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Yousef Elyaman:
Yeah, and because what I do, I’m a primary care physician, so I see people in an insurance-based model. Even though they come to me for other reasons, many times, we’re going to do some screening tests, we’re going to check their cholesterol, we’re going to check blood work, and yeah, that happens often where they come in for one thing and then as we start building rapport and we start digging in a little bit further, we start finding out, unraveling some of the metabolic dysfunction that they have.

Kalea Wattles:
Absolutely, and I mean, what proportion of your patients would you say, in a primary care setting, what proportion of patients have some signs or symptoms of metabolic dysfunction?

Yousef Elyaman:
Over 80%.

Kalea Wattles:
Yeah. So as we’ve said before, this is super common, and functional medicine is particularly well-suited to meet these patients where they’re at and to dive in to support their metabolic health. Will you tell us a little bit about, what are the signs and symptoms that might indicate an assessment, a workup for metabolic dysfunction?

Yousef Elyaman:
So signs would be signs of insulin resistance because insulin resistance does drive a lot of this. But with the subtypes, we realize that it’s not all about insulin resistance. Some of our diabetics don’t have insulin resistance, but just from a physical point of view, if you see that they have obesity, that is a sign that they may have metabolic dysfunction. If their blood pressure is high, that’s a sign. We can look, if they have darkening that can happen in the back of their neck or darkening of the skin of their elbows, that can be a sign of insulin resistance. And also, believe it or not, skin tags, the little skin tags people get, that’s a sign of insulin resistance as well. So that’s kind of more from a physical signs point of view.

And then looking a little bit deeper, then we can look at lipids. And in functional medicine, we deal with advanced lipids. Actually, one of the things that I teach on the Cardiometabolic Module is the advanced lipids, how to interpret and check advanced lipids. So we not only look at regular LDL, which is referred to as bad cholesterol, but it’s not really bad cholesterol. If there’s too much of it, it’s bad. But there’s the LDL, there’s the HDL, the triglycerides, and the total cholesterol that everyone’s accustomed to looking at. But we also are going to look a little bit deeper, and we’re going to look at the particle size of the LDL. So the LDL, or what’s called bad cholesterol, in some cases can be the big fluffy ones that don’t cause an issue, or the tiny ones, which cause an issue. Good cholesterol as well. Good cholesterol’s job, or HDL, is to take cholesterol out of your tissue and bring it back to the body or bring it back to the liver. And the good cholesterol could be dysfunctional, the good cholesterol could be, is it the larger stuff that works better or is it the tinier ones? And we look at inflammation as well. And another thing that a lot of people are not looking at is uric acid. So uric acid isn’t just about gout. Higher uric acid can cause lowering of nitric oxide levels, fatty liver disease, and metabolic dysfunction. So that’s another one we would be looking at.

Kalea Wattles:
Right, I’m hearing from you, there’s so many tools that we can call upon to assess someone’s metabolic health. And one thing I think is really powerful about these nutrition-oriented physical exam findings that you’ve mentioned is these are observations we can make about our own body. So maybe we haven’t been to the doctor for a while, or we have a doctor who maybe isn’t so savvy in the field of nutritional physical exam. We can make these observations about ourselves, and it gives us a bit of an empowerment to go to our clinician and say, “Hey, I suspect something is happening. What can we do to look further into this?”

Yousef Elyaman:
Yeah, absolutely. And I mean for me, every time I teach on IFM’s module, I look in the mirror afterwards and I see I have more gray hair in my beard. I don’t know what that’s about, but I’m sure there’s a connection.

Kalea Wattles:
I’m sure there’s a connection, but then we know you have so much fun that it reverses your biological aging.

Yousef Elyaman:
Oh, yeah, yeah. On the inside, it makes me youthful. And actually, I think it makes me look a little smarter. What do you think? A little bit.

Kalea Wattles:
A little smarter, very youthful. And as we’re making all these observations and we’re thinking about, once you know the physical exam findings that you’re looking for, you can never unsee them. Do you find yourself out in the world diagnosing folks with metabolic conditions, when you’re at the state fair, you’re at the grocery store? Because now you know.

