Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today's episode, this is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight podcast. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone. I am so excited today to bring on a guest. This is Dr. Caissa Troutman. She is an obesity medicine physician like myself, but also specializes in the menopause space and supports patients with their sleep as well. And today we are going to have a conversation about the overlap of all of those things. We know that weight is impacted by so many things in our health, whether it is our hormones, whether it's our food, our movement, our sleep, our stress, all of these things combine together. And so it's amazing when we can work to support patients in this comprehensive way. And that is what Dr. Troutman does in her practiced weight remedy. She is located in Pennsylvania. Dr. Troutman, thank you so much for joining us today. Dr. Caissa Troutman: Well, thanks for having me, Sarah. Dr. Sarah Stombaugh: Yes, absolutely. Tell us a little bit about yourself and how you came to be practicing in this way. Dr. Caissa Troutman: Absolutely. So my name Caissa Troutman. I'm a quadruple board certified physician. I'm board certified- Dr. Sarah Stombaugh: Quadruple? I'm impressed! Dr. Caissa Troutman: I'm board certified in culinary medicine, so we have that extensive nutrition background, obesity, medicine like yourself. I'm also board certified by the Menopause Society and I'm a family medicine by training. So my practice, which is a direct care practice I opened really is I would say started out with me search. Everything that affected me is what drove me into looking into all my current professional accomplishments. I am a patient that struggled with obesity and have struggled with it my entire adult life. And just like many of my patients felt that it's my fault I'm broken, something's wrong with me, why can't I lose weight kind of mentality. And when I realized the science of obesity medicine that it's not my fault and it's in my brain, it was very empowering and I lost the weight and have kept my own weight off around 30% of my total body weight off using the same principles that I teach my patients, which as obesity medicine physician, we talk, not just, but we talk about the meals, movement, mind and medication. Right, the nutrition, physical activity, behavior change and FDA approved meds to help. Dr. Sarah Stombaugh: Yes, absolutely. Okay, I love that. And it sounds like your personal passion has driven you into this place. Dr. Caissa Troutman: Absolutely. And I think that's what makes us good physicians. If it's hitting a certain point in our life where this is how I can best help my patients, if I could do it, they certainly can do it. You know what I mean? And it's definitely not willpower. That's the main thing. So many of our patients that struggle with weight really feel that it's their fault. And then the other side of my practice is I prescribe FDA approved hormone therapy for women struggling through perimenopause and menopause because again, alert, I am a woman going through perimenopause and it's the same research sources. It's like, okay, what's going on with me? Why am I not feeling like myself? And that I put air quotes on that and that again led me to understanding. And interestingly enough, my main issue, it was insomnia, which is kind of why I did the cognitive behavioral therapy for insomnia and really found out that perimenopause, in perimenopause insomnia is actually a very, very common struggle that women in midlife face. Dr. Sarah Stombaugh: Yeah, absolutely. So tell me a little bit about that overlap, because it makes sense, the science of it, and a lot of women are struggling with the same, especially that triad of issues, weight gain either prior to and then compounded by menopause, the hormonal hot flashes and sleep changes, and then maybe sleep issues in general, which are worsened during menopause. So tell me about the overlap of these things. Dr. Caissa Troutman: How many minutes do we have? Just kidding. Yeah, so I mean, I think the thing I always encourage my patients who think about is, again, it's not about calorie in, calorie out, and that is our weight is primarily a dysregulation in our brain. And that central regulation in our brain is controlled by hormones, and these are the hunger hormone, the satiety hormone. But on the flip side is also insulin hormone and cortisol hormone. We know with menopause perimenopause, the insulin hormone is affected so so-called insulin resistance, which is a change that occurs simply because we are losing estrogen or estradiol or have that fluctuating levels. And on the other side, when we do not sleep well either having insufficient sleep or non restful sleep, then our cortisol goes up, which also increases our hunger hormone, ghrelin and leptin. So it is a very complicated intricate dance between all these hormones, which I think makes it challenging and makes, again, every person is different, right? No two patients will have the same story. So many ways it can change for everyone. Dr. Sarah Stombaugh: Absolutely. Well, tell me, when we think about menopause, I think so many women identify with regardless of what