A Multi-Faceted Approach to Weight Loss: A Case Report

Abstract

Background

A 55-year-old, post-menopausal, obese female with obesity-related symptoms seen by a nutritionist using motivational interviewing and self-determination theory assisted a client with an elimination diet and lifestyle modifications to lose weight.

Case/Intervention

An elimination diet was the primary component of these recommendations, identifying food sensitivities associated with an inability to lose weight. Biomarkers identified abnormalities to help individualize and guide nutritional recommendations. Motivational interviewing and the self-determination theory were used in this functional nutrition approach.

Conclusion

Over a six-week period the client had an 18-pound reduction in weight, a loss of 22.5 inches of girth and decreased bloating.

INTRODUCTION

A body mass index (BMI) greater than 30.0 classifies a person as obese.^1,2 Obesity-related health conditions include diabetes, cardiovascular disorders, arthritis, sleep apnea, and some cancers.^1,3 The causes of obesity are multifaceted and include genetics, environmental factors, and lifestyle choices.^3,4

Historically, the primary treatment approach has been to counsel people to eat less and move more. While that approach can be effective, it often does not get to the root of the problem. This case report describes the use of a system-oriented approach to weight loss, based on emphasizing “the importance of high-quality foods and phytonutrient diversity to address clinical imbalances and move individuals toward the highest expression of health.”⁵ A 5 to 10 percent weight loss can delay or prevent some of the diseases mentioned above.¹ Studies have confirmed that diet alone does not lead to long-term weight loss for most people.⁶ The functional approach taken in this case included a customized elimination diet from the Institute of Functional Medicine, the use of biomarkers, motivational interviewing, lifestyle modifications, as well as utilizing the self-determination theory.

Case Presentation

The client is a 55-year-old, post-menopausal, overweight, Caucasian female with a chief concern of weight gain interested in losing 50 pounds. She complained of bloating, indigestion, gas, neurological symptoms, forgetfulness, depression, fatigue, arthritis (joint pain and stiffness), and dry skin. She has trouble making good nutritional choices, leads a high-stress life, and recently began smoking after having quit ten years ago.

Her quality of life is affected by her weight and contributes to a sense of poor self-esteem, exacerbated by a decade’s long history of failed attempts at long-term weight loss. She avoids mirrors and trying on clothes at stores. In the past, she received regular vitamin B₁₂ injections. She recently began acupuncture treatments and was given a series of herbal supplements.

As a child, she had a normal weight and began taking “diet pills” in high school to avoid gaining weight. She continued to gain weight in college and remained 10-15 pounds over her desired body weight. In 1987, at age 25, after the birth of her daughter and while working at a sedentary job, she gained an additional 30 pounds. At age 27, she went on a liquid diet and lost 30 pounds, which she regained within two years. She continued to unsuccessfully try the latest fad “diets.”

Timeline.

At age 38, she started playing tennis and began a high fat, low carbohydrate diet (Atkins). She lost 30 pounds over eight years. A shoulder injury limited her ability to play tennis, and she began to gain weight back and increased her consumption of simple and processed carbohydrates. She also began various diet plans and was unsuccessful in losing weight. In 2014, she gave up trying to lose weight and began taking antidepressants that were prescribed by her primary health care provider.

In February 2018, she joined a gym and started working with a trainer. Although she has not lost weight, she reports feeling better and having better mobility. She consumes her evening meal quickly in order to play with her grandchild. She is an emotional eater and feels she is under a lot of stress.

In June 2018, the client sought the help of a functional nutritionist via teleconferencing. During the initial assessment, she appeared to have hypochlorhydria, dysbiosis, and possible candida overgrowth. A stress assessment indicated a high level of stress. Her current diet, an “attempt to eat healthy,” included daily eggs and coffee, some nuts and seeds, and was low in vegetables and fruit. She states that she eats in restaurants 2 to 4 times per week and enjoys cheese and bread. In her initial consultation, she was given an Elimination Diet Plan and was recommended to continue working with her fitness trainer at least three days per week. She was also given a tape measure and educated on how to measure her own girth, a body fat caliper (to use later), and a blood pressure monitor. She was also instructed to have initial photos taken and progress pictures every four weeks. She was instructed to record her progress and report her results every two weeks before each of the “virtual” meetings with her nutrition practitioner. The practitioner used a Google shared drive to document and report the client’s progress, measurements, pictures, biomarkers, and a food journal (as needed) for continuous feedback and accountability.