Yousef Elyaman:
Sometimes. Sometimes you can obsess a little bit, and I have to turn it off, quit staring at people.

Kalea Wattles:
Move on. Yeah, I totally understand that.

Yousef Elyaman:
It’s not what you think. I’m just looking at that darkening of your arm.

Kalea Wattles:
Trying to assess your insulin over here, which we can do with some blood work. Like you said, we have some tools. I think many people will go to their doctor, let’s say, for their annual exam, and they might get, you know, their complete blood count and their comprehensive metabolic panel. Maybe just a standard lipid panel. But you’ve mentioned so many of these other tools. Do you have any advice for our listeners who might be patients about, you know, how you might talk with your doctor about the importance of ordering some of those other metabolic markers?

Yousef Elyaman:
I would talk to them, I would say, look, I went to this podcast and, or I watched this podcast, and they were talking about advanced lipid testing. And the regular lab can do something called an ion mobility or an RMR, and I can get like an inflammation test, a high-sensitivity CRP and even a uric acid. And would you be willing to do that? And they may say yes, and they may say no, but maybe look into whatever lab your insurance allows, if you’re going through insurance, and maybe get some of that information ready. But also look into, try to find a practitioner that knows how to deal with these things so that you’re not having to do all the work.

Kalea Wattles:
Right, yes. The power of functional medicine. And even let’s say that someone doesn’t have access to a fasting insulin. Will you talk to us a little bit about what a lipid panel can tell you? Because even without a fasting insulin, you can tell a little bit about hyperinsulinemia with your lipid panel, right?

Yousef Elyaman:
Yeah, yeah. So with your, just a standard lipid panel, if your triglycerides are high, and not just regular lab high, if they’re greater than 75, that’s a good indication that you have some sort of insulin resistance going on. Now the liver has an enzyme called hepatic lipase, and that breaks down triglycerides. So there are some people that are going to have, genetically, they just make more hepatic lipase, and they have insulin resistance, but their triglycerides would look okay. So that’s why it’s not 100%. The other thing to look at is your good cholesterol, or HDL. If that HDL is looking low, that’s another chance, or that’s another clue that you may have metabolic syndrome.

Kalea Wattles:
Right, and when we’re working up patients, you talk about this in the Cardiometabolic Module, about kind of the natural history or the natural progression of how your body becomes insulin resistant, and all of the effects that has on your glucose control. I’ve read and learned from functional medicine that sometimes we can see our insulin, we can see hyperinsulinemia or elevated insulin, like 10 years before we see a progression to diabetes. Is that something that you’re seeing out there in the real world? You’re catching a hyperinsulinemia in patients who, you know, are on that track to progress to diabetes?

Yousef Elyaman:
Yes, yes, all the time. And it’s not just, what’s becoming more readily available is a test called an insulin resistance score. And it not only looks at insulin, it looks at C-peptide and it gives you an insulin resistance score from that. So it’s going to look at, based on those numbers, there’s a formula or calculation, and it will tell you if it’s looking like you have insulin resistance. So insulin—the pancreas makes insulin, but it starts off by making something called proinsulin. And proinsulin is really two molecules. It’s an insulin and it’s a C-peptide stuck to each other, and that gets cleaved off, and the insulin, it gets used up by the body much faster. And the C-peptide will linger around a little bit longer before we clear it out. So, because it’s looking at a more complete picture, I would encourage people to try to get that. And you can tell your provider, all insurances are different, but if you use abnormal weight gain or if you use some symptoms like fatigue, sometimes it gets covered, checking that insulin resistance score.

Kalea Wattles:
And is that something that you need through any fancy specialty labs or this is something that you’re ordering through our national labs that are very readily available to us?

Yousef Elyaman:
National labs, readily available, insulin resistance score.

Kalea Wattles:
Great. Yeah, that’s very helpful. And I think what you’re saying, and what we’re talking about is that metabolic dysfunction is a spectrum, and that there’s all of these checkpoints along that spectrum. So when you’re in clinic, how might you address someone with signs of, you know, insulin resistance versus someone who’s pre-diabetic versus someone with frank diabetes?

