or your expectations were that everything was going to be wonderful if you just lost weight.

For people who've been obese all their life, they really don't know what their social, and emotional, and physical self is going to be. And when they get there at their goal weight and find that everything is not completely ducky, they can have a loss of expectations. And that can lead to depression.

Now, this is where, in the process of your weight loss process, being in touch with yourself and being able to reach out if you need help . . . if you find that you're depressed, if you find you've done all this hard work, and you don't feel wonderful, getting someone to help you would be really important.

Dr. Agarwal: Going through a transformation like this, people have to dig down really deep. There's pain involved, physical pain. There's a lot of adjustment. There are adjustments with people at work, with people at home. I think the resiliency of individuals really comes out.

A lot of people lean towards maybe meditation, maybe it's their church, maybe it's just loved ones. I think everyone has their own what holds them up when times are tough. But this is a tough time.

I think one thing we try to do is let people know that this is a hard journey. Surgery is not easy. And it's not like you're just going to go in and walk out like a hair salon or something. You go through it. It's a few months. And you get to know your surgeons really well. You rely very much on your team and your family. And I think whatever tools that you have . . . like I said, down deep you learn what's going to hold you up when times are tough.

Dr. Jones: I think that's exactly right. It's what holds you up when the going gets tough. And often it can be family, or it can be this kind of reliance on something that's bigger, or knowing where you find things that make you feel like you're part of something bigger. Whoever you are, that you're okay, and this transformation is going to be part of you but your inside is still beloved is really important.

Dr. Agarwal: That's right.

Dr. Jones: Well, Cori, thank you, and I'm going to let you go.

Dr. Agarwal: All right.

Well, let's talk a little bit about the financial domain. Certainly, people who've lost a lot of weight may find that they want to have surgery or weight loss surgery to re-sculpt their body, to change the skin, and maybe have a breast augmentation now that their breasts are deflated after so much weight loss. And that certainly can be something that's financially demanding because your insurance may not pay for this.

But let's talk about something more fun, and that's shopping for new clothes. Maybe if you're like me, you have some boxes of clothes. You've got your fat jeans and your skinny jeans. You've got clothes that you used to wear before you had that baby, before you got pregnant, when you weighed 40 or 50 pounds less, and you've just been keeping them hoping that you could wear them again someday.

Well, good for you. You already have a wardrobe that's waiting. But your wardrobe may be 30 years out of date and they don't wear clothes like that. Your bell bottoms that you wore when you were 18 aren't exactly in style.

Or maybe you have been overweight all your adult life since you were a teen. Now, you've had bariatric surgery, you've lost 150 pounds, you've never had a small body, and you're not even sure what kind of clothes you should be wearing.

So if you don't have your fat jeans and your skinny jeans like I do, or your fat clothes and your skinny clothes, what do you do and when do you think about going on a shopping spree?

The first thing is don't spend a lot of money all at once. First of all, your body may not be exactly where you want it to be, even though you've lost a lot of weight. So going on a big shopping binge may not be just the right thing.

Find out what your body really looks like. Maybe you were hoping for the perfect hourglass body. You were kind of a round person and you were hoping for a figure eight person, but that didn't exactly happen. Weight doesn't come off exactly the way it went on. So even the body that you had when you were much thinner, that may not be the body that you have right now.

So get your measuring tape out and measure your body and see what kind of clothes might work best for you. Maybe back when you had an hourglass shape, certain clothes would be great for you. But now that you've lost weight, maybe that's not exactly your body style.

What kinds of things can you do while you're trying to figure out exactly what your body is? Well, I think stretchy pants, which can accommodate big and small people, are great. And you can wear a tunic top with a belt that you can continue to let in and out as your body is readjusting.

And here's a little joke. This is a joke you have to do in your head. You have to think about this. What did the zero say to the eight? Nice belt. Well, that's just a little joke. But it turns out that you can adjust your clothes if you wear a tunic top with a big belt. And that would be something that you can accommodate as you're getting used to your new body.

You can reward yourself with some pretty things, something really pretty that fits you exactly. You can go and have someone help you buy that one thing that will just make you feel really terrific.

And if you have old clothes that are your favorites, there are people who are very, very talented at sewing who can help you take them in.

So before you spend a lot of your hard-earned money on a brand-new wardrobe, think about the understanding that although your body is new, it's not really done with its rearranging. So you might want to wait a little bit and get things that you're comfortable wearing while you wait until your body settles in finally.

One of the discouraging things about weight loss is that a significant percent of people, 80% in fact, gain most of their weight back. And most everybody who watches TV knows this is true. About 20% of dieters who start off overweight are successful in keeping their weight off. And in the intellectual domain, what are the tricks that make the people who keep their weight off different than people who gain their weight back?

Well, one of the first things is that people, once they get to their target weight, think that they're all done with dieting. And in fact, that's not the case. Once you started to make serious changes in the way you eat that allowed you to achieve your weight loss goals, being very careful about how many carbs you eat, and watching your fat, and watching your calories, most people will have added exercise to their diet routine, most people have gotten on the scales once a week, those things you are going to have to continue to do. The number of calories you need every day is so much less than it was when you were 35, 50, or 100 pounds more.

So that's a biggie. You're going to have to be very careful about watching.

And one of the best bits of advice that I've received as someone who's been yo-yo dieting for most of the last 50 years is that people who are successful weigh themselves once a week while they were losing weight, and they weigh themselves every day to every other day while they're trying to maintain.

Why would that work? Getting on the scales once a week means that you're not hyper-aware of the little ups and downs that might happen in a week that might discourage you from your weight loss plan. So once a week, most people will see some success most weeks, once a week.

Why does getting weighed every day to every other day be an important part of your weight stabilization? It's a lot easier to get on the program for one pound than it is for five pounds. So being back on the scale without being too obsessive, but being able to make the changes that you already know how to make to get yourself back on target if you spent a weekend partying and eating the way you know you probably will have to deal with later on. So regular weighing in is an important part of being successful with weight maintenance.

The other thing seems to be exercise. Just because you were successful at getting to your goal weight doesn't mean that you can stop your exercise. People who are successful in keeping their weight off were pretty compulsive about their exercise.

Some studies have suggested as much as 200 minutes of moderate physical activity a week. That's only 30 minutes a day. And that's recommended for everyone anyway.

Another study pitched it a little bit higher, at about 2,200 calories a week or about 300 calories a day, which is about an hour a day.

So an hour a day walking can be built into most people's lives, and you don't have to do it all at once. But clearly, people who stayed on their exercise routine, or if they didn't have one, now that they're feeling a little more fit, they might be more willing to go out and spend some time walking with a buddy or doing some weight training. Both of those are going to be important in maintaining your weight.

And weight training itself helps you build back muscle that you might have lost. So building your muscle back up using those muscles and weight training, trying to get some cardio in, and being consistent, people who do that are the ones who are most successful in their weight stabilization over time.

The last thing of many things is that people who are successful have maintained the dietary changes that they made that helped them be successful. They were good at eating a fair amount of protein, because protein not only takes more energy to metabolize, but it also makes you feel a little fuller, and they eat more fiber.

So people who are successful in maintaining their weight loss have been people who are eating a fair amount of protein, and they're eating more fiber, and they're really careful about their refined carbs.

There we go. For those of you who've been successful and you've lost all this weight and you're maintaining your goals, but you're not exactly where you want to be in terms of your body, your finances, your emotional, and social, here are some tips to help you be successful with your new self.

We're going to finish with a haiku, and this is the 7 Domains After Weight Loss haiku.

The numbers look right
But what is this new body?
Just take a deep breath