Obesity is an epidemic disease and is rapidly becoming a pandemic health concern worldwide, beginning in the United States and spreading to other Western countries. While about 75% of Americans fall into either the overweight or obese categories, as many as 93% of Americans have poor metabolic health. As body mass index increases, the risk of type 2 diabetes consistently increases as well. With the rising costs of prescription medications for diabetes and increasing awareness of functional medicine for the treatment of both diabetes and obesity, addressing their underlying causes and improving overall holistic health helps focus on individualized care and root cause resolution.

A functional medicine approach for the treatment of obesity and diabetes includes several key principles:

• Nutrition therapy
• Physical activity
• Weight management
• Inflammation reduction
• Gut health promotion
• Stress management
• Sleep improvement
• Supplement optimization

This article first discusses the underlying link between obesity and diabetes to understand how the diseases interplay. It then presents the functional medicine principles in treating obesity and diabetes. Understanding gut health, nutritional interventions, and dietary modifications is crucial, and the values of sleep, stress management, and emotional well-being all play a part. Coordinating care from a holistic perspective and applying personalized treatment are the cornerstones in utilizing functional medicine for obesity and diabetes.

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Understanding the Link Between Obesity and Diabetes

Obesity and diabetes are directly linked, and understanding their association is a fundamental step towards better health. Adipose tissue, or body fat, is not an inert substance. Instead, it causes a number of poor cardiometabolic effects, including insulin resistance, pancreatic beta cell dysfunction, hepatic steatosis, atherogenic dyslipidemia, and hormonal dysregulation.

There are several types of adipose tissue. White adipose tissue is pro-inflammatory with high endocrine activity. It plays significant roles in fat storage, metabolism, hormone secretion, and insulin release. Insulin resistance is a key initial driver of poor metabolic health. It causes resistance to the effect of insulin in the skeletal muscle and in the liver, plus alterations in beta cell function in the pancreas. When tissues are resistant to insulin, the pancreatic beta cells respond by making more and more insulin, leading to elevated fasting insulin levels. Insulin is a “fed-state” hormone, so it promotes fat storage and inhibits fat breakdown. This leads to more storage of adipose tissue and obesity. 

 As the volume of adipose tissue increases, the risks of both obesity and type 2 diabetes mellitus continue to rise. Adipose tissue also reduces satiety (fullness) hormones, increases hunger hormones, and promotes a pro-estrogen state. It produces damaging free radicals, leading to oxidative stress and mitochondrial dysfunction. Mitochondria are the energy powerhouse of cells. Damage to mitochondria leads to abnormal cellular metabolism. And as obesity and type 2 diabetes mellitus worsen, chronic inflammation continues to progress, causing long-term damage to mitochondria, cells, tissues, and other organs. 

Principles of Functional Medicine in Treating Obesity and Diabetes

Functional medicine is root-cause-focused health care. Rather than relying on a series of specific protocols uniform across every patient, functional medicine sees the body as a system, and it applies biology to the concepts of form and function as interdependent and interconnected units. 

When it comes to obesity and type 2 diabetes mellitus, which are directly linked, functional medicine does not view them as two separate, unrelated disease processes with different paths of treatment. Rather, functional medicine acknowledges that the body is a system. And, because they are directly linked, many of the same functional medicine approaches to treating obesity and type 2 diabetes mellitus are unified.

Not everyone with obesity has type 2 diabetes mellitus, and not everyone with diabetes has obesity. However, they are directly associated with the linkage of increased body fat in both diseases. With the increased adiposity comes insulin resistance, which is a core metabolic derangement in both obesity and type 2 diabetes mellitus, plus chronic inflammation and its downstream effects.

The functional medicine approach to obesity takes this abnormal function of increased body fat and addresses that root cause. Addressing the root cause of increased adiposity improves insulin sensitivity, reduces inflammation, lowers weight, improves HbA1C, and helps normalize other metabolic components.

However, it is important to understand that the personalized treatment of functional medicine is vitally important. Individuals are unique, and physiology varies from person to person, from gene expression to nutritional status to neuroendocrine hormones to other metabolic factors. This is where functional medicine testing can help elucidate the root-cause etiology and can guide personalized treatment for patients with obesity and diabetes mellitus.

