Identifying Cause of Your Weight Gain (Questionnaire)
15 Jun 2007 02:59:21 PM
DO YOU HAVE A FUNCTIONAL OR MEDICAL ISSUE CAUSING
WEIGHT GAIN?
A SCREENING QUESTIONNAIRE
NAME_________________________________ DATE______________
Insulin Resistance
Endocrine (Hormonal)
Allergy
Chronic Illness
Depression
Hypoglycemia
ANSWER KEY
Toxic Lifestyle Section
1. I eat out ten or more times in a week.
2. I consume 14 or more alcoholic drinks in a week.
3. I seldom eat more than two servings (combined) of fruit and vegetables daily.
4. I consume a can of soft drink such as Coke daily.
5. I consume refined sugar/carbohydrates at least several times a day.
6. Foods such as hamburgers, hot dogs, bacon, beef, pizza, fried chicken, fries or chips are consumed almost every day.
7. I often eat white bread, pasta or cakes and I have less than 7 bowel motions weekly.
8. I have had frequent toxic chemical exposures from applying pesticides several times yearly to my flat or garden, or I have worked in a chemical related industry or lives in a toxic residential area.
9. My flat or workplace makes me sick or is mouldy (black mould grows in damp areas)
Total Circled________
If four of the above are circled please also do the MAQ
Insulin Resistance Section
1. My family history is positive for Diabetes Mellitus.
2. My past medical history is positive for high triglycerides.
3. My past medical history is positive for infertility, unwanted facial hair, or cysts on the ovary.
4. I have crash dieted many times in my life, but am now heavier than ever
5. I frequently crave sugar and/or carbohydrates.
6. I experience erratic energy and/or mood swings that can be affected by eating.
7. I gain weight in abdomen especially
8. I experienced gestational diabetes and/or delivered a baby that weighted more than nine pounds.
9. My past medical history is positive for borderline or confirmed high blood pressure.
10. My past medical history is positive for gout.
Total Circled_________
Endocrine Section
1. My family history is positive for thyroid problems.
2. I am frequently cold when others are comfortable.
3. My face and body are often puffy or swollen.
4. I am very sluggish in the morning and have difficulty getting up or I have a morning headache often.
5. My hair appears to be less healthy or is falling out.
6. My skin has become too dry.
7. My nails are brittle.
8. I have a history of high cholesterol.
9. I am taking Synthroid or other thyroid replacement.
10. I experience craving and weight gain with PMS.
11. My weight gain has been associated with going through puberty or at the peri-menopause or menopause.
12. My weight gain has been associated with taking hormone replacement therapy or the birth control pill.
13. I have significant issues with decreased libido.
14. I have an unusual amount of facial hair, facial acne and/or a history of ovarian cysts.
15. My weight gain has coincided with very high stress, or I have had a very hectic work/home life that has been stressful and affected my weight.
16. I am completely exhausted from stress.
17. I have gained weight distributed in my upper back below the neck level.
Total Circled__________
Allergy Section
1. As an infant or small child I had problems with colic, allergies or recurrent respiratory infections.
2. I have a past or current medical history of asthma.
3. I have a past or current medical history of chronic nasal or sinus problems.
4. I have a past or current medical history of hives or eczema.
5. I have a past or current medical history of Irritable Bowel Syndrome.
6. I have a past or current medical history of excessive headaches.
7. I have a past or current medical history of musculoskeletal aches and pains.
8. I eat a lot of wheat or milk-based foods, and crave for them.
Total Circled__________
Chronic Illness Section
1. I started gaining weight after I contracted a chronic illness.
2. I have a chronic illness, e.g., Chronic Fatigue Syndrome, Fibromyalgia, Rheumatoid Arthritis, etc.
3. I frequently feel exhausted.
4. I frequently feel sick all over, like having the flu or chronic virus.
5. I am very sensitive to medications.
6. I am presently or have in the past taken a lot of Prednisone, NSAISDS (e.g., Motrin, Advil, Ibuprofen), antibiotics, antidepressants or other medications I suspect have contributed to my weight gain.
