Manage the obese patient: Diet and lifestyle recommendations

Dieting does not work because of built-in survival mechanisms. The concept is also flawed because it is designed to be a temporary fix and the problem is much more complex than counting calories. The changes need to be permanent, and strictly limiting the amount of food is not sustainable.

This article presents some suggestions for managing your obese patients. Just remember: Teaching them what to eat and when to eat is much more important than how much they eat. 

Insulin insensitivity

Insulin insensitivity is sometimes called insulin resistance or prediabetes. The condition exists in most people who need to lose weight. The average American consumes more than 200 pounds of sugar each year (compared to about 10 pounds in the 18th century). About half of the calories the average American consumes consist of refined carbohydrates, which the body treats the same way it treats sugar. As a result, we are producing too much insulin. Eventually, we become insensitive to insulin, and that has serious health consequences. Insulin insensitivity can become diabetes if not treated.  

Symptoms of insulin sensitivity include fatigue, weight gain, brain fog, carbohydrate craving and periods of hypoglycemia after a high carbohydrate meal (often needing a nap after eating). Approximately 50% of people with high blood pressure are insulin insensitive. If weight is an issue, then insulin insensitivity is also an issue.   

You can have insulin resistance but still have normal lab results. If your fasting blood sugar is over 100, it may be due to insulin resistance. Another thing to consider is that insulin resistance can lead to high triglycerides, although that test is not used to diagnose diabetes. A more reliable test is the hemoglobin A1C test (sometimes just called the A1C test), which indicates blood sugar levels over time. An A1C level of 6.5 percent or higher on two separate tests indicates diabetes. An A1C between 5.7 and 6.4 percent indicates prediabetes (insulin resistance). Below 5.7 is considered normal. 

Insulin resistance can also lead to metabolic syndrome (sometimes called “Syndrome X”). According to the  Journal of the American Medical Association, if a patient has three or more of the following symptoms, Metabolic Syndrome (Syndrome X) is present:  

1. Waist measurement greater than 40” in men (35” in women) 
2. Triglycerides greater than 150 mg/dl 
3. HDL lower than 40 mg/dl 
4. Blood pressure greater than 135/85 
5. Fasting glucose of 110 mg/dl or more 

Getting insulin insensitivity under control

The following are some ways your patients can get their insulin insensitivity under control: 

Eat foods with a low glycemic load: Glycemic load is a measurement that helps you determine how much insulin is produced with a certain food. Do not eat anything with a glycemic load greater than 10. A diet high in fiber and polyphenols will help balance the microbiome.  

Exercise: Daily light exercise (not heavy workouts) can help bring insulin insensitivity under control.  

Intermittent fasting: This is a well-researched way to get insulin insensitivity under control and lose weight. You have an eight-hour window to eat. There needs to be 14 hours between dinner and breakfast the next morning (according to recent research). If you eat dinner at 5:00 pm, breakfast is at 7:00 am the next morning. It works because when you fast you produce glucagon, a hormone that helps break down fat.^1,2  

Magnesium taurinate: Producing excess insulin interferes with the absorption of magnesium, so most people with insulin insensitivity tend to be magnesium deficient.³ Magnesium is also important for blood sugar control and can help prevent the transition from prediabetes (insulin insensitivity) to diabetes,^4,5,6 Taurinate is a good form to use because it also addresses high blood pressure. 

Other glycemic support includes berberine. Also, most vitamin companies make a multiple that is designed to help with glycemic control.  

The microbiome’s role in weight management

Microbiome refers to the bacteria growing in the intestines. Your GI tract is an ecosystem. The right kind of bacteria will help remove toxins, produce vitamins, nourish the intestinal lining and keep pathogens (bad bacteria and yeast) in check. If the wrong kind of bacteria grow, they produce toxins and irritate the GI lining. New research is showing if the type of bacteria growing in the intestine can determine if you are overweight or not. 

A recent article gave an overview of the role of the microbiome in weight control.⁷ The authors concluded, “While diet and behavioral modification programs aiming to reduce weight gain and promote weight loss are effective in the short term, they remain insufficient over the long haul as compliance is often low and weight regain is very common. As a result, novel dietary strategies targeting the gut microbiota have been successful in decreasing obesity and metabolic disorders via different molecular mechanisms.” Other research supports this idea.^8,9   

What you eat affects the microbiome — and polyphenols are the key: A diet that is 75% (by volume) fruits and vegetables will help grow a healthy microbiome. Vegetables are high in polyphenols. Polyphenols are micronutrients obtained from plants. They are rich in antioxidants and research has demonstrated many health benefits from consuming polyphenols. They are produced by the plant to protect itself from ultraviolet radiation and pathogens. They are powerful antioxidants. 