their weight was going into the perimenopausal years, that all of a sudden them doing the exact same thing and now the weight has just stacked on. So you sort of alluded to with insulin and cortisol, tell us a little bit about why that happens, Dr. Caissa Troutman: Right? Yes, absolutely. I mean, for anyone listening that has said those words, just so you know, we believe you. I mean, that's the first thing I think we need to any providers listening, I think we want to validate that truth because that is really a very common subject or complaint that patients bring up. So I always validate my patient's concerns. Very true. So I think maybe let's start with some definitions. So menopause is literally one day, and that is the 12 months after the last menstrual cycle. However, the symptoms of menopause aka, the symptoms of the fluctuating levels of estrogen, progesterone and testosterone happen way before that one day. And studies have shown perimenopause, which is literally the number of years it's defined as the number of years before that one day the symptoms can start 10 years before LMP [last menstrual period]. So you have those 10 years of weight gain, insomnia, anxiety, et cetera. So does that happen? Yes. So when we have the either fluctuating or lower levels of estradiol, so first of all, one of the things I always encourage with my patients is just recognizing that estradiol, estrogen is a hormone, and it's not just a sex hormone. It's actually a hormone that affects so many cells in our body, from our brain to our heart, to our liver, to the blood vessels. Estrogen is actually and has anti-inflammatory neuromodulation ethics. So that is why when we in midlife, and guess what happens in midlife, right? Midlife is actually when estrogen and progesterone kind of fluctuates, it's very common that our cholesterol goes up without you changing anything. Our LDL goes up, our HDL goes down. It's also very common again that the sugar starts creeping up. So that insulin resistance and what happens when we have also lower levels of survival is what we call deposition of visceral fat. So instead of our excess calories being deposited as well, let's just back up. So there's two types of fat, right? There's the subcutaneous, which is right under the skin, and our visceral fat, which is the type of fat that's located around our important organs, specifically in our belly, which we don't like that Because visceral fat is actually very metabolically unhealthy. So it's the one, if it's higher, we actually have higher risk of heart disease. And that then feeds the insulin resistance. So basically it's insulin. When we go through perimenopause or menopause and have lower levels of estrogen, we have that higher insulin resistance. And the second factor that makes that happen is actually we also have less muscle mass. So I think it's at 30, it's a certain percentage of muscle mass loss that is expected and that so you match a lower burning ability of the calories plus a less efficient way of metabolizing our calories. So that creates that weight gain. Dr. Sarah Stombaugh: Yes, absolutely. And so we've got this effect. I mean, estrogen, as you said, works throughout our body. We think of it as a sex hormone. We think of it as a hormone just in women. Interestingly, men have a little bit of it too. And it has all these roles and things like brain fog and mood changes and heart health and weight and all of these things, bone health, muscle health, as you said, all compound together. And so we see the impacts of that, which may be much more significant below the surface, but then we see it outwardly in our weight because we wear our weight on the outside of our body. So a lot of times that is the thing that patients may be coming to us as clinicians and saying, yet we know that that is a sign of a lot of other things starting to happen here. So I'm curious, when a woman is telling you that, what are you doing in terms of evaluation then, and how are you supporting her medically from the hormonal piece? Dr. Caissa Troutman: Yeah, so there's different ways. The first thing I always explain to my patient is what's happening, right? It's normalizing what's going on, and they're not going crazy. Again, it's just that non-stigmatizing. It's not your fault. This is a normal transition of a woman's life, but you do not have to suffer the symptoms. Suffering is optional. There are ways, strategies that a person can do to help with the symptoms, and there are of course lifestyle strategies. So for example, CBTI, cognitive behavioral therapy for insomnia is a strategy that I use for my patients that struggle with sleep as we know how we eat and how we move. Our body also affects our general health and our sleep. So talking to them about higher protein, low glycemic intake, higher protein, higher vegetables, higher good fiber water. So all the things that we normally would talk about. And then on the other hand, those that are specifically interested in FDA approved hormone therapy in the form of estrogen, progesterone, and testosterone. I clear out the misconceptions. There is so many misconceptions and myths about it. And honestly, the data, even though it's not advertised, is that for majority of