The Role of Gut Health in Obesity and Diabetes

The gut microbiome contains a complex community of trillions of bacteria, viruses, and fungi (called the microbiota). The microbiome plays an integral role in disease prevention and in disease treatment. Your gut has massive impacts on immunity, cardiovascular health, metabolic health, overall nutritional status, and the risk reduction of autoimmune disease, cancer, gastrointestinal dysfunction, inflammatory diseases, and more.

The balance of your microbiome can be tipped out of equilibrium by many factors, like a poor diet, stress, inflammation, medications, and other factors. This unfavorable shift in the microbiome allows harmful bacteria to take over and good bacteria to die off, a condition called dysbiosis. Dysbiosis promotes a cascade of inflammation, neurohormone dysregulation, insulin resistance, and other metabolic derangements, illustrating the direct links between dysbiosis and obesity and type 2 diabetes.

A diet high in fat, sugar, and heavily processed foods feeds harmful bacteria within the microbiome. As the populations of harmful bacteria grow, their populations grow and release toxins that trigger inflammation in the gut lining and increase intestinal permeability (often called leaky gut), leading to inflammatory effects throughout the body. Dysbiosis has also been linked to many of the complications of type 2 diabetes as well, such as kidney disease, vascular disease, and neuropathy.

Because the foods you eat have a direct impact on your gut, learning to eat to optimize your gut health can have massive implications on your overall health. Just like an overgrowth of bad bacteria can lead to detrimental gut inflammation, feeding the good bacteria helps fight inflammation and can even protect the intestinal mucosa layer.

Prebiotics and probiotics are essential to optimal gut health. Think of prebiotics as the food or nourishment for the microbiota. All living organisms require nutrition. Prebiotics are found in certain foods. They travel through the gastrointestinal tract to the large intestine, where they are fermented and broken down by the microbiota, a process that releases anti-inflammatory compounds like short-chain fatty acids. The most common prebiotic is dietary fiber, but certain foods like oats, apples, leafy greens, garlic, and flaxseed function as prebiotics as well. While prebiotics are the nourishment, probiotics are the living organisms themselves. When dysbiosis is present, it can take months of a dedicated probiotic regimen to restore a healthy microbiome. In order for oral probiotics to be effective, they must survive the harsh conditions of the gastrointestinal tract to make their way to the large intestine. Many foods act as favorable probiotics, like yogurts, kimchi, kombucha, and sauerkraut. 

Nutritional Interventions and Dietary Modifications

Optimal nutrition is imperative for dietary modifications in diabetic care. Both obesity and diabetes are pro-inflammatory states. Proper nutritional strategies for obesity and diabetes depend on anti-inflammatory diets. Processed foods, refined carbohydrates, added sugars, artificial sweeteners, chemical additives and preservatives, and genetically modified organisms are all pro-inflammatory food ingredients. When these foods are consumed and their breakdown begins, they trigger a cascade of inflammation, which leads to an increased risk of (or worsening of) heart disease, insulin resistance and diabetes, weight gain, and other inflammatory conditions. 

In contrast, many foods in their more natural states actually function to fight inflammation, called anti-inflammatory foods. These help with blood sugar regulation, weight management, and overall metabolic health. The best nutritional strategies for obesity and diabetes include a diet full of anti-inflammatory foods, which not only help reduce inflammation but also improve overall metabolic health by controlling insulin, blood glucose, and neuroendocrine hormones. 

Minimizing pro-inflammatory processed foods and maximizing anti-inflammatory whole foods is recommended for everyone, especially those with obesity and/or type 2 diabetes mellitus. Evidence also suggests that a higher protein and lower glycemic impact diet helps control insulin resistance. Still, the ideal breakdown of macronutrients for the treatment of obesity and type 2 diabetes mellitus must be individualized. A functional medicine mindset includes a personalized nutrition approach based on the whole person.

Physical Activity and Exercise Programs

Physical exercise, defined as intentional physical activity, is a cornerstone of the treatment of type 2 diabetes mellitus and obesity. Not only does physical exercise help with weight reduction, but it also aids in the treatment and prevention of many associated complications of diabetes and obesity. Cardiovascular exercise offers more calorie burn and, thus, loss of adipose tissue, which can help reverse metabolic derangements. Strength (resistance) training helps improve muscle mass while also improving insulin sensitivity, and it also helps reduce stress on major joints like hips and knees.