More than 8,000 polyphenols have been identified in various plant species. Studies have shown diets rich in plant polyphenols may help protect the body from cancer,¹⁰ cardiovascular disease,¹¹  diabetes¹²  and neurodegenerative diseases.¹³   

The most important thing polyphenols do is affect the microbiome in a way that assists in weight loss. Resveratrol (a polyphenol you may have heard of), for example, helps reduce insulin resistance.¹⁴  Other studies have shown polyphenols to help alter the gut microbiome in a way that improves health.^15,16,17,18  

Chemical toxicity, liver and weight loss: Changes in liver and gallbladder function can lower bile production and lead to biliary stasis, especially in people who eat a highly refined diet. The amount of bile produced by the liver decreases, and it becomes thick and sluggish. If left untreated, bile can back up and cause further damage to the liver. Biliary stasis can also lead to the formation of gallstones. 

Poor bile production causes poor absorption of essential fatty acids and fat-soluble nutrients (vitamins A, D, E and K). The earliest symptom is usually itching. Pain (upper right quadrant, right shoulder or between the shoulder blades), varicosities and spider veins, dry or flaking skin, skin peeling at the heels, deficiencies in oil-soluble nutrients, constipation and even GERD (gastric reflux) can be the result of biliary stasis. Biliary stasis is very common in patients with insulin insensitivity.  

Consider giving a supplement to thin bile (artichoke extract base is best). It will help eliminate toxins. An article appearing in The Lancet¹⁹  indicates there may be a connection between persistent organic pollutants (POPs) and insulin resistance. Insulin resistance, if left unchecked, can lead to type 2 diabetes. POPs include chemicals like pesticides (e.g., dieldrin, DDT, toxaphene and chlordane) and several industrial chemicals like polychlorinated biphenyls (PCBs), dioxins and furans. The authors cite research showing a strong relationship between type 2 diabetes and the level of POPs in the blood. 

Research in Obesity Reviews looked at systematic reviews of relevant studies published between 1995 and 2016 pertaining to obesity and chemical exposure. The authors found, “Accumulated evidences show positive associations between pollutants and obesity in humans. Future large, long-term, follow-up studies are needed to assess impact of chemical pollutants on obesity risk and related mechanisms.”²⁰  

Final thoughts

It isn’t about losing weight; it is about getting healthy. If it was just about weight, Keith Richards would be a spokesperson for a weight loss company. The only thing we did not cover is the possibility of food sensitivity. Gluten and dairy are common culprits. See if there is a food the patient “absolutely has to have,” chances are that is the problem food. 

PAUL VARNAS, DC, DACBN, is a graduate of the National College of Chiropractic and has had a functional medicine practice for 34 years. He is the author of several books and has taught nutrition at the National University of Health Sciences. For a free PDF of “Instantly Have a Functional Medicine Practice” or a patient handout on the anti-inflammatory diet, email him at paulgvarnas@gmail.com. 