The practitioner recommended the Institute of Functional Medicine’s Elimination diet⁸ to this client to assess potential connections between food sensitivities and digestive issues, inflammation, and pain. The recommended diet eliminated meat, dairy, soy, certain grains (barley, corn, rye, spelt, wheat), peanuts, corn, sugar, shellfish, eggs, processed foods, certain beverages, chocolate, and artificial sweeteners. She was instructed not to count calories but to eat three meals per day following the Harvard Medical School Plate. The plate consisted of 25% lean protein, 25% complex carbs and dietary fat, and 50% fruits and vegetables. A 3:1 ratio of vegetables to fruit was recommended. A copy of the client’s nutritional plan can be viewed in Table 1. In addition to eating three meals per day, she was instructed to consider time restricted feeding, aiming for a 12 to 15 hour fasting window where she avoids calorie containing foods and eating within a 9-12 hour window. For breakfast, it was recommended that she consume a green shake to incorporate a variety of phytonutrients and polyphenols to optimize gastrointestinal function. Foods such as fresh ginger, frozen berries, kale, celery, and psyllium husks were encouraged for added fiber.

Table 1.

Nutritional Intervention

Foods to Avoid	Foods to include	Other tips
Grains That Contain Gluten (Barley, Corn, Rye, Spelt, Wheat, Bulgur, Seitan)	Cruciferous vegetables (such as broccoli, cauliflower, Brussel sprouts, celery)	Do not count calories
Dairy: Milk, Butter, Cheese, Cream, Yogurt, Ice Cream	Onions, garlic, shallots	Three meals per day
Meat: Beef, Pork, Processed Meats	Spices and herbs such as garlic, ginger, curcumin	25% lean protein, 25% complex carbs or fat, 50% fruits and vegetables
Corn	Antioxidant fruits such as blueberries, pomegranates	3:1 ratio of vegetables to fruit
Peanuts	Leafy greens such as kale, spinach, lettuce, romaine	Time restricted eating window of 9 to 12 hours
Soy	Herbs such as basil, cilantro, parsley, mint	Green shake for breakfast-ginger, kale, celery, fiber, berries
Sugar	Healthy fats: nuts, olive oil, avocados	Follow the 80/20 rule
Artificial Sweeteners (Diet Soda)	Lean protein: chicken and fish	Chew food thoroughly
Processed foods	Dairy Alternatives	Change eating environment-quiet setting, minimal distractions
Shellfish	Gluten-Free Whole Grains (amaranth, kasha, millet, buckwheat, quinoa, oats, rice, teff)	Slow down eating speed
Chocolate	Seeds	Drink a glass of water before meals
Alcohol, Coffee, Soft Drinks, Tea	Legumes	Diversify food intake, try not to eat the same food each day
Eggs	-	Limit consumption of nightshade vegetables such as tomatoes and peppers

The client was directed to restrict her intake of processed foods, soda, and sugary snacks both in the short-term and long-term. The changes were implemented gradually, and she was given significant support during the process. The 80/20 rule was recommended to allow for gradual habit building after the Elimination Diet. The 80/20 rule is a flexible approach to weight loss. It incorporates balance and moderation, so the individual has room for error. In this rule, 80% compliance to the diet is enough to deliver results without promoting emotions of guilt and failure. She received a shopping guide and recipe book to help her plan her meals. Flexibility was built into her program so that she did not feel deprived or feel the need to binge eat. She received regular education to support adherence to a healthier long-term eating plan. Vegetables were a primary focus, including broccoli, watercress, and leafy greens—foods associated with a reduction in inflammation. Other recommended foods included onions (high in quercetin), garlic, spices including curcumin and ginger (associated with anti-inflammatory properties), and pomegranates and blueberries (high in antioxidants). Healthy fats were recommended daily.

The client was instructed to run a hydrochloric acid (HCL) challenge to evaluate potential hypochlorhydria. The client started with one capsule of betaine/HCL/pepsin (650–750 mg) with a meal containing protein and increased the dose to tolerance (a healthy stomach may produce 1.5 L of gastric acid daily). At four pills, she experienced heartburn, so she reduced her dose to two pills. It was determined that she had mild stomach acid deficiency, which may be contributing to some of her digestive issues and nutritional deficiencies. It was recommended that she take an appropriate dose of HCL when eating protein-containing foods and digestive bitters with other meals.

On her second “virtual” appointment two weeks later, she reported her digestion has improved, and she no longer felt the food was “sitting in her stomach” after meals. She noted an increase in creativity and improvements in her moods. She reported consuming green shakes and added fruits and vegetables to her diet. She also reported having lost four pounds in the first week; however, was distraught at having gained two pounds in the following week. She reported decreased bloating.