Yousef Elyaman:
So I think the big thing is to make a big deal about all of it. Unfortunately, one of the things that I see often is even if it gets to the point where their blood sugar is elevated, but it’s not at the point where they would be diagnosed with diabetes, for example, a fasting sugar being 126 two times is needed to make that diagnosis. So they may see your fasting sugar of 110 and the doctor or the provider they see says, oh yeah, you have nothing to worry about. Your sugar’s a little bit high. So what we’re going to want to do is we’re going to want to catch it when it’s in that pre-phase, and then we’re going to talk to them about it. We’re going to want to figure out, we would obviously do more testing and try to see what metabolic pattern we’re seeing. Like what are the things that are off?

And we go back to the basics. We work on a healthier food plan. We work on making sure they’re getting enough exercise. If they’re sitting, if they have jobs where they’re sitting often, we have them set a timer every hour or every two hours if they have to, but every hour, get up and walk for two minutes and then go back down and sit. Things like that can be extremely helpful. There’s different forms of intermittent fasting that we can sometimes implement with them. So there’s a various amount of ways that we would tackle that. And a big thing is gauging patient readiness. But I think the first start is that you empower the patient with the information and what it means and letting them know that there are things they can do about it. And then you gauge the patient’s readiness to see what kind of changes they’re willing to make. And then from there, they are the ones that are the captains of the ship. We’re just helping them guide them along. And we have to remember that maybe they’re not ready. Maybe they’re not ready to exercise, but maybe they’re willing to walk for five minutes a day.

Kalea Wattles:
Very important. The readiness to change. And I’ll just reiterate, wherever you’re starting on that spectrum, the foundations are going to be lifestyle medicine is what I’m hearing.

Yousef Elyaman:
Yes. Lifestyle is number one.

Kalea Wattles:
And I have to ask the question that I know everyone is thinking. Is it possible to reverse type 2 diabetes?

Yousef Elyaman:
It is, depending on which subtype of diabetes and how far along it is. So if you catch it early, I believe, if you catch it early and you dig deep enough and you work hard enough, I believe that most cases we can reverse. Sometimes we can’t figure out what’s causing it and sometimes it is what it is. But it’s my belief that the majority of them, if we catch it early enough and we look at the right things, we can.

Kalea Wattles:
Well, this is the perfect time for us to talk about these subtypes because we know that a group of researchers in 2020 put forward this diabetes subtyping framework that essentially divides type 2 diabetes into different categories based on clinical parameters. And the hope is that then we have better personalization of our treatment plans. Will you just give us a little primer and tell us a bit about these subtypes?

Yousef Elyaman:
Yeah, so they call them, they’re different clusters. So they call them different clusters. And it wasn’t just the 2020, I believe there was something in 2017, and if you look at the literature, they’ve been talking about these subtypes before. But bottom line, their whole purpose is to take a look at people that are diabetic and to say, what is causing this person’s diabetes? Because we know that there’s several possible imbalances that can cause diabetes. So, first of all, what is diabetes? Diabetes is having an elevated blood sugar, either through checking a test like an A1C hemoglobin, which is an average three-month blood sugar, or a fasting blood sugar, or a non-fasting blood sugar, or a blood sugar after taking what’s called a glucose tolerance or challenge test where they take a certain amount of sugar. But bottom line, the way that they test it, there are different number values, and once it hits a certain number value, you can be diagnosed with diabetes. But once they have that elevated blood sugar, we don’t know for sure what is driving it. So what could be driving it?

Well, the first one that happens is it’s the most common one to hit the younger children, younger, non-obese children. And that’s going to be like an autoimmune type. But it turns out that adults can get an autoimmune type as well. Autoimmunity is when the body is attacking itself. So what happens is that our body makes these antibodies for some reason or other that will turn around and attack the cells in the pancreas that make insulin, and you destroy the body’s ability to make insulin. You need insulin to drive blood sugar into muscles, into other tissue. And what ends up happening is, if you don’t have enough insulin, then the sugar will wait around, and it can’t make its way in the muscle, and then the higher sugar can lead to all kinds of issues. So adults could be in that first cluster or subtype, and that’s autoimmunity.

