Interview
Interview with Elizabeth Boham MD, MS, RD
Interview by Tony Nimeh MD
Dr. Tony Nimeh of PracticeUpdate talks with Dr. Elizabeth Boham of the UltraWellness Center in Lenox, Massachusetts, about managing obesity from the stance of functional medicine. In Part 1, Dr. Boham describes functional medicine and how it is uniquely positioned to help the patient with obesity, often multifactorial. In Part 2, she discusses specific triggers of obesity, such as sleep disorders and imbalance in the microbiota, and working with the patient on the behavioral change necessary to maintain a healthy weight.
Dr. Nimeh: Welcome, Dr. Boham. Before we begin, will you please say a few words about your background and how you got involved in your current practice?
Dr. Boham: Certainly.I am board-certified in family medicine. I practice functional medicine in Lenox, Massachusetts, at the UltraWellness Center. My undergraduate degree was in nutritional biochemistry and my graduate degree was in nutrition education and exercise physiology. During my graduate work at Columbia, I also received my registered dietitian degree. I worked in the field of nutrition for a few years and then decided to go to medical school. When I completed medical school and my family medicine training, I worked in a practice consisting of five physicians with nutrition backgrounds; we did everything from working with patients with obesity to working with patients who had diabetes, or really anything nutritionally related.
We did a lot of in-hospital and at-home total parenteral nutrition, as well as enteral feeding and support for the surgeons doing gastric bypass surgery in our area. Then, I learned about functional medicine. Functional medicine has been a great way for me to continue to bring my background in nutrition to my medical practice, because, in functional medicine, we use often use nutrition as medical therapy,
What is functional medicine?
Dr. Nimeh: What is functional medicine, and how is it different from traditional approaches in medicine?
Dr. Boham: Functional medicineis a way of looking at a patient’s problems by searching for the underlying cause. We focus a lot on behavioral change and modification.
We recognize the fact that, of 10 people with obesity, there may be 10 different reasons for it. If possible, we want to understand the root cause of the individual’s obesity so that we can treat that person more effectively. One patient’s obesity may be related to a genetic predisposition, whereas another patient’s may be related to his food choices. Another patient’s obesity may be related to her movement or exercise, and yet another’s may be toxin-related. The idea in functional medicine is to identify and treat the root cause of the problem and help to rebalance systems in the body that may be out of balance.
The obesity epidemic
Dr. Nimeh: Why are we going through an obesity epidemic right now, and is there a way out?
Dr. Boham: There are many reasons why we are going through an obesity epidemic, including change in our lifestyle to one that is less active and because our jobs require less physical activity. We are definitely eating more calories, more foods that cause inflammation, and more processed foods, which all influence weight. Other factors include toxins in the environment, such as persisting organic pollutants, bisphenol A (BPA), and hormone disruptors, as well as our microbiomes.
Many of us have heard the statistic that more than one-third of adults in this country are obese, and that is having a huge impact on our medical costs. Is there a way out? I think so. The medical profession is working very hard to prevent obesity from becoming a problem with our kids and to identify it in our patients. We try to at least discuss it during appointments and help our patients to make some changes in their lifestyle that can help to prevent and reverse obesity.
An article in JAMA that was released in February showed that the obesity rate in children between the ages of 2 and 5 years has actually declined.1 In 2003 and 2004, the rate of obesity was 14%, and by 2011 to 2012, it had decreased to 8%. While that is just one data point, one point in time, the study shows us that there may be a way out of this if we work really hard to continue to identify people early, especially children, so that we can prevent obesity from becoming a problem in the first place.
Dangers of obesity
Dr. Nimeh: Can you please say a few words about the dangers of obesity?
Dr. Boham: Obesity increases the risk of heart disease, stroke, diabetes, and especially certain cancers, including cancers of the breast, prostate, colon, and lung. The way we are classifying obesity now in most studies is by body mass index (BMI), with a BMI over 30 being obese. However, many people who have a high BMI may not have an excessive percentage of body fat; so, BMI really does not give us all of the answers about somebody’s individual risk. Some people have a high BMI, but, because of their high percentage of lean muscle mass, do not have as much risk as somebody with a high percentage of body fat.
On the other hand, patients may have a normal BMI but a high percentage of body fat (eg, patients with sarcopenia or a low lean-muscle mass) and may be at an elevated risk for diseases associated with excessive body fat. Thus, BMI gives us some information, but we also need a physical exam to determine the patient’s body fat percentage.
Importance of a patient history
Dr. Nimeh: What is your approach to a patient complaining of obesity?
Dr. Boham: The first thing I do is get a very careful history. It’s important to figure out this patient’s timeline. When did she start to gain weight? How quickly has she been gaining weight? Was she overweight as a child? Was she obese as a child? Was this more of a slow, steady weight gain that occurred in her middle years? Did this weight gain start suddenly and quickly accelerate? Answers to those questions can provide information on what may have contributed to the weight gain. If it was a slow, steady weight gain and the patient is living in an obesogenic environment, then we intervene in a different way than we do for somebody who experienced a quick weight gain, for which we would investigate thyroid function or some acute distress.
So, it is important to first and foremost obtain a very good, detailed history and determine when the obesity began. In addition, we know that if a person has been overweight for his whole life or if he was heavy as a child, it is more difficult for him to maintain a normal weight as an adult. I start with a detailed timeline and figure out what the patient’s potential triggers for weight gain may be. We know that many things that can influence weight, and we are learning more and more about the effects of genetics and the epigenome.
We are learning that genetic variation influences many factors that impact our weight, from the absorption of nutrients to metabolism to the sleep cycle and circadian rhythm. These factors can all influence how difficult it may be for a patient to lose weight. That is important for physicians to understand because some patients who really work hard at weight loss don’t see the same results as others; great variation exists between people based on genetics in terms of how well they will respond to an intervention. We need to really address that point with the patient and help him to understand that the type of response he may have to a specific intervention may not be the same as someone else’s response.
As we learn more and more about obesity, we realize that it results from a real interaction among the genome, epigenome, and environment, all three of which have a huge impact on weight throughout a lifetime. It is also very interesting to recognize the fact that a mother’s weight and weight gain during her pregnancy influences her offspring’s weight and weight gain throughout his life. Gestational diabetes, not enough calories, and too much weight gain during pregnancy have all been associated with increased weight and obesity in offspring.
Dr. Nimeh: It seems that this is not just a genetic component, but also a developmental component that occurs in the embryo stage.
Dr. Boham: Absolutely. It’s a combination of genetics, epigenetics, and early environmental influences, which all have an influence on somebody’s weight and how difficult it is for that person to maintain weight or how easy it is for her to develop insulin resistance. Some people have to be very careful with excess sugar or refined carbohydrates in their diet because they develop insulin resistance much faster than others, and we think, “Oh, genetics are involved”; but, early environmental influences may also have a big impact.
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