Laboratory studies revealed abnormal biomarkers including dyslipidemia, hyperinsulinemia, hypercholesterolemia, and elevated fasting glucose. In addition, her hs-CRP was elevated, and Vitamin D levels were decreased. Uric acid and homocysteine were also above range. See Table 2 for a more detailed view of the client’s biomarkers and the corresponding intervention.

Table 2.

Lab Results and Interventions

Test Result	Value	Suggested Intervention	Length of Intervention	Why Supplements or Interventions Were Chosen
Low Vitamin D, 25-OH	20mg/ml	Vitamin D3/K2 (5000 IU), 10-30 minutes of sunlight 2-3 times per week, increase consumption of foods high in Vitamin D	Recheck levels in 3 months	25(OH)D is inversely associated with BMI, waist circumference, & body fat; positively associated with age, lean body mass, & vitamin D intake.7 Research: Vitamin D associated with a reduction in levels of IL-6.9
Elevated Cholesterol	247 mg/dL	Limit processed fats, processed foods, include essential fatty acids	Long-term	A cardioprotective diet includes whole grains, vegetables, fruit, and legumes and is limited in meat products and refined and processed foods. A heart-healthy diet is high in dietary fiber, complex carbohydrates, vitamins, minerals, polyunsaturated fatty acids, and phytochemicals.10 Weekly exercise durations of <2.5 and ≥2.5 hours are positively associated with HDL.11
Low HDL	43 mg/dL	Increase exercise & consumption of healthy fats	Long-term
Elevated LDL	180 mg/dL	Decrease consumption of refined and saturated fats and sugar	Long-term
Elevated triglycerides	116 mg/dL	Decrease consumption of refined and saturated fats and sugars	Long-term
Elevated glucose	111 mg/dL	Reduce foods high in refined carbohydrates & sugar, increase fiber and lean protein intake	Long-term	Research: diets containing whole grains, fruits, vegetables, legumes, nuts, moderate in alcohol consumption, and lower in refined grains, red/processed meats, and sugar-sweetened beverages may help reduce risk of diabetes and improve glycemic control and blood lipid levels.12
Elevated insulin	25 uIU/ml	Reduce foods high in refined carbohydrates & sugar, include more fiber & healthy fats	Long-term
Elevated serum homocysteine	10.6 umol/L	Multivitamin: Nutrient 950 with NAC, increase consumption of folate-rich foods & foods high in Vitamins B6 and B12	Recheck levels in 3 months	B vitamins and N-acetylcysteine (NAC), a thiol-containing antioxidant, can lower levels of homocysteine.13
Elevated hs-CRP	7.1 mg/l	Fish oil (TID)- 1-2 g with meals (1.5:1 EPA: DHA), Vitamin C: equivalent to 1,000 mg per day	Recheck levels in 3 months	Omega-3 fatty acids may lower inflammation. Omega-3 decrease serum levels of TNF-α, a pro-inflammatory cytokine.14 Vitamin C is related to lower levels of hs-CRP which may protect against inflammation.15
Elevated uric acid	8.9 mg/dL	Refer to the physician to check for gout, atherosclerosis, circulation disorders, diabetes, etc.	-	Further testing may be needed to understand the root cause of the elevated uric acid.

As a result of her abnormal lab results, the client was motivated to continue with the program and improved her health to reduce her health risks. She was given basic nutritional and supplemental recommendations and was advised to consult with her health care provider before beginning the intervention.

The focus of the second appointment was digestive optimization. Strategies such as drinking a large glass of water before meals, avoiding drinking water during the meal, and chewing her food thoroughly were discussed. It was recommended to eat slowly and find a quiet time to eat her meal without distractions. She continued to take two HCL with protein containing foods and digestive bitters with non-protein containing foods. These suggestions were aimed to enhance digestion as well as improve assimilation and subsequent metabolic function.

In the third appointment (week 4), the client reported she had lost a total of six pounds and continued to lose inches from her girth; she was pleased with the results. She had received some compliments from friends and family. She reported the digestive bitters were causing indigestion and were discontinued. She was prescribed a six-day course of Methylprednisolone for a blocked tube behind her ear by her primary health care provider.

She was concerned that her progress would slow down now that she was including snacks. She was advised to continue with the Elimination Diet (including nightshade vegetables) and choose lower glycemic fruits, lean proteins, nuts, and raw vegetables for any snacks. She indicated she is quitting smoking as a result of her laboratory abnormalities, weight concerns, and possible candida overgrowth. The client received daily telecommunication for support between follow up appointments.