The second one is called is severe insulin deficiency. And that’s where, not by autoimmunity, not that the body is attacking itself, but for some other reason there, the adrenal, or I’m sorry, the pancreas cannot make enough insulin. It could be toxicity. It could be, a lot of the medicines that we use regularly can potentially hurt your pancreas. And it’s a slow process that can happen over time. Maybe environmental toxins. But for some reason or other, they don’t make enough insulin. Or they went through like an insulin resistance, and over time, they turned into that. But if you’re catching them in the beginning, this subtype, we don’t know if it’s autoimmunity or not, but we do know that the pancreas can’t make enough insulin. Your problem is insulin. That’s going to be the second cluster or subtype.

Then the third one is I think the kind that everybody usually deals with or thinks about when they’re thinking about type 2 diabetes, and that’s severe insulin-resistance diabetes. That’s going to be more of your middle-aged person that has maybe some obesity but not extremely obese. And they have, if you check that insulin resistance score, it’s sky high. What ends up happening is that they make the insulin, but the insulin is, the receptors in the cells, they are resistant to the insulin. So you end up needing more and more insulin to get the same effect.

The next type is going to be a, it’s called mild obesity-related diabetes. And that’s where people are overweight and they have just elevated blood sugar but no severe insulin resistance. And it’s really driven by being overweight more than a deeper severe metabolic syndrome. And then the last one is mild age-related diabetes. And that’s these older patients that are maybe 70, 80, their sugar is up but really things don’t change too much. It’s been up for years and years. Not much insulin resistance, but they do make insulin. And that’s really the fifth. And that’s the fifth subtype.

So in a nutshell, those are the different clusters. And what they make us do, I mean, if you look at the research, the researchers had access to only a couple of tests. So it wasn’t like they were doing a whole bunch of testing. We in the functional medicine world and with conventional labs, we could dig a little bit deeper to figure out a little bit more. But they were really looking for, how do we, in the most inexpensive way possible, try to save a lot of time and energy, try to figure out what’s driving this person’s diabetes? And I think they did a good job with it, but I think that, I think that we could potentially dig a little bit deeper from a functional medicine approach and find out more.

Kalea Wattles:
I mean, what are some of those other factors that you’re thinking? Inflammation, I heard you say earlier, but what are some of the other things that through a functional medicine lens would add even more specificity to this picture?

Yousef Elyaman:
Well, so they usually only would check GAD antibodies. So the type of antibodies they would check is GAD, but then you can check anti-islet cell antibodies as well. We’re going to look at oxidative stress, we’re going to look at inflammation, but we can check things like GGT or an oxidized LDL to see if there’s oxidative stress happening. Because inflammation and oxidative stress can affect the pancreas’s production, and they can also drive insulin resistance. Plus we’re going to do the deeper insulin resistance score. We’re going to be doing…like we’re not just checking an insulin. So I think those are a few. Actually, I take it back. In the research, they do check the insulin resistance score. They check the form of it. But I think oxidation, which is rusting, inflammation, is the body inflamed, and we can check other antibodies. And I think we start fine tuning as we check advanced lipid testing, we start fine tuning it more. We could even check things like, there’s something called adipokines, and those are substances that can affect the body’s metabolism that are made by fat cells. So you have things like leptin that can cause inflammation, tumor necrosis factor that can cause inflammation. But you can readily check leptin. You could check something called adiponectin. And when your fat cells are toxic, the adiponectin levels are going to be lower, and adiponectin actually helps you fight against insulin resistance.

Kalea Wattles:
From your perspective, is it important for clinicians to identify their patient’s unique subtype or cluster before they begin a treatment plan? I mean, how important is it for us to make these classifications?

