2: The 8 Pillars of Metabolic Health

When it comes to healthy and sustainable ways to lose weight, nothing works without a comprehensive approach. These key pillars of weight management are exactly the sorts of medical and lifestyle factors you would expect to discuss if you worked with an obesity medicine physician. 

Obesity is a chronic medical condition, it is not a lifestyle choice. So we need to put our detective hats on and really dig deep into the different areas where we can find tools that can help us. While we do not have a cure, we do have a lot of treatments for it.

When patients come into my clinic, there are certain factors I like to address in order to develop the best approach for them. Remember there is no ‘one size fits all’ when it comes to obesity.

While this is not a comprehensive list of all the factors I consider, these are definitely some of the key aspects I like to discuss.

Medical History

I like to see what type of medical conditions a person might have been diagnosed with in the past.  I look at things like if they have a diagnosis of diabetes, PCOS, or insulin resistance. Their mental health history is also extremely important. Looking for issues like anxiety, depression, ADHD etc. really matters because that is going to inform a lot of what I do to support this patient. 

Medications

Looking over medications really cannot be stressed enough. We use the word obesogenic, meaning weight promoting medications. A lot of the time, people can be on a number of medications and some of them might be leading to a lot of weight gain. 

Sometimes you are going to have to stay on these medications because they might be helping to keep your mental health managed, for example. Neuropathy is another area where I see this. People who have severe nerve pain might be taking a medication that’s causing weight gain but without it, their pain level is at a 10/10. Sometimes we might be able to swap something out or look at other things we could add to negate that.

When it comes to medication, I also like to look at the medication list and consider, if we were able to get X, Y, Z amount of weight off, what would be likely to change about that list? If I see someone is on four blood pressure medicines and their weight comes down,  they would likely need less. Maybe none. I don't ever overpromise because not all medical problems are because of weight but a lot of the time I see the blood pressure medicine going down. Or maybe your pain levels are down because you're physically carrying around less weight. 

So medication is interesting from two main standpoints: 

1. Is there any medication leading to weight gain? 
2. If we were able to get weight down, how could we see that medication list change? 

It is usually very motivational for people to just know that these are the types of changes they could expect.

Lab Work

This includes all of the traditional things like thyroid function, blood sugar levels, and cholesterol. But what's interesting is that it doesn’t provide a complete picture. Just because a problem has not emerged yet doesn't mean that someone is not very metabolically sick. Lab work does not check hunger hormones, for example.

A lot of the results from the lab work typically follow what I’d call the ‘metabolic syndrome picture’. That's when the blood sugar is elevated, the good cholesterol is too low, and the triglycerides are too high. It’s a certain profile that we see if you have extra weight, but some of you will have a clinical picture that does not fit that. So if you’re not fitting that picture, that’s something you’d want to know as there may be more of a genetic syndrome or something else happening. This is why it's very helpful to go over lab work in detail with your physician.

Body Composition

What I really care about here is the constitution of the person in front of me. The simplest thing that you could do right now, no matter what your access level to care is, is to figure out your waist circumference.Here is the tape measure I recommend often. This is a very telling number because if your waist circumference is elevated, that means that there's a lot of visceral adiposity(visceral fat) in the stomach area. This really lets you know that you're at increased risk of metabolic diseases like heart disease.

Nutrition

It is not just about focusing on calories and calories out. What I prefer to do is look at the quality of what someone's eating. I look at how much ultra-processed food they have, if they're drinking sugary beverages, and how much water they're taking in. It’s also important to look at their eating patterns, whether they’re eating out a lot, eating in front of the TV etc. I need to know if they’re eating mindfully and listening to their hunger cues, as this will have a huge impact on weight.

Exercise

Everyone is at a different place with this. Some people have absolutely no movement, whereas others are exercising a lot and get frustrated because they're not losing weight.

A ton of exercise is really not the main way to lose weight. It's really great for weight maintenance and for mental health and for maintaining muscle and a lot of other things. But it's not the first place that I start with people on day one. However, I do need to know where they're at so we can quickly start to bring it in.

Stress/ Mental/ Emotional Health 

Looking at a combination of a patient’s stress levels and their mental and emotional health is significant in being able to work out next steps and what will be the correct approach going forward. I need to learn about a patient’s work environment, their family dynamic, their coping strategies, and what their support system looks like if they’re making big life changes. 

This really matters because people's bandwidth is different at different times in their life.  So if you’re ‘time poor’ for example, we’d have to create different nutritional plans and tools for you. We just need to know what we're working with to come up with the best approach.

Sleep

Sleep quality is crucial because it plays a huge part in our hunger hormone regulation, as well as a lot of other things such as our mental health. It goes beyond assessing issues like sleep apnea. It includes looking at if you’re snoring, if sleep is fragmented,  and whether you actually feel restored in the morning.  

Sleep is highly complex but it has a lot of intersections with weight. A very practical first step could be asking your  primary care doctor if you need to get a sleep study done if you’re not feeling fully rested in the morning. 

Conclusion

This list is in no way comprehensive but by just looking at some of the different areas you can dig into with your physician, shows us that there is a wide spectrum of factors that need to be considered. Obesity is a complex condition and it’s highly  likely there’s a reason that you haven't been able to simply solve this on your own up to this point. That’s not a reason to beat yourself up, but a reason to seek the proper help you need  to guide you through it.