Integrative management of obesity

Photo Cred: Freepik

By Kellie Blake, RDN, LD, IFNCP

Obesity has many consequences and can be overwhelming for practitioners to treat. There is no one root cause to target, an insurmountable amount of misinformation exists, and the American food system is broken. Despite the billions of dollars spent each year on programs, pills, and surgeries, obesity rates continue to rise.

According to the U.S. Centers for Disease Control and Prevention (CDC), the prevalence of obesity in U.S. adults increased from 30.5 percent in 1999-2000 to 42.4 percent in 2017-2018. These statistics are alarming, as obesity is a gateway to other chronic inflammatory diseases and conditions including type 2 diabetes, heart disease, stroke, and cancer.

Many of my overweight patients are frustrated and confused. They’ve been led to believe the answer is simply eating less and moving more. However, this oversimplified approach takes the individual out of the equation and neglects to consider the countless contributing factors that lead to obesity, such as genetics and epigenetics.

While calories are important to a certain extent, we now know obesity is a multifaceted, chronic inflammatory condition requiring a personalized, comprehensive nutrition and lifestyle approach to truly help patients achieve long-term success. Unfortunately, there is no one nutrition plan that is appropriate for every patient and there are often many underlying root causes to address. With my weight loss patients, I target the gut microbiome and often utilize a variety of fasting methods. Additionally, lifestyle measures such as ensuring healthy sleep, physical activity, and stress management are high priority.

The gut microbiome and obesity

The gut microbiome is now known to be extremely important to overall health. The multitudes of bacteria residing in the gastrointestinal tract significantly affect energy harvesting, metabolic pathways, brain function, behavior, and inflammation and can thus be a target of therapy for obesity prevention and treatment.

Overweight and obese patients have an altered gut microbiome when compared to controls. These gut microbiome changes can be the result of obesity, but can also predispose individuals to the development of obesity. According to a study published in the journal Current Obesity Reports, there seems to be a reduction in Bacterioidetes and an increase in Firmicutes in obese humans and mouse models. Altering the gut microbiome in mice has been shown to partially prevent obesity. As reported in the journal Science, when the microbiome of lean mice was transplanted into mice with a signature obese microbiome, obesity was prevented to a certain degree. This was only the case when a diet lower in fat and higher in fiber was consumed. When the mice were fed a high fat diet, low in fiber, they experienced an increase in body and fat mass solidifying the importance of nutrition in obesity management.

In addition, all chronic inflammatory diseases share increased intestinal permeability in common. As described in F1000 Research, there is an upregulation of the zonulin family of proteins in obese patients when compared to the non-obese. This increase in zonulin may occur due to microbial imbalance, which allows for toxins that should be leaving the body to enter the circulation causing the inflammation that is seen in obesity. But, butyrate-producing bacteria can help to decrease zonulin levels, decrease gut permeability, and lower inflammation.

Fasting and obesity

While calorie restriction has been shown to help both prevent and reverse obesity, it is difficult to follow and long-term success is generally poor. In addition, the loss of lean body mass is a concern. I prefer to tailor fasting strategies for my overweight and obese patients, which seem to be easier to implement with higher adherence.

Fasting functions to switch the body from using glucose for fuel to using ketones derived from fatty acids, which improves the insulin resistance, dyslipidemia, and inflammation that are seen in obesity, while increasing muscle mass. In addition, fasting can decrease visceral fat and enhance mitochondrial function. When compared to continuous calorie restriction, as reported in Ageing Research Reviews, those practicing intermittent fasting did not over-consume calories on their non-fasting days and spontaneously reduced calorie intake by 23 to 32 percent on non-fasting days. Those in the fasting groups were also more compliant with the intervention.

Case Study

Vickie is a 60-year-old female seeking nutrition counseling for weight loss, but she was also concerned about her rheumatoid arthritis, depression, shortness of breath, and fatigue. Vickie is five foot three and initially weighed 185 pounds. She reported a 15-pound weight gain over a five-month period, mostly related to depression from several deaths in her family.

Her initial body mass index (BMI) was 32.8 indicating obesity class one and her desired weight was 155 pounds. Vickie reported trying to follow a gluten-free meal plan with no soda, she was eating two meals and two snacks per day and she cooked most of her own meals. Her water intake was inadequate and Vickie was not exercising due to shortness of breath. Vickie described her life as stressful and she didn’t feel well enough to move her body. Initial medications and supplements included methotrexate, folic acid, golimumab, iron replacement, metoprolol, montelukast, an inhaler, phenytoin, vitamin D3, atorvastatin, and duloxetine.

