Dr. Tony Nimeh of PracticeUpdate talks with Dr. Elizabeth Boham of the UltraWellness Center in Lenox, Massachusetts, about managing obesity from the stance of functional medicine. In Part 1, Dr. Boham describes functional medicine and how it is uniquely positioned to help the patient with obesity, often multifactorial. In Part 2, she discusses specific triggers of obesity, such as sleep disorders and imbalance in the microbiota, and working with the patient on the behavioral change necessary to maintain a healthy weight.

Dr. Nimeh: How do you approach a typical patient struggling with weight gain with no obvious metabolic or hormonal abnormalities?

Dr. Boham: First of all, you want to carefully evaluate her anthropometrics, including waist circumference and waist-to-hip ratio, to look for signs of excessive weight around the midsection. Often in patients with dysmetabolic syndrome or in people who are insulin-resistant, we should not wait until they have the official criteria for metabolic syndrome. At that point, they’ve had those issues for years. We try to pick it up earlier and look very carefully at the waist-to-hip ratio, fasting insulin levels, and fasting blood sugar, although that’s not always elevated right away. We also look at other biomarkers, such as elevated triglycerides, low HDL, or even elevated levels of small, dense LDL particles. If you see signs that a person has insulin resistance or dysmetabolic syndrome, then she will respond well to a low-carbohydrate, low–glycemic impact, and low–glycemic load diet. And that will be helpful for in terms of weight loss.

If the patient has more weight gain around the midsection, a large waist circumference, or an elevated fasting insulin level, or if she isn’t achieving the weight loss that you want to see, then you want to focus on lowering the amount of refined carbohydrates in her diet. For so many years, we were focusing on low-fat diets; however, many articles and research papers have emphasized that it is more important for us and for most of our patients—especially adults—to focus on a low–refined carbohydrate diet. In terms of fats, it is important to avoid trans fats, to lower the saturated fats, and to focus on eating more polyunsaturated fats.

We know that, after eating food with a high glycemic load or impact, many patients get a quick rise in blood sugar, which then results in a drop in blood sugar a few hours later and a subsequent increase in hunger. This can lead to increased food cravings, hunger, and weight gain.

When we are working to lower the glycemic load of patients’ diets, we really focus on fiber. First, we often ask patients whether they drink any of their calories. We find out whether they are consuming soda or juice or if they are consuming foods with excess sugar. That is where you really want to work to remove those foods from their diet and focus on increasing the fiber in their diet by getting them to eat more fruits and vegetables. This gives them more fiber to help manage the glycemic load without lowering it. That’s a place to start for many patients.

Sleep patterns

I also focus on their sleep patterns, because we often miss the identification of sleep disorders and sleep deprivation, which have a large influence on weight. We know that across the lifespan, as somebody’s sleep decreases, as he becomes more sleep-deprived, his weight increases. We know that sleep deprivation is associated with increased levels of ghrelin, which make people hungrier, increased levels of insulin, which cause people to gain weight and cause insulin resistance, and decreased levels of leptin, which is a hormone that helps people stay full. Because of this, I always get a very detailed sleep history. I find out how many hours the patient is sleeping and whether he has any signs of sleep apnea. I ask about snoring and daytime fatigue, and I look at the blood pressure, or look at tonsils in children, and really think about the possibility of sleep apnea. We know that both sleep apnea and sleep deprivation are tied to obesity. When a patient is having a hard time and is not losing weight, I ask, “Okay, are you getting adequate sleep?”

Microbiota

I also start to look for signs of imbalances in the microbiota, or the bacteria in the digestive system. A lot of really interesting research has looked at how these imbalances in our microbiota influence weight and insulin resistance. If a patient is having digestive imbalances, problems with bowel movements, and bloating, then I might focus more on thinking about his microbiota and what can influence a healthy microbiota balance. High-fiber foods can help good bacteria grow; so, again, we need to focus on increasing the amount of vegetables, beans, legumes, nuts, seeds, and other high-fiber foods in the patient’s diet.

Prevention can also have a big impact in terms of the microbiota. One reason that breast-fed babies may have a lower rate of obesity is because of how breastfeeding influences the balance of the microbiota. Encouraging our patients to breastfeed can have a big influence on their children’s health. In addition, avoiding unnecessary antibiotics has a big influence on the microbiota.

Dr. Nimeh: How do you evaluate someone’s microbiota?

Dr. Boham: Researchers are starting to do some stool testing using PCR to look at the levels of helpful and not so helpful bacterial species. However, much of that is really early in terms of use in everyday clinical practice. Many times, the evaluation of someone’s microbiota is based only on his or her history; if I know that somebody has had a lot of antibiotics or he has a lot of digestive issues, I recognize the fact that this may have an influence on his overall health and maybe even on his weight and inflammation in his body.

