Roughly 45 million Americans diet each year, spending upwards of 33 billion dollars on weight loss products. However, the number of Americans who are overweight or obese continues to climb year after year. People who are overweight or obese are at a higher risk for chronic health issues, such as cardiovascular disease, high blood pressure, arthritis, and more. Weight loss can be stalled for many reasons, including inflammation, hormone imbalances, metabolic disorders, digestive disorders, and micronutrient malnutrition, to name a few. A Functional Medicine Approach to Weight Loss includes a thorough patient intake, specialty labs, and an individualized protocol. Below is an excellent example of a root cause approach to weight loss.
CC: Trouble Losing Weight, Joint pain, Decreased Mobility, Fatigue, Pre-Diabetes, Depression.
Ashley* was a 37-year-old female with a history of weight gain, followed by crash dieting, and inevitably regained weight once she stopped dieting. She recently hit her heaviest weight, 278 pounds, at a height of 5'6".
Ashley did not want to go on a strict diet again, and was more concerned with some of the other symptoms that had started bothering her, including joint pain (especially the knees and hips), decreased mobility, fatigue that seemed to be getting worse, elevated blood sugar and insulin in her labs. She reported she was feeling depressed and hopeless about her health and inability to stay at a healthy weight.
Ashley was currently on medication for high blood pressure (Prinivil) and high cholesterol (Crestor) that she began six months ago. She did not want to start Metformin for elevated blood sugar. Her endocrinologist co-managing her case supported her trying diet and lifestyle recommendations for three months before re-evaluating.
Additionally, Ashley took ibuprofen 3-4 times per week for joint pain as needed and was currently taking a vitamin D supplement.
Ashley's fatigue had become noticeable in the past 4-5 months, and she was finding it hard to get out of bed in the morning. She also often wanted to nap in the afternoon, and it was challenging to find the energy to get out and walk or exercise. Talking about this became emotional for Ashley, and it was clear she truly wanted to feel better and felt so frustrated with where her health was currently at.
Ashley's health history showed that she had always tended to carry extra weight, even as a child and teenager, and that she had grown up learning how to "diet" starting in middle school when her mom took her to Weight Watchers. While she had been active, enjoying hiking, biking, and playing softball through the end of high school, Ashley admitted that food had always been her "emotional crutch" when she was stressed.
Over the last 20 years, Ashley had done Weight Watchers, Atkins, intermittent fasting, Paleo, keto, Whole 30, vegetarian, and multiple "cleanses" - all would help initially, but her results would reverse as soon as she stopped whatever "plan" she was following. In her words, it was "just really hard to find a balance between real life and following a nutrition plan."
Her recent blood work at the time showed Elevated:
- High sensitivity C-reactive protein
- LDL cholesterol
- Total cholesterol
- Fasting glucose
- Her TSH was borderline high, and her free T3 was low.
At the time of her consultation, Ashley had been following a Mediterranean-type diet for about three months, which she stuck to about 75-80% of the time.
She was eating eggs and fish but no other animal protein, which seemed to "sit in her stomach." She often felt super hungry at night and admitted that's when she'd dive into snacks like nuts, fruit, popcorn, or toast.
She had lost 3 pounds since starting eating this way but mostly just noticed she felt more bloated and had a lot of gas.
She had one bowel movement per day and occasionally took Gas-X for her symptoms.
Ashley had a regular menstrual cycle of 28-30 days in length, with mild PMS symptoms in a day or two leading up to it, including water retention, mild cramping, and fatigue.
Her main movement consisted of walking her dog, but her joint pain limited how long she could walk. She tried some at-home workouts using the Les Mills program but didn't feel she could comfortably do most of the movements.
Ashley was currently working from home as a marketing VP for an online company; she had worked for this company for ten years and loved it.
Ashley's history of dieting was paired with struggles with body image and feeling confident in her own skin. She tied her weight to her self-worth and had recently started working with a therapist in this area to have a better relationship with food and her body; her therapist was willing to co-manage this case.
Ashley was taking the following supplements at the time of her initial consultation:
- Liquid vitamin D drops, 2000 IU per day, Apex Energetics
- Liquid collagen from Isagenix (recent; started two weeks before the first consultation)
Initial Lab Work
Comprehensive Stool Test Results:
- Pancreatic elastase LOW
- SCFA LOW
- Bifidobacterium LOW
- Zonulin HIGH
- Meat Fibers, Vegetable Fibers MODERATE
NutrEval (Genova Diagnostics) Results:
- Vitamin A LOW
- Plant-based Antioxidants LOW
- Vitamin C LOW
- Zinc LOW
- Glutathione LOW
- B vitamins LOW
- CoQ10 LOW
- Oxidative Stress HIGH
- Mitochondrial Stress HIGH
- Lipid Peroxides HIGH
Ashley’s lab work points to a few core issues that are contributing to her trouble with weight loss, as well as other symptoms she’s been experiencing:
- Ashley had decreased progesterone with normal estrogen levels; this could result in symptoms of estrogen dominance like increased inflammation, PMS-related symptoms, and fatigue. Additionally, she had low cortisol throughout the day, which could explain why she was having difficulty with her energy and feeling motivated to exercise.
- Additionally, her TSH is mildly elevated, and her free T3 is low, indicating she is also experiencing mild hypothyroidism. Hypothyroidism may be contributing to her inability to lose weight, as well as her symptoms of fatigue, joint pain, and feelings of depression. Hypothyroidism may also be linked to higher lipid profiles.
- Last, Ashley had high blood glucose, high fasting insulin, and high HgBA1C, indicating her insulin response was not ideal, and she was in the pre-diabetes range.