The initial plan for Vickie included:

1. A full elimination diet for at least four weeks with the goal of eight weeks, due to autoimmune disease, significant gut microbiome dysfunction, and suspected food sensitivities.
2. Consume at least 85 ounces of water daily.
3. Walk for 10 minutes after every meal to target suspected insulin resistance.
4. Begin a meditation practice with the goal of two, five-minute sessions per day to address stress hormones.
5. Consider beginning a yoga practice to target stress and inflammatory rheumatoid arthritis pain.
6. Testing to include at-home stomach acid testing, fasting insulin, celiac panel, ferritin, vitamin D, hsCRP, thyroid antibodies, homocysteine, MMA, comprehensive stool testing, salivary cortisol testing.
7. Supplements to include a probiotic, phosphatidylserine, CoQ10, omega-3 fatty acids, vitamin D with K2, and a B-complex.

After four weeks, Vickie had lost 10 pounds and her symptom score had dropped to 38. Vickie reported more energy, less brain fog, much improved breathing, and less sinus symptoms and joint pain. In addition, she was able to decrease her anti-depressant medication by half due to much fewer depressive symptoms. Vickie was taking all the recommended supplements except the phosphatidylserine, which seemed to interrupt her sleep. Labs indicated optimal vitamin D level of 56.8ng/mL, normal blood sugar with HgbA1c of 4.8 percent and glucose of 89mg/dL. Her fasting insulin was higher than optimal at 15.2mIU/mL, but her thyroid function and MMA were both normal. The results of her at-home stomach acid test revealed inadequate hydrochloric acid. She declined salivary cortisol and comprehensive stool testing due to cost.

Follow up goals included:

1. Continuation of the elimination diet for four more weeks.
2. Change the phosphatidylserine to magnesium glycinate before bedtime to promote relaxation.
3. Add digestive enzymes with betaine HCl prior to meals and snacks to enhance digestion.
4. Add one-quarter cup of walnuts and two to four tablespoons of high-quality olive oil per day to target insulin sensitivity and inflammation.
5. Implement intermittent fasting with a 16-hour overnight fast twice per week.
6. Continue all previous lifestyle and supplement goals.

After four more weeks, Vickie had lost two more pounds and her symptom score dropped to 25. She was walking 5,000 steps per day, which she reported not being able to do previously due to pain and shortness of breath. Vickie reported her joint pain and stiffness were minimal and she weaned completely from her anti-depressant medication. The shortness of breath was much improved and she felt her sleep was more refreshing. She liked intermittent fasting and said her food cravings were practically gone.

From there, follow up goals included:

1. Continue all previous supplements, but may switch to eating fermented foods instead of using the probiotic supplement.
2. Begin the reintroduction of eliminated foods, but continue to avoid gluten, dairy, corn, and soy at this time. Work toward a maintenance meal plan that is anti-inflammatory, low-glycemic, gluten-free, low in grains, and high in quality fats.
3. Focus on leafy green vegetables with the goal of at least four servings per day and continue the olive oil and walnuts.
4. Continue with two 16-hour overnight fasts per week.
5. Consider strength training at least two days per week to target insulin sensitivity and increase muscle mass.

After a total of five months, Vickie had lost 16 pounds and her BMI was 29.9, indicating movement from obesity class one to overweight status. Her symptom score went up to 36 from 25, but was down overall from 85 indicating significant improvement. Vickie said she was still walking 5,000 steps per day, but she had not yet added the resistance training. Additional labs indicated ferritin was low at 14.7ng/mL, as well as her iron level at 25mcg/dL. Her fasting insulin had improved from 15.2mIU/mL to 12.9mIU/mL. Vickie indicated she had a history of eczema behind her ears and on her eyelids, which had improved, but was still bothersome.

Follow up goals included:

1. Continue the maintenance meal plan, as well as the walnuts, olive oil, and leafy greens.
2. Add ½ teaspoon cinnamon per day to further target blood sugar and insulin sensitivity.
3. Add cold-pressed hempseed oil topically or orally for the eczema.
4. Continue with all previous goals and supplements, but add a non-constipating iron supplement daily.

Vickie continues to work toward her weight goal and she has been very pleased with her improvement. Prior to nutrition and lifestyle intervention, she was unable to play with her grandchildren, but states she can get in the floor with them and actually get back up without experiencing joint pain or shortness of breath.

References

Fasano A. (2020) All disease begins in the (leaky) gut: role of zonulin-mediated gut permeability in the pathogenesis of some chronic inflammatory diseases. F1000Research. Retrieved from: https://f1000research.com/articles/9-69/v1

Mattson, M. P., Longo, V. D., & Harvie, M. (2017) Impact of intermittent fasting on health and disease processes. Ageing Research Reviews. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5411330/

Ridaura, V. K. (2013) Gut microbiota from twins discordant for obesity modulate metabolism in mice. Science. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3829625/

Sanmiguel, C., Gupta, A., & Mayer, E. A. (2015) Gut Microbiome and Obesity: A Plausible Explanation for Obesity. Current Obesity Reports. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443745/

U.S. Centers for Disease Control and Prevention. Adult Obesity Facts. Retrieved from: https://www.cdc.gov/obesity/data/adult.html.

Editor’s note: Photo courtesy of Freepik.