US adults, US women, hormone therapy is safe. Again, that's not a blanket statement, but that's why I think every patient, every woman needs to have that individual risk benefit discussion, especially if they're within 10 years of menopause. Dr. Sarah Stombaugh: Absolutely. I feel like as a medical community, we're really seeing the tide changing on that. When we look at studies like the Women's Health Initiative that came out about two decades ago, there has been so much more data to say, for a while, we were very concerned that there were negative health consequences from hormone replacement therapy, but really over the last decade, we've started to revisit some of that data and see where there are really significant benefits for potentially Yes. Yeah, it about time. Yeah. And I feel so lucky. What's that? Sorry. Yeah, no, I feel so lucky to be one, able to be at a stage of my career where I can really support patients with this, and I am not yet perimenopausal, so I'm like, let me learn all of these things so that when it comes my time, I know exactly what to either do or how to advocate for myself best. So excellent. I'm glad to hear that you're supporting your patients in that way. Dr. Caissa Troutman: Well, what's funny to know or here is did you know perimenopause can naturally start at age 35? Dr. Sarah Stombaugh: Okay, I'm 36. Dr. Caissa Troutman: So the symptoms, so it's so funny when I look back at my own life, I mentioned about insomnia was my main symptom, but once I looked back at my life using the lens of what I understand with hormones and estrogen, progesterone, testosterone, and I wear those glasses or lens, I was like, oh my God, that's probably me going through perimenopause or Oh my God, that's probably, so I literally counted around 15 symptoms, obviously not happening all at once, but just Oh, that dry eyes. I thought it was just, I'm looking at the computer, it's probably the or. There's so many things. Dr. Sarah Stombaugh: Yeah, that sort of hindsight is 20/20. You can look back with that lens and see it. Dr. Caissa Troutman: Yeah. So you talk to me after this and see. Dr. Sarah Stombaugh: Yeah, exactly. Exactly. Tell me, in terms of the sleep piece, I think there is that classic woman who's in perimenopausal years who's dealing with hot flash symptoms, the movie or story where she's throwing off all the covers, and that's certainly the case, but sleep issues can present in other ways as well. So tell us a little bit about how women in the perimenopausal years may also be dealing with sleep issues beyond just the hot flashes. Dr. Caissa Troutman: Absolutely. Yeah. So they've actually done studies to evaluate women that's going through perimenopause, menopause. And yes, if we have hot flashes, that can certainly contribute, but the sleep disruptions, when they've done the sleep tests happen out away, not even related to hot flashes. So that's one we would have that sleep awakening simply because of the estrogen fluctuation or change. Also, the second issue is in perimenopause menopause, there are other sleep disorders that are more prominent. For example, sleep apnea actually becomes more common or becomes more prevalent when we're in perimenopause. And that has to do with less estrogen, less collagen support for the structures anatomy supporting the airway, so more floppier so that can preclude or not preclude them to sleep apnea. Restless leg is another one that becomes more common also in perimenopause, manuse because usually the anemia, thyroid, et cetera. So we have the sleep disorders that are more common because of perimenopause, menopause or the change of estrogen. And again, the fluctuation or lower estrogen also affects the sleep cycle. So normally we have four sleep, four stages of sleep, non REM and REM, and there's some data that the low estrogen affects certain areas of the sleep cycle that again, you have that sleep disruption or lower quality of the sleep. Dr. Sarah Stombaugh: Very fascinating. Absolutely. Go ahead. Dr. Caissa Troutman: I was just going to say that it just affects, again, it affects everything. And also what happens in menopause per menopause is progesterone also goes down, and progesterone is a hormone that affects the GABAergic pathway in our brain, and that's really more the relaxing kind of type of neural activity. And so very commonly that would be the patient that I actually would probably start a patient that struggles with that kind of initial symptom would be somebody that would benefit from progesterone. Dr. Sarah Stombaugh: Yeah, absolutely. And interestingly, progesterone is the main hormone that we see go through the roof in pregnancy. And the one that really drives fatigue, for example. And so if you think you've a woman who's been pregnant and you think to that very early stage of pregnancy, we're like, why am I so exhausted? The progesterone just going through the roof is a big driver of that. And my husband is an anesthesiologist, actually, and there are some really interesting rodent studies where they use progesterone alone to anesthetize rats. And so it's interesting because the progesterone can actually cause breaths to fall asleep, which is wild. And so when we're supporting people when they're