Yousef Elyaman:
Personally, I think, I think it’s important. And I know that a large majority, you can tell just by looking, I mean if they’re much older and now their sugar’s a little high, you can kind of keep an eye on it and you can say age-associated, right? If they’re younger and you’re just not getting anywhere with treatment, it may, the typical treatment, it may give you a sign. But I think that because these tests are readily available, I think it makes sense to check them early on. I’ll give you another test that I like checking. I like checking iron levels because iron overload can cause destruction of the pancreas and it also can worsen fatty liver disease. And I mean, if they have iron overload, I’ve had patients that have had diabetes and you check and they’re not really that insulin resistant, and you check their iron levels and they’re sky high, and sometimes you find out they have something called hemochromatosis, which is a severe iron overload condition. And by having them go get phlebotomies or giving blood and getting that iron level down, I’ve seen their diabetes reverse. So I think it’s important, at least in the beginning, testing it. Now, do I check antibodies in everybody? No. A lot of times they’ve been diabetic for years, so if it’s an autoimmune condition, and they’ve been diabetic for 10 years, it’s probably not autoimmune. But if it’s a brand new diabetic that wasn’t diabetic and now all of a sudden they’re diabetic, I would probably look for all of them.

Kalea Wattles:
What about patients who maybe have other autoimmune conditions? Like they also have Hashimoto’s thyroiditis. Is that raising your index of suspicion that they might have an autoimmune type?

Yousef Elyaman:
It would, it would, because autoimmune conditions run together.

Kalea Wattles:
So interesting. Now looking at treatment, the conventional conversation around these subtypes has really been mostly focused on pharmaceutical management, but it seems like this framework might also be helpful for personalizing our lifestyle recommendations. Is that, I mean, from your perspective, is that helpful as you’re creating a functional medicine treatment plan?

Yousef Elyaman:
Very, yes.

Kalea Wattles:
I’m picturing, as you’re telling the subtypes, like all the different nodes of the matrix popping up. You mentioned the autoimmune types, and I’m thinking defense and repair, and maybe I wouldn’t think to go there so quickly if I didn’t know that there was an immune component.

Yousef Elyaman:
Right, right, right. Absolutely. So there’s the defense and repair. So if there’s an issue with the immune system, I mean we can go through them. So if somebody has more of an autoimmune thing happening, from a defense and repair point of view, there are certain things that increase our risk of autoimmunity. And then there are certain things that drive the autoimmunity. So with autoimmunity, for some reason your body is attacking itself. So if your body is attacking itself, you want to ask why. Why is it attacking itself? Your body’s supposed to attack something that’s foreign. So if your body is attacking itself, that means you look foreign. So then how can our body look foreign? What will make our body look like it’s something that is not recognizable, like the enemy? Well, what makes your body sense foreign earlier on would be something like a vitamin D deficiency or not having the right good bacteria in your gut. So we can work on their gut and we can optimize their vitamin D levels. A lot of times providers don’t look at the right level for vitamin D, it’s the 25-OH vitamin D, and we want it 50 or greater, where most labs say that 30 is okay. So you would make sure that that’s all okay.

And then you look at what can make the body look different? Well, there’s something called molecular mimicry. So molecular mimicry is where maybe there is a food that you’re eating and there’s a region on that food, along with something called leaky gut, where now large particles are leaking in your bloodstream, but a region on that food that looks very similar to a region in your body. And the more you eat that food, the more your body tries to attack it, because it thinks it’s a foreign invader, and then it turns around and attacks your body. That’s molecular mimicry. The other thing that could happen. When you have toxins in your body, toxicity, toxins change the way your body looks. So if you change the way your body looks, there’s more of a chance that your body’s going to attack itself. Another thing, sugar, which already we know diabetes is a problem with sugar dysregulation. Higher amounts of sugar, what they do, they do something called glycate, or caramelize. So if you’re glycating, if you’re caramelizing your tissue, it could look foreign, and that caramelization or that foreign, that could cause your body to attack it.

And then oxidative stress. So if your body is rusting, you don’t have enough antioxidants or you have some sort of a chronic infection going on, or the foods you’re eating are making it look like a chronic infection is happening and you get this oxidative stress and this inflammation, that can change the way that the body looks.