- Although she did not have an excess of “digestive” symptoms, Ashley’s comprehensive stool tests showed us several areas that needed support. She had low growth of beneficial bacteria such as Bifidobacterium and had several markers indicating decreased digestive enzyme function and the presence of malabsorption. Without breaking down and absorbing her food, Ashey is at risk of nutrient deficiencies, some of which we can see in her labs (low zinc, borderline low vitamin D, and low folate, to name a few). Her body may not have been registering the nutrition she was eating because she was not absorbing it.
- Additionally, Ashley had high zonulin levels, a marker linked to increased intestinal permeability, resulting in inflammation and immune dysregulation.
- Ashely’s Omega-3 index was quite low, putting her in the high-risk category for inflammation in the body. Paired with an elevated CRP and elevated oxidative stress and lipid peroxides in her NutrEval, it was clear she was dealing with excess inflammation that was likely contributing to weight gain, joint pain, and fatigue.
- Along with the results in her stool test of malabsorption, we saw in both her blood draw and nutreval that several nutrient deficiencies were going on (zinc, vitamin D, folate, vitamin A, and Vitamin C, to name a few), many of which are relevant to reducing inflammation and promoting healthy hormone function needed for weight management. She also had low CoQ10 levels, a common nutrient deficiency that can occur with statin use for cholesterol management. This often presents as fatigue and musculoskeletal pain.
Functional Medicine Approach to Weight Loss: Interventions
- We started Ashely on an anti-inflammatory nutrition program to help reduce inflammation and focus more on nutrient-dense foods. The focus was on three balanced meals throughout the day instead of limiting food intake all day and then binging on snacks at night.
- Ashley started a diet lower in refined carbohydrates to help with her inflammation, focusing on quality protein, fats like avocado and coconut oil, and carbohydrates in the forms of fruits, green leafy vegetables, root vegetables, and some gluten-free whole grains. Each meal contained protein, healthy fat, and fiber. Her carbohydrate sources primarily came from vegetables, low-glycemic fruit, and sweet potatoes. We also added more pumpkin seeds and lean red meat at least once per week to help her zinc levels.
- We added a few other things to support her gut health, including a probiotic (Metagenics) and Enzymix-Pro digestive enzymes before meals and a targeted elimination diet with the removal of foods that came back in her food sensitivity panel.
- CoQ10 with PQQ, 200 mg per day, to address the CoQ10 deficiency
- Increased her Vitamin D, 5000 IU per day since she was still borderline low in her labs
- Antioxidant support, Organifi Red Juice, one scoop per day added to filtered water.
- Started omega-3 supplement, Metagenics SPM, 2000 mg per day
- Apex Energetics Glysen Synergy, 2x per day with meals, to support blood sugar response
In co-managing with her endocrinologist, Ashley started Armour thyroid to support her thyroid levels and decided to go off her cholesterol medication for a few months while implementing diet and lifestyle changes. She started on the following supplements instead:
- Life Extension Chol-Support (plant sterols/stanols to support healthy cholesterol levels)
- Tudca, one capsule per day with meals, to support healthy bile flow
- Therapeutic foods like ground flaxseed and ground chia seeds to provide fiber and healthy fats
- Increased water intake
- Dry brushing 2-3x a week to help with lymphatic drainage and detox support.
- Daily walking to tolerance
- Sunlight exposure 3x/day to help circadian rhythm (morning, midday, evening)
- Started working with a personal trainer on joint mobility and flexibility to get her feeling confident to start working out again (2-3x/week).
3 Month Follow Up
Follow Up Lab Interpretation
When we re-ran labs and intake at three months, we saw many things trending in the right direction. We did a DEXA scan and found out she had lost 19 pounds of fat and gained 4 pounds of lean muscle, which she was thrilled about. She had much more energy, and she felt her joint pain had decreased tremendously; she was now weight training twice per week with her trainer. She mentally felt much more positive and was sleeping great most nights.
Ashley's labs showed that her blood glucose had normalized, her HgBA1c was decreasing, and the Armour had helped normalize her thyroid function. Additionally, her cortisol levels had normalized, and her cholesterol levels had decreased, trending in the right direction.
While she had a rough time the first month cutting out foods she had frequently been eating (like olives, bread, and mozzarella), she noticed a rapid relief in her joint pain after cutting out her "problem" foods. At the ten-week mark, she had decided to start adding back in the foods to gauge her response, and she found gluten and dairy irritated her symptoms and made her "feel bloated." She added back in olives, egg whites, and nuts without any symptoms.
Due to her history with chronic dieting, we opted not to count calories and focus on cuing into her hunger, energy, and craving signals to regular her nutrition intake.
She had enjoyed not following a strict "diet." We focused on intuitive eating and not snacking when she was bored or stressed. This naturally regulated her caloric intake; alongside the increased movement, her weight had steadily decreased over the last 12 weeks.
At this point, we continued with her plan, focusing on supporting her digestion, healthy blood sugar levels, and lipid panel alongside her endocrinologist and therapist. Plans are to re-run her DUTCH hormone panel, thyroid, and lipid panels at six months.
*This case study will be updated after 6 month follow up.
This case highlights how weight loss is a complex topic that encompasses physiological and emotional factors. Simply telling clients to "eat less and exercise more" is not an acceptable approach to weight management.
It's essential to look at what physiological symptoms have been impacted and support those systems while encouraging a healthy relationship with food and body image to meet each client's personal goals. For Ashley, that was to feel better and move better without restrictive diets while getting back to pain-free movement.