References

1. Klempel MC, et al. Intermittent fasting combined with calorie restriction is effective for weight loss and cardio-protection in obese women. Nutr J. 2012;11:98. NIH:NCBI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3511220/. Accessed Feb. 9, 2024. 
2. Furmli S, et al. Therapeutic use of intermittent fasting for people with type 2 diabetes as an alternative to insulin. BMJ Case Rep. 2018;2018:bcr2017221854. PubMed.  https://pubmed.ncbi.nlm.nih.gov/30301822/. Accessed Feb. 9, 2024. 
3. Alzaid AA, et al. Effects of insulin on plasma magnesium in noninsulin-dependent diabetes mellitus: evidence for insulin resistance. J Clin Endocrinol Metab. 1995;80(4):1376-1381. PubMed. https://pubmed.ncbi.nlm.nih.gov/7714113/. Accessed Feb. 9, 2024. 
4. ElDerawi WA, et al. The Effects of Oral Magnesium Supplementation on Glycemic Response among Type 2 Diabetes Patients. Nutrients. 2018;11(1):44. PubMed. https://pubmed.ncbi.nlm.nih.gov/30587761/. Accessed Feb. 9, 2024. 
5. Corica F, et al. Effects of oral magnesium supplementation on plasma lipid concentrations in patients with non-insulin-dependent diabetes mellitus. Magnes Res.1994;7(1):43-47. PubMed. https://pubmed.ncbi.nlm.nih.gov/8054260/. Accessed Feb. 9, 2024. 
6. Hruby A, et al. Higher magnesium intake reduces risk of impaired glucose and insulin metabolism and progression from prediabetes to diabetes in middle-aged Americans. Diabetes Care. 2014;37(2):419-427. PubMed. https://pubmed.ncbi.nlm.nih.gov/24089547/. Accessed Feb. 9, 2024. 
7. Van Hul M, Cani PD. Targeting Carbohydrates and Polyphenols for a Healthy Microbiome and Healthy Weight. Curr Nutr Rep. 2019;8(4):307-316. PubMed. https://pubmed.ncbi.nlm.nih.gov/31161579/. Accessed Feb. 9, 2024. 
8. Liu R, et al. Gut microbiome and serum metabolome alterations in obesity and after weight-loss intervention. Nat Med. 2017;23(7):859-868. PubMed. https://pubmed.ncbi.nlm.nih.gov/28628112/. Accessed Feb. 9, 2024. 
9. Olli K, et al. Independent and Combined Effects of Lactitol, Polydextrose, and Bacteroides thetaiotaomicron on Postprandial Metabolism and Body Weight in Rats Fed a High-Fat Diet. Front Nutr. 2016;3:15. PubMed. https://pubmed.ncbi.nlm.nih.gov/27376068/. Accessed Feb. 9, 2024. 
10. Arts ICW, Hollman PCH. Polyphenols and disease risk in epidemiologic studies. Am J Clin Nutr. 2005;81(1 Suppl):317S‐325S. PubMed. https://pubmed.ncbi.nlm.nih.gov/15640497/. Accessed Feb. 9, 2024. 
11. Graf BA, et al. Flavonols, flavones, flavanones, and human health: epidemiological evidence. J Med Food. 2005;8(3):281‐290. PubMed. https://pubmed.ncbi.nlm.nih.gov/16176136/. Accessed Feb. 9, 2024. 
12. Rizvi SI, Zaid MA. Intracellular reduced glutathione content in normal and type 2 diabetic erythrocytes: effect of insulin and (-)epicatechin. J Physiol Pharmacol. 2001;52(3):483‐488. PubMed. https://pubmed.ncbi.nlm.nih.gov/11596865/. Accessed Feb. 9, 2024. 
13. Scarmeas N, et al. Mediterranean diet and Alzheimer disease mortality. Neurology. 2007;69(11):1084‐93. PubMed. https://pubmed.ncbi.nlm.nih.gov/17846408/. Accessed Feb. 9, 2024. 
14. Harikumar KB, Aggarwal BB. Resveratrol: a multitargeted agent for age-associated chronic diseases. Cell Cycle. 2008;7(8):1020‐1035. PubMed. https://pubmed.ncbi.nlm.nih.gov/18414053/. Accessed Feb. 9, 2024. 
15. McGrattan AM, et al. Diet and Inflammation in Cognitive Ageing and Alzheimer’s Disease. Curr Nutr Rep. 2019;8(2):53-65. PubMed. https://pubmed.ncbi.nlm.nih.gov/30949921/. Accessed Feb. 9, 2024. 
16. Jiang R, et al. Serum Concentration of Genistein, Luteolin and Colorectal Cancer Prognosis. Nutrients. 2019;11(3):600. PubMed. https://pubmed.ncbi.nlm.nih.gov/30871032/. Accessed Feb. 9, 2024. 
17. Mezynska M, et al. Extract from Aronia melanocarpa L. Berries Protects Against Cadmium-induced Lipid Peroxidation and Oxidative Damage to Proteins and DNA in the Liver: A Study using a Rat Model of Environmental Human Exposure to this Xenobiotic. Nutrients. 2019;11(4):758. https://pubmed.ncbi.nlm.nih.gov/30935147/. PubMed. Accessed Feb. 9, 2024. 
18. Cattaneo C, et al. New insights into the relationship between taste perception and oral microbiota composition. Sci Rep. 2019;9(1):3549. PubMed. https://pubmed.ncbi.nlm.nih.gov/30837660/. Accessed Feb. 9, 2024. 
19. Jones OAH, et al. Environmental pollution and diabetes: a neglected association. The Lancet. 2008;371(9609):287-288. PubMed. https://pubmed.ncbi.nlm.nih.gov/18294985/. Accessed Feb. 9, 2024. 
20. Wang Y, et al. Do environmental pollutants increase obesity risk in humans? Obesity Reviews. 2016;17(12):1179-1197. PubMed. https://pubmed.ncbi.nlm.nih.gov/27706898/. Accessed Feb. 9, 2024.