And then the last one, which is a little controversial, but it’s plausible, is this issue, this concept of lectins. So if your body, if your gut is not intact and large particles that are supposed to be digested and go through you are able to leak into your bloodstream, one of the things that may leak into the bloodstream are things called lectins. Lectins are a form of plant-like defense system. So the plants use lectins to fight against invaders that try to attack it, right? So there are certain lectins that will bind, lectins will bind to certain sugars. And part of our body, there are certain types of sugar, like galactose or, I’m sorry, like glucosamine that are in our structure, that are part of our structure of different parts of the body, right? So what can happen potentially is that you eat certain foods, your intestines aren’t intact, the lectins of the plant go and stick to these parts of the body. That combination of the lectin plus that little molecule of your body looks foreign. The body attacks it.

So if you start seeing that they have, like you said, they have a history of autoimmune, other autoimmune conditions. If you check their GAD antibodies, you check their islet cell antibodies, you see that elevated, and you’re looking and realizing, man, this person does not have insulin resistance, then you’re going to want to say, all right, we need some sort of an extreme measure. So we would put them on an elimination food plan. Sometimes with something, we call it a detox or a cleanse where we’ll give them certain foods to help the liver get rid of toxins and chemicals. Because remember, toxins can affect autoimmunity. Put them on that food plan, check them in a month, stick to it, right? Eliminate the foods, get your vitamin D levels up, do all those things, check it in a month. If those antibodies start to go up, oh shoot, what else are we doing? If they start to go down, maybe we’re onto something.

Kalea Wattles:
The reason why I love talking about this and hearing you talk about it is because I think when we talk about metabolic dysfunction, it would be so tempting to say like, oh, a low-carb diet and get some exercise and that’s it. But from your perspective and the functional medicine approach, it’s like, well, we have all of these other options to increase our intestinal barrier function and reduce oxidative stress and quench our inflammatory burden. And that’s so much more comprehensive, not just so that you know, their A1C gets better or that they’re more insulin sensitive. But we know that our metabolic function rolls into so many of our other body systems. I mean, thinking about our hormones and our neurotransmitters, I mean everything. So we’re really doing our patient a great service by cultivating really robust health in all of their body systems. And I just have to call that out because it’s so fun to hear you talk about it. So, looking towards interventions, I know that you’ve recommended food plans. You’re also, I know, doing a lot of exercise recommendations in the clinic. So do these subtypes help you to customize that type of approach? Or almost anyone is going to need, you know, exercise, sleep, stress management?

Yousef Elyaman:
Pretty much. There’s different pathways on why exercise would help. There’s different reasons, but at the end of the day, increase your exercise, increase your movement. Something, the most important thing is something that patients can sustain, that they can do. Like for me, for a time, watching shows on a treadmill did it for me. It doesn’t do it for me anymore. Now I have to listen to podcasts, listen to something inspirational, and I have to go out on a walk. I’m in Florida, I got to take advantage of that, right? But there was a time in my life where that just didn’t do it for me. I’d get bored. But I realized, you go 15 minutes in one direction, you have no choice but coming back, and only one time did I call my wife and say, come pick me up. That was because lightning was hitting all over the place. Other than that, I will not like, unless I’m worried about being struck by lightning or a neighbor dog or something that’s about to kill me, I went that 15 minutes.

Kalea Wattles:
Yeah, you got out there. Okay, we love the dedication. So you talked earlier about the importance of sustainable behavior change and helping patients figure out, you know, why they want to make these changes and doing your motivational interviewing. So I would love to hear how you talk to patients who maybe you can see they have some clinical signs of metabolic dysfunction, but they don’t have a diabetes diagnosis. And so you’re trying to catch them early on and help them understand why it’s so important to act now.