having those low levels and they're having insomnia, they're having especially onset issues, the progesterone piece can make a huge difference there. But I always thought that was so fascinating. Dr. Caissa Troutman: And I think the background, because again, progesterone is pro gestation, so to support the pregnancy, but there was some theory, it's so that the women don't panic when they're pregnant. It's like, sure, you just got to calm the mom down. Dr. Sarah Stombaugh: Yeah. Oh, that's so interesting. So tell me, when we think about then treating some of the sleep disorders, obviously understanding if there is a true sleep disorder versus if this is really solely in the picture of hormonal changes, for example, it still will require this medical piece plus this behavioral piece. And I think the bridge of those two things in so many areas of medicine where we can both support people with what is the underlying medical physiological problem, and there may be a medication that can directly support that, but the behavioral piece is really important as well. So speak to me a little bit about that piece Dr. Caissa Troutman: For sleep, particularly? Dr. Sarah Stombaugh: Yes, absolutely. Dr. Caissa Troutman: Yeah. So there is this component called CBTI or cognitive behavioral therapy for insomnia. Sounds like a fancy name, but really the idea is learning the skills of sleep. There's actually five skills, it's cognitive reframing or changing your thoughts about insomnia. Two would be sleep efficiency training, basically making sure the time you're in bed is the time that you are primed to sleep. Three is stimulus control. It's just where our environment for sleep is. Again, supportive of a going to bed. Four would be the relaxation training where again, it's helping you to go to sleep as opposed to being in that active sympathetic stage. And five would be sleep hygiene. So sleep I think gets thrown around a lot. And I remember the word sleep hygiene gets thrown out a lot, I should say. And I remember an analogy that was given to me. When you go to dentist, you have a dental hygiene cleaning, that's when you are not having any issues with your teeth. So when you have insomnia, sleep hygiene is not going to work. Dr. Sarah Stombaugh: It's just a small piece of the picture. You need all the treatment piece of it, right? Dr. Caissa Troutman: So that was like, oh, yeah, that makes sense. You see all sorts of sleep hygiene, tips kind of being given out, and they're amazing and they could be helpful, but they're really more for patients that have, for the most part, great sleep, good sleep, one who's truly struggling with insomnia, the sleep skills, even if one of them or all of them can be very helpful. Unfortunately, there's not a lot of licensed CBTI. There are some online sources or resources that, and I think they're a great help as well. Dr. Sarah Stombaugh: Absolutely. Well, I really love that analogy with a dental hygiene because if someone came into a dentist and had a cavity, you wouldn't tell them to go brush their teeth. You wouldn't tell them to just do basic hygiene. There would be a more aggressive treatment for that. I don't know enough about dental care to talk more about fillings and preventative stuff, but for insomnia, then. Yeah, it makes a lot of sense that are we working on these other components and actually treating the underlying cause in addition to the hygiene being in place that should be in place for all of us, Dr. Caissa Troutman: Right? Right. Exactly. Exactly. Yes. You said it better than I did. Dr. Sarah Stombaugh: No, that was a great analogy. I'm absolutely going to use that because I think I've probably even in my own practice, been guilty of having some of these conversations because I'm not CBTI trained. I'm not a sleep specialist, and I certainly refer my patients to those providers when it makes sense. However, a lot of people are struggling with sleep issues in some capacity or another, whether it's even a short-term thing or a long-term thing. Dr. Caissa Troutman: Right? Yeah, I mean the statistics, I forgot, CDC is high. It's like 60% or something like that. I mean, in our environment, our society is productivity and rest is the last thing that we prioritize, which is very sad because just like a cell phone, if the battery is low, it's not going to function. So same thing when our brain is not getting the rest it needs, the sleep it needs. If it doesn't get in that deep sleep, that REM sleep, you're not going to, I mean, our brain is meant for sleep, is helpful for memory consolidation for a lot of the normal housekeeping that the brain does. And if you don't get that, you just feel sluggish, anxious, depressed, I mean so many things and gain weight. Dr. Sarah Stombaugh: Yes. And for my listeners, talk to me about the role of sleep in weight, because I think as you were saying, our society, a lot of people don't really value sleep. You hear things like, oh, I'll sleep when I'm dead. And sleep is a lot of times the first thing that people will sacrifice when they're trying to put more things onto their plate or when they're trying to tackle and manage a lot of things. So sleep is really important, and we hear that, but answer for me, why is