In the 4th appointment (week 6), the client reported she had lost a total of 10 pounds and continued to lose inches from her girth. Her clothes were fitting significantly looser on her, and her family noticed her weight loss. As a result of food sensitivity testing, she was recommended to eliminate the high and medium reactive foods and rotate the low reactive foods in her diet. She discovered fungal overgrowth through organic acid testing, which was ordered by the nutrition practitioner, and expressed the desire to begin antifungal therapy. She was recommended to rotate monolaurin, oregano oil, olive leaf extract, and caprylic acid as part of her supplemental regimen and to include oregano and garlic regularly in her diet. Although her weight continued to fluctuate, she was no longer distressed about the fluctuations. She also indicated that she does not have intense food cravings anymore and is now enjoying the eating plan. She has become more conscious of her hunger and satiety and plans to continue working with the fitness trainer three times per week. She will be walking on days she is not exercising at the gym.

In the 5th appointment (week 8), the client reported she had lost a total of 11 pounds, but no additional inches from her girth. She was happy with her results so far. See Table 3 for a more detailed view of the client’s starting and current measurements. She has removed the foods that were flagged on her food sensitivity test and has continued with the elimination of those select foods. She indicated the need for additional exercise modalities due to time constraints and was recommended to start HIIT (high-intensity interval training) three times per week. The training consisted of full body cardiovascular and weight training at a higher intensity, alternating with periods of rest. HIIT is also known as HIIE (high-intensity intermittent exercise). She expressed a desire to continue with the program until she has reached her goal of 50lbs in total.

Table 3.

Starting and Current Measurements

	Weight	Waist	Chest	Arm	Neck	Hips	Total inches
Starting measurements	230	49.5	51.25	20	18	53	191.75
Current measurements	212	42.75	46	16.25	15	46	169.25
Total weight loss	18					Total inches lost	22.5

In the 6th appointment (week 12), the client was pleased to report she had lost a total of 18lbs. She indicated that she no longer has strong cravings for sweets, but she still misses eating bread. She no longer drinks soda and has adapted to drinking plain carbonated water as a substitution. Although she is following the original diet, she is now allowing herself to deviate somewhat from the program, and it has not negatively impacted her weight loss. She has indicated a desire to consume bread on her trip to Europe, and she was advised to incorporate a gluten digesting enzyme (“GlutnGo”) to avoid any potential reactions to gluten. Overall, she is pleased with the results and plans to continue with the program.

DISCUSSION

Obesity is defined by the World Health Organization (WHO) as ‘abnormal and excessive growth of the amount of fat in adipose tissue to significantly disrupt the health’ and is a risk factor for food intolerances, inflammation, and chronic disease.¹⁶ According to the WHO, half of the world population has a food intolerance (FI), which is a type 4 delayed hypersensitivity and is associated with chronic systemic inflammation.¹⁶

The long-term weight management of obesity is challenging and associated with a high risk of failure.¹⁷ A comprehensive approach including personalized nutrition, motivational interviewing, lifestyle modification, and utilizing the concepts of self-determination theory may better address the physiological, emotional, and motivational factors that contribute to this client’s success after years of struggle.

The elimination diet is often helpful in discovering and eliminating foods associated with symptoms that may interfere with weight loss. Foods are commonly reintroduced after elimination to further assess individual sensitivity and tolerability.⁸ Some foods appear to cause reactions in some people, particularly if their digestive symptoms are associated with ‘leaky gut’, a breakdown of the tight junction barrier in the intestinal epithelial lining, resulting in chronic inflammation.¹⁸ Gluten, casein, soy, eggs, and corn are common triggers for symptoms suggesting food sensitivities. The elimination diet facilitates the discovery of foods associated with symptoms in an individual client.¹⁹ Eliminating foods to which a client is sensitive and replacing them with nutrient-dense, non-reactive foods can be added to what is commonly accepted as necessary to lose weight: a reduction in calorie-dense foods, the need to limit portion sizes, and the need to increase physical activity.

