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.  

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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
• Triglycerides
• Fasting glucose
• HgBA1C
• Her TSH was borderline high, and her free T3 was low.

Additional History

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

Lab Interpretation

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:

Hormone Imbalances:

• 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.

Digestive Health

• 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.

Inflammation

• 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.

Nutrient Deficiencies

• 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).

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3 Month Follow Up Labs

3 Month Follow Up Lab Interpretation

While focusing mainly on nutrition, lifestyle changes,  and movement in the first 12 weeks of working together, there were still initial presenting issues that we had to work through, including supporting Ashley’s hormone levels, improving insulin sensitivity, and continuing to decrease inflammation.  

Hormone Imbalances

While supporting her thyroid with a combination of medication, nutrition changes, and stress management had Ashley feeling much better and saw her levels in a normal range, she had also initially shown some imbalances with sex hormones.

At her initial workup, Ashley had decreased progesterone with normal estrogen levels; this could result in symptoms of estrogen dominance like increased inflammation, PMS-related symptoms, and fatigue. Initially, she had also had low cortisol throughout the day, which was likely contributing to her fatigue.  Her cortisol measurements had shifted into the normal range at the 3 month mark.

Last, while Ashley’s fasting blood glucose had been normal at her 3-month lab check ins, she still showed elevated HgBa1c and elevated fasting insulin, indicating her insulin sensitivity still needed improvement.

Inflammation

Ashley’s omega-3 index was in the “intermediate” range at the 3-month mark, indicating she was not yet in the optimal range for reducing cardiovascular risk.

Functional Medicine Approach to Weight loss: Interventions (Weeks 12-24)

Nutrition

We continued on an anti-inflammatory diet that limited dairy and gluten, based on Ashley’s elimination diet reintroduction.  Ashley found she didn’t feel great with grains in general and that she had an elevated blood sugar reading followed by a “crash” when she ate them (as seen on continuous glucose monitor), so we moved her towards a Paleo approach that still emphasized quality protein, healthy fats like avocado and coconut oil, fruits, green leafy vegetables, root vegetables, and seed like pumpkin seeds and sunflower seeds.

We added in cooked broccoli, brussel sprouts, and other cruciferous vegetables, especially in the second half of her cycle, to support healthy estrogen levels

We focused on increasing her protein intake to meet her new exercise demands by adding a half-portion on to her meals, since Ashley did not want to do any tracking or counting.

Each meal contained protein, fat, and fiber to support blood sugar, and we focused on three balanced meals without snacking between them.

Supplementation

• Ashley continued with Enzymix-Pro digestive enzymes before meals and a probiotic to continue to support digestion and overall gut health.  We switched from Metagenics to a spore-based probiotic to change things up.
• Continued vitamin D at a dose of 2000IU/day
• Continued omega-3 supplement, Metagenics SPM, 2000mg/day to address omega-3 index and inflammation
• Added in Vitex (Gaia Herbs), 500mg/day to support healthy progesterone levels
• Continued Life Extension Chol-Support (plant sterols/stanols to support healthy cholesterol levels) and Tudca to support healthy bile flow to address her cholesterol.
• Continued Apex Energetics Glysen Synergy, 2x/day with meals, to support blood sugar response
• Continued Organifi red juice Antioxidant support, one scoop per day added to filtered water

Lifestyle

We started to use a continuous glucose monitor (CGM) at week 14 to monitor how Ashley’s current diet, exercise, and lifestyle were affecting her blood sugar level.

We found that grains and having too much fruit at a given meal raised her blood sugar (sometimes above 200) and that it often took several hours to return to a baseline.

Ashley continued dry brushing for lymphatic support, and also started using a castor oil pack over the liver once per week.

Ashley started a strength training program to continue to support joint mobility and to build muscle, 3x/week following the principles of progressive overload for compound movements like squats/leg press, deadlift, overhead press, etc.

She incorporated sunlight exposure 3x/day to support circadian rhythm (morning, midday, evening) as well as daily walking which included a desk treadmill to add more walking in during her work day.

6 Month Check in

At her 6-month check in, Ashley had lost an additional 35 pounds, and had gained 5 more pounds of muscle according to an InBody scan her personal trainer ran, for a total of 54 pounds of fat loss and a gain of 9 pounds of muscle in six months.  Other than the occasional sore muscles from starting to strength train, Ashley felt her joint pain was now non-existent during walking and weight training.

When we re-ran labs, we saw improvements in her initial hormone panels, with progesterone metabolites now in normal ranges, and with maintenance of in-range thyroid and cortisol levels.  Ashley felt her PMS-related symptoms were improving, and really only noticeable the day before her period, though they “didn’t interfere” with her lifestyle.  Her energy levels continued to increase, and she stated that she felt a surge of confidence from starting to strength train with her personal trainer.  She slept through the night and overall seemed excited to continue her progress.  She started having 1-2 bowel movements per day and felt that she “never had digestion this good.”

Her labs showed her insulin markers had dropped into a normal range, and the use of a continuous glucose monitor had helped us make tweaks to her nutrition and meal timing to keep her blood sugar balanced as much as possible.  The data from the CGM also let us continue to focus on intuitive eating and avoiding snacking versus following a strict diet and counting calories, since this was an important component of a sustainable plan for Ashley.  

At this point, Ashley wanted to continue on a maintenance plan for another 3 months to continue on her weight loss journey, with an ultimate goal of dropping below 200 pounds and focusing on building muscle while generally optimizing her health.

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Summary

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. For Ashley, it took phases of healing underlying metabolic dysfunction and inflammation while integrating healthy lifestyle habits that met her where she was at, all while fostering a healthy relationship with food and her body.  Her progress was steady and sustainable, as she did not partake in crash diets or intense workout regimens and instead focusing on moving more, eating in a way that made her feel better, and reducing stress in all areas of life.