7. Due to my illness I am quite sedentary.
8. I have chronic pain
9. I have had frequent yeast infections (including thrush).
Total Circled___________
Depression Section
1. I feel miserable and sad.
2. I no longer find it easy to do the things I used to do and enjoy.
3. I get a very frightened or panicky feeling for apparently no reason at all.
4. I have, or feel like having, weeping spells.
5. I cannot get to sleep easily without sleeping tablets.
6. I feel anxious when I get out of the house on my own or avoid leaving home or avoid socializing.
7. I have lost interest in things.
8. I am more irritable than usual.
9. I wake early and then sleep badly for the rest of the night.
10. I experience suicidal thoughts.
Hypoglycemia Section
1. Regular fatigue, weakness, sudden tiredness relieved temporarily by caffeine/ sugar/cakes
2. Lack of concentration, drowsiness, distorted judgment
3. Irritability, restlessness, hyperactivity (especially in children)
4. Anxiety, panic, sweats, with pale damp skin or hot flashes when hungry
5. Headache or migraine, often with dizziness weakness or low blood pressure 6. Crying spells, depression, mood swings
7. Heart flutters, tightness in chest, fast pulse when hungry
8. Blurred vision or faintness, leading to blackout in severe cases
9. Poor self-control, violent crime, alcoholism, severe carbohydrate addiction and/or drug addictions
10. Obesity – fat deposits especially of the abdomen – and mature onset diabetes
Total Circled_________
ANSWER KEY
Toxic Lifestyle Section
Section T. L. deals with the likelihood that a toxic lifestyle is a central issue in your struggle with weight. Four or more circled questions indicate this area be prioritized in designing your patient's weight management program. Any circled questions should be addressed in the patient's patient education/monitoring part of his program. The MAQ score over 30 is an indication of high toxic levels.
Detoxification is required as a key to weightloss and disease prevention.
Insulin Resistance Section
This section screens your patient for the likelihood that insulin resistance (Syndrome X) is a central issue in your struggle with weight. Five or more circled questions indicate this area needs to be prioritized in the weight management program being designed. Three or four circled answers indicate further suspicion and may warrant additional lab and/or screening tests.
You may want to evaluate the fasting triglyceride/HDL ratio. If the ratio exceeds 4.0 then this diagnosis is likely. A fasting insulin greater than 10 and/or a two hour post-prandial insulin greater than 50 is confirmatory. Fasting insulin levels over 9 are also indicative. A waist circumference exceeding 35 inches in females and 37 inches in males also has a high correlation. Elevated blood pressure and uric acid are frequently correlated with Syndrome X.
Physical findings may include multiple skin tags, PolyCystic Ovary Syndrome and facial hair in females.
A low GI diet, with herbal, nutritional and possibly well considered medical therapy is advised. This problem needs careful assistance as the metabolism is well towards diabetes.
Endocrine Section
This section screens you for the likelihood that an endocrine problem such as functional hypothyroidism, a female hormonal imbalance or functional adrenal excessive output may be central issues in your struggle with weight. Seven or more circled questions in this section are considered a positive response. Specifically, questions one through nine apply to the thyroid, questions ten through thirteen apply to the female hormone issues, and questions fourteen and fifteen apply to the adrenals.
The hypo-thyroid patient may exhibit dry skin, brittle nails, thinning hair, thinning of the lateral eyebrow, edema in the extremities and/or a slight thyroid enlargement to palpation. Lab work can include TSH, free T4 and free T3, reverse T3, and thyroid antibody screening.
Female hormone screening may include FSH, LH, Serum Estradiol, Total and Free Testosterone, and 2 hydroxy estradiol/16 hydroxy estradiol ratio.
The adrenals may be evaluated with a salivary cortisol/DHEA determination. A serum DHEA-S level may also be helpful.
After determination of the problem a consideration of natural therapy and possibly bio-identical hormone therapy is advised.
Allergy Section
This section screens you for the likelihood of a food allergy as a central issue to your weight management problem. Four or more circled questions are considered a positive response.
On physical exam such patients may have allergic "shiners" under the eyes, swollen boggy, pale nasal mucosa, and appear pale. They sometimes are "mouth-breathers" and may have patches of eczema. Their pharynx may exhibit chronic irritation from postnasal drainage. The lungs may have telltale wheezes.
There are a couple of popular food allergy blood tests used in Functional Medicine including the Elisa, Rast IgG4, and MAST tests. These are very helpful in pinpointing the problem, because as IgG mediated phenomena, the clinical symptoms may lag 48-72 hours after ingestion of the food, making detection by history difficult.
After diagnosis of the allergy a supportive program for recovery is recommended.
Chronic Illness Section
This section screens you for the likelihood that experiencing a chronic illness has been a major factor in precipitating your weight problem. Five or more questions are considered a positive response.
Helpful tests include hepatic detoxification profiles, stool cultures for bacteria, yeast, and parasites, and the Lactulose-Mannitol Gut Permeability Test. Based on this data, appropriate dietary advice with consideration of a liver detoxification and/or leaky gut program can be pinpointed.
A careful plan for recovery is needed with a physician familiar in natural medicine and immune building.
Depression Section
This section screens you for the likelihood that experiencing a period of depression. Some of these symptoms mimic adrenal exhaustion as well and the two conditions may overlap.
A score of five or more of these may indicate depression.
It is important to get experienced help for this, both nutritional and natural or synthetic medication may be needed..
Hypoglycemia Section
This section screens you for the likelihood of low blood sugar levels, or fluctuating levels that affect brain functioning and moods.
Four or more of these indicate problems with blood sugar levels. An Oral Glucose Tolerance Test can be used for diagnosis if necessary.
Advice on a hypoglycemic diet is needed, and nutritional supplements of chromium, magnesium, manganese and B complex are usually needed for quickly normalizing the deficiencies.