Biomarkers can guide the practitioner and can also motivate a client. With this client, biomarkers served as motivation to quit smoking and adhere to her diet plan. Some of the client’s biomarkers were outside of an optimal range. “Macronutrients in the adipose tissues stimulates them to release inflammatory mediators such as tumor necrosis factor α and interleukin 6, and reduces production of adiponectin, predisposing to a pro-inflammatory state and oxidative stress.”20 When interleukin 6 is elevated, the liver is stimulated to create and secrete C-reactive protein (CRP). Inflammation (in this case precipitated by obesity) acts as a mechanism for the development of cardiovascular disease, metabolic syndrome, insulin resistance, and diabetes. Obesity and inflammation are also associated with the development of non-cardiovascular diseases such as psoriasis, depression, cancer, and renal diseases.²⁰

Motivation can be seen as a predictor of treatment success, and Motivational Interviewing (MI) can be used in weight control programs.²¹ MI is a “patient-centered communication style that uses specific techniques, such as open-ended questioning, reflective listening, autonomy support, shared decision making, and eliciting change talk.”²²

Through MI, behavior change techniques aim to help clients identify and change behaviors that may be interfering with the desired outcome. “If we want to change behavior it is necessary to change the underlying beliefs and feelings related to that behavior.”²³ Throughout the process, modifying behaviors, thoughts, and feelings associated with behavior change encourages autonomous regulation. This technique takes time but can ultimately lead to improved long-term outcomes in weight management. Five principles of Motivational Interviewing used with this client include: (1) empathy, (2) avoid arguments, (3) support self-efficacy, (4) accept resistance, and (5) develop discrepancy.²³

Self Determination Theory (SDT) is based on a social-contextual approach to motivation by encouraging clients to have input and choice (autonomy support) in making healthy lifestyle choices.²¹ SDT reinforces that a client’s experience can be enjoyable and self-initiated through autonomy, and that supportive interactions promote and sustain behavioral change. Through autonomous motivation, the extent to which a behavior is personally endorsed and engaged is with a sense of choice and desire. Changes based on autonomy are more likely to be sustained over a long period of time.²¹

Exercise is a key component of an effective weight loss strategy. Unfortunately, few adults meet the weekly guidelines of 150+ minutes of moderate –intensity or 75+ minutes of vigorous-intensity aerobic physical activity and 2+ days of resistance exercises per week.²⁴ The good news is that high-intensity interval training (HIIT) provides fitness and health improvements in less time per week than current guidelines requires. Compared to continuous training, HIIT can promote similar or greater improvements in fitness and cardiovascular function in a shorter amount of time.²⁴ This style of exercise is often appealing since there is less of a time commitment as well as enhanced outcomes from the exercise. Although the intensity requirement for HIIT may be intimidating, the reduced time requirement may be appealing to many adults. This shows potential for higher rates of adherence.²⁵ HIIT also significantly lowers insulin resistance and can result in physiological adaptations that result in enhanced body fat oxidation and improved glucose tolerance. Longer term responses to HIIT include increased overall fitness, decreased fasting insulin and insulin resistance, as well as reductions in subcutaneous and abdominal fat.²⁶

This multi-faceted approach makes it difficult if not impossible to measure the effect of any one component on the desired goal — weight loss.

Patient Perspective.

I have learned so much on this program. It is so refreshing to have someone actually LISTEN to me and not just telling me to eat fewer calories and exercise more. I appreciate that the path I am on is based on a functional approach and not the diet of the month. To date I have lost 11 pounds and over 21 inches. I can feel my stomach has gone down some, my arms are smaller, my clothes are fitting better, and I can move around better. I will continue the elimination diet, it is a challenge, but I am seeing results, so I will continue. I am surprised that I have not had more cravings especially for bread and cheese and eggs. Also, my hunger has gone down.

I also appreciate the constant contact from my nutritionist. It helps me to stay in touch with what I have committed to doing. It keeps me focused on a day to day basis. If I were just weighing in once a week, I think I would be much more tempted to have a couple of “cheats” here and there. I do enjoy reading the articles she sends, but it is the contact that has the most impact. I know I still have a long way to go, but I am confident in time I will get there.

CONCLUSION

This case report demonstrates the possible utility of using a functional nutrition approach to help with resolving a client’s long-term battle with obesity. The main approach utilized was the Institute of Functional Medicine’s elimination diet. The comprehensive plan also encompassed motivational interviewing, other lifestyle modifications, and concepts of the self-determination theory. Specific biomarkers were utilized to help guide the practitioner to design a personalized nutrition plan in accordance with the elimination diet. The biomarkers also prompted the use of dietary supplements to help achieve the desired results of weight-loss and a reduction in the other obesity-related symptoms the client is suffering from. Over an eight-week period, the client had great success with weight loss and the loss of inches. While the practitioner and the client have been successful with achieving a loss of weight, it is difficult to determine which component of the functional nutrition approach led to the success. However, the multi-faceted approach was found to be beneficial.