When type 2 diabetes mellitus and obesity occur together, physical exercise for diabetic obesity shows significant improvements in glycosylated hemoglobin (HbA1C) levels, insulin sensitivity, cardiovascular disease risk, and weight reduction. Losing weight is often very difficult in patients with diabetes because of the alterations in hormones and metabolism. Physical activity is imperative in both weight loss success and maintaining weight loss.

The general recommendation for physical exercise in obesity and type 2 diabetes includes moderate-intensity cardiovascular exercise for at least 150 minutes per week. Adding strength (resistance) training at least 2-3 days per week shows significant improvement in metabolic markers. Strength training can be easily combined with cardiovascular exercise by adding light weights into aerobic activity, or it can be performed separately in addition to the cardiovascular components. 

Staying with a physical exercise program is not easy and requires commitment. For the best chance of success, exercise for diabetic obesity should be individualized. Some people may prefer to exercise in four 40-minute sessions per week instead of five 30-minute sessions. Others may find that three 50-minute increments are most reasonable. Individualization is important, even down to specific activities based on individual abilities or preferences.

Stress Management and Emotional Well-Being

Chronic psychosocial stress can be detrimental to overall health and well-being. Psychological, social, and physiological stresses can all increase the risk of and accelerate the progression of various diseases. 

Chronically elevated stress levels have been linked to worse long-term glycemic control in patients with type 2 diabetes mellitus. Chronic physical and mental stress contribute to abnormal stress hormone levels, chronic inflammation, intestinal dysbiosis, and even higher risks of developing autoimmune disease. Chronic inflammation and intestinal dysbiosis are directly implicated in obesity, as they lead to both weight gain and more difficult weight loss or maintenance. 

Both type 2 diabetes mellitus and obesity cause significant negative psychological stress. Obesity is heavily stigmatized, making it difficult even to seek care. The spectrum of disease in diabetes can require notable lifestyle changes overnight. And both obesity and type 2 diabetes can make people feel helpless, with things out of their control.

At the same time, positive emotional well-being in obesity and in type 2 diabetes bears a significant impact on treatment success and adherence. Addressing this paradox is vital to improving overall health; it is a driving principle within functional medicine. 

Treating the physiological components of illness can help improve chronic physiological stress. Addressing emotional stress includes strategies like mindfulness, meditation, prayer, breathing techniques, yoga, hobbies, time with family and friends, and adequate rest and sleep. Adopting an individualized approach to stress management and emotional well-being is imperative in achieving long-term success.

Monitoring and Personalized Adjustments in Treatment

People are living entities, constantly changing and adapting to their environments. Functional medicine acknowledges the body as a system, and it understands the concepts of biological form and function don’t exist in a vacuum. Metabolic processes are constantly affected by variable factors. Take nutrition, for example. Each food interacts with body systems–hormones, microbiome, metabolism, and gene expression. Not to mention the quality of the macronutrients and the other vitamins and minerals the food contains, all of which dictate how foods are broken down by the body. The effects of obesity and type 2 diabetes treatment are not uniform across every individual. 

Continuous glucose monitoring, HbA1C trends, weight tracking, serial fasting insulin levels, regular lab testing, dietary recalls, and physical activity logs are just a few assessment tools available to monitor individual responses to treatment. Using these results to monitor responses to diabetes and obesity treatment offers the opportunity for personalized treatment adjustments. The data gathered from these assessment tools is beneficial not only if it drives meaningful change but also if it occurs at regular intervals, focusing on the ever-evolving form and function of body systems. Personalized treatment adjustments must move in the direction of better health, addressing the root cause of obesity and type 2 diabetes mellitus interplay.

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Interventions for Obesity in Diabetic Patients: Key Takeaways

Poor metabolic health plagues our current world, and it is the underlying link between diabetes and obesity. From nutrition to physical exercise to stress management and much more, functional medicine is uniquely poised to improve health outcomes in patients with obesity and diabetes, improving quality of life through personalized and holistic care. As the field of functional medicine continues to grow, it offers promise in not only disease treatment but also in disease prevention. Viewing the body as a whole and looking at interrelated forms and functions allows for the best possible holistic treatment.