Hormone treatment

Dr. Nimeh: Do you do a male and female hormonal workup?

Dr. Boham: Absolutely. It’s very important to look at female and male hormones as well carefully evaluate the thyroid and adrenal glands. Low testosterone is linked with insulin resistance and obesity, and you can often influence testosterone levels with diet alone. Low testosterone in male patients can be detected based on laboratory testing or physical exam findings such as loss of hair growth on the legs, weight gain around the belly, or gynecomastia. These patients often have insulin resistance and dysmetabolic syndrome and often respond beautifully to a low–glycemic load diet.

You can start by figuring out how much sugar the patient gets in his diet on a typical day, such as whether it’s coming from soda, putting sugar in coffee, or a donut. It can also come from too much bread or pasta that is not being burned off, especially as patients get older. That’s where you can eliminate sugar and refined flours and see a large impact. Many times, treatment with hormones can also be helpful. If a patient’s response is not what he would like, adding hormone therapy may also be helpful. However, I have seen the testosterone level rise for some patients just with lifestyle changes.

Exercise

Of course, we have to focus on exercise as well, because we know that exercise has a huge impact on our ability to maintain weight.

The National Weight Control Registry, which has been around for many years, has studied people who have lost weight and maintained that weight loss. I think that participants have to lose at least 30 pounds and keep it off for at least a year, and then the researchers ask questions such as, “What do you do every day?” and, “What do you eat?” For example, the researchers know that people who are more likely to maintain weight loss eat breakfast, but they also know that most who are able to maintain that weight loss exercise for at least an hour every day.

We know that it is important to encourage our patients to exercise because it helps improve lean muscle mass, which in turn helps improve hormone balance and maintain a better metabolism. Additionally, we know that it is important just for burning calories in and of itself. I think that exercise is really an important thing for us to focus on for all of our patients. In addition, this conversation is a great starting point for physicians to delve into the reasons for obesity and start to recommend some changes. This is also a great time for us to refer our patients to a nutritionist, registered dietitian, or exercise trainer—somebody who can work with them regularly to help them stay on course and perform frequent follow-up. These professionals can find out exactly what the patient is eating and help him make and maintain necessary dietary changes.

Behavioral aspects of weight loss

Dr. Nimeh: How do you effectively tackle the behavioral component of weight loss?

Dr. Boham: When physicians actually bring up a behavior that needs changing, people are more likely to pay attention and attempt to make that change. First and foremost, it is important that we address weight gain at every office visit, just as we address smoking at every office visit. Determine whether the patient is ready to make a change. Then, set very specific, attainable, and measurable goals with him or her.

Frequent follow-up is really helpful; if you are not able to do it within your practice, you can bring in a registered dietitian or other staff who can help. I think that group office visits can also be an effective way to work with this population. In a group office visit, patients come in and focus on their weight or even some of the side effects of their weight, such as hypertension or diabetes. The group support is so wonderful because it helps patients to see that weight loss is attainable. Talking to other people who are dealing with their same issues and seeing the changes that others have made help patients to recognize, “Okay. Maybe this is something that I can do.” They will feel more hopeful about it.

It is important to realize that, although we’re talking about obesity today, lifestyle changes that we help patients make really impact all of their major chronic health issues. Because of this, I focus on a lot more than weight with my patients because, sometimes, especially if they have been overweight for many years or were overweight as a child, they might not be able to attain what we call a normal BMI. However, if we can help them to lower their blood pressure, get their triglycerides under control, or move their fasting insulin into a more acceptable range, or reduce their waist circumference, then we’re really doing very well by our patients.

We want to move past just looking at weight and BMI and look other markers so that we can tell them, “Okay, you’re being really successful here. We’ve got your fasting blood sugar down, and look at your triglycerides—they’ve gone from 280 to 100. Great job!” Other measurable markers can show that patients have been making some real substantial changes in terms of their lifestyle.

Really focus on the fact that prevention is key, and if we can work more with our pediatric population, we can help prevent obesity from becoming as much of an issue. The 5-2-1-0 recommendation by the American Academy of Pediatrics is wonderful. It focuses on getting 5 servings of fruits and vegetables, 2 hours or less of screen time, 1 hour of physical activity, and 0 sweetened beverages every day. While this is what is recommended for our children, we can also recommend it for our adult patients. They are good recommendations for everybody to think about—“Did you do your 5-2-1-0?”—every day, because that is going to have a huge impact on their overall health for the rest of their life and prevent obesity from even becoming an issue in their future.