it important, especially in the context of our weight, Dr. Caissa Troutman: Right? Yeah, absolutely. So I think the first thing that we want to remember is that weight is based in our brain, and there's specifically two major components of that is the homeostatic or the biological regulator, which we talked about a little bit earlier, and the hedonic system, which is driven by wants and desires. So when we do not get enough sleep, ghrelin, which is the hunger hormone and leptin, which is a satiety hormone, they get dysregulated in that first part of the brain. I mentioned that biologic regulators. So what happens is no sleep or minimal sleep, ghrelin goes up. So I'm so hungry, leptin goes down, I'm not never full, which leads to that behavior of eating more food or getting more energy and getting more food. And then the impact of lack of sleep on the hedonic pathway is that I want, normally we don't want broccoli and carrots. Normally we want high calorie, high fat foods, which is usually in the form of sugar processed foods and stuff. And several studies have shown that inadequate sleep, insufficient sleep actually increases our desire for hyper palatable, I think they call it foods. Absolutely. Which again, increases. So that increases again, that energy intake. And then conversely, when we don't sleep, it affects insulin resistance, which then means that our ability to process that on the energy expenditure side of the picture is less, it gets deposited more. So insulin is again that storage hormone. Right? Dr. Sarah Stombaugh: Yeah, absolutely. And an analogy I use a lot is your body needs energy. And a lot of times when we've not gotten adequate sleep, our body starts then looking for food to sort of replace that energy that should have come from sleep. But now we're looking to food to sort of give us that boost of energy. And it does, when we eat certain foods, especially those hyper palatable foods, things that are high in sugar, things that are high in flour, things that are really fatty or processed fats especially, they give you sometimes that burst of energy. There's the crash that comes down from it, but your body is sort of looking and seeking for those foods. Dr. Caissa Troutman: And I think there's also more time to eat if you're awake more or if you're not sleeping because cramming for a test, which I mean, I'm going to raise my hand and I did that, or eating to stay awake. Everybody has different reasons for having those issues. Dr. Sarah Stombaugh: Yeah, absolutely. And then tackling that as we were talking about both from that medical piece, but then also from those behavioral piece, because those two things always go hand in hand in medicine. Dr. Caissa Troutman: Oh, yeah, absolutely. And I just don't think it can go back to just here's a medicine. No, no. Dr. Sarah Stombaugh: No, absolutely. And I think once you start to understand and in practices like yours or mine where we're able to spend a bit more time with patients, really work through some of those things, it's such a pleasure to be able to support patients in that way where you get to pull out both the medical piece and the behavioral piece. I think that's just where the magic is. Dr. Caissa Troutman: Yes, a hundred percent. A hundred percent. Dr. Sarah Stombaugh: Excellent. Well, tell me, Dr. Troutman, as we wrap up, is there anything you haven't had a chance to share with my audience that you think is really important for them to know? Dr. Caissa Troutman: Well, if ever there's one thing, I would say something to the effect like advocate for yourself, whether you're a person struggling with weight or a woman going through perimenopause or both, there is a biological reason why this happens, and there are biological ways to treat both conditions, helping with weight and or helping with the fluctuating transition of life with perimenopause and menopause. Dr. Sarah Stombaugh: Yes, absolutely. Thank you. I think that message abdicating for yourself is really one of the most important things you can do, probably just in life in general. And I'm so pleased that in the healthcare space, we're starting to embrace patient advocacy as well. Dr. Caissa Troutman: Yeah, for sure. Yep. Yep. Dr. Sarah Stombaugh: And tell me if people are interested in learning more about you with working with you, where can they find you? Dr. Caissa Troutman: Yeah, so I am licensed in the state of Pennsylvania, so I have a brick and mortar practice in Camp Hill, but I also see patients via telemedicine. My website is www.weightremdy.com, and I'd be happy to help anyone going through struggles with weight and or seeking FDA approved hormone therapy for their perimenopause and menopause symptoms. Thanks for having me. Dr. Sarah Stombaugh: Absolutely. Yes. This has been wonderful. We'll make sure to put all of your information in the show notes. So for any of our listeners who are looking to learn more, especially about this transition through perimenopausal years, the impact that has on weight, and if anyone's in Pennsylvania that they definitely should seek you out. I am not licensed in Pennsylvania, and I absolutely will give you my endorsement. And so thank you everyone for joining us today. We will see you all next week.