Yousef Elyaman:
Right, well, one of the things we do, which I found to be very helpful is, if they have a lot of these metabolic syndrome signs, we’ll send them to get something called a FibroScan. And a FibroScan is ultrasound technology that takes a look at the liver and it looks at two things. It looks at how much fat is in your liver and how much hardening is in your liver. And the nice thing about that, there’s a lot of research centers around that will do these tests for free, or you can get it through insurance. But the nice thing about that is that really when you look at all this metabolism, this metabolic metabolism, the liver is the primary organ that is dealing with it all. And based on what the liver spits out, we can have heart disease, we can get hypertension, we get all kinds of different downstream issues, dementia, but the liver is really that center. And for some reason, once they realize that they do have fatty liver disease, that the liver is accumulating with fat, I don’t know, for some reason people work harder. But you check and see if they have fatty liver disease. Sometimes just by sending them to get that test, what I realized is that they start, they’ll lose like 10 to 15 pounds by the time I see them to go over the results, because they’re thinking, oh shoot, I got to take care of my liver. But we do put things in perspective.

We mention that, look, you have what’s called insulin resistance. This insulin resistance increases your risk of Alzheimer’s disease, increases your risk of high blood pressure, increases your risk of heart disease, strokes, heart attacks. And luckily, we’re catching you so early right now that we can stop it from even happening. And I think they really appreciate that. And then you kind of put that out there, and then you kind of go over or you kind of gauge their reaction, and based on what their reaction is, if they’re like, all right, tell me what I got to do, then we kind of go over some possible choices. Otherwise, like I said, that’s where gauging the readiness is. And if they’re not ready to even think about it and they’re like, yeah, whatever, whatever, whatever. That’s where I will kind of try to figure out what are some little things that they could start doing. Like, okay, you don’t want to change your food plan, but what if you could eat a handful of unsalted nuts every day? Because that can help. What if you could have two servings, you’re not having any vegetables. Can you have two servings of vegetables a day? The goal is six, but can you get two in there? And then you kind of work with them from there. I don’t know if that was the original question.

Kalea Wattles:
Yeah, that’s great. Kind of related to that, I’m just thinking of patients who we see, they come in with a diagnosis. I mean even something, cognitive decline or even menstrual irregularity, something that we might suspect has a metabolic root, but it’s not so intuitive. How do you help patients to make that connection and understand how our metabolic health might be related to, I mean, a number of other chronic conditions?

Yousef Elyaman:
Yeah, I think showing them their lab work and giving them a story and explaining what this is showing and what this can turn into. I think that’s very powerful. I think that’s enough. I think most people or most providers, from what I hear, they don’t go into that detail. They just say, yeah, your labs are all right. Your cholesterol’s a little off. Work on your diet, bye, see you later. And that’s not what we’re doing. You put it out there. So there’s that ancient model that the doctor is like, way up here, and the doctor tells you what to do and you do it and doesn’t really give you much information, but that’s the doctor, so you listen. Although romantically, I think just from a…I don’t know if romantically is the right word, but although that sounds really good, me being a doctor, that’s really not the most healthy way of dealing with things. And that’s why I don’t deal with things in that way. And I think that just by explaining it to patients and just by believing, and they can tell, believing that they can change and that they will change, it makes a huge difference. I think we get tired because, because we deal with so many patients, and it’s something we see commonly, we forget that, to me it’s a Tuesday morning, but to the patient, this is their life. This is what’s happening in their body, so we need to make a big deal about it.

Kalea Wattles:
I really appreciated that answer. And I’ve heard you say a couple times now, like, we need to make a big deal about this. And how I’m interpreting that is we don’t want to minimize this. This is somebody’s real life. And so no matter where they are on that spectrum of metabolic dysfunction, this is real. And they ultimately have to make a behavior change that’s going to reverse this, and that might feel, might feel really challenging, it might feel scary. And so being that support person and having that therapeutic partnership, I think, is a really important part of the conversation.

Yousef Elyaman:
And I don’t like scaring people. So it’s more like, hey, listen, this is what can happen. I’ll tell you, if you go to most providers, they’re not even going to comment on this, but I think that’s why you’re coming and seeing me, because we want to catch things before they become a problem and we want to work on it. And then from there we kind of work on what the plan is going to be, and then we come up with a follow-up. And then we kind of see how they did. And if they did good, great. If they didn’t, the people that I make a bigger deal about are those people that are, they’re, everything is red. They’re in the age that they usually would get heart attacks and strokes, and the first presentation will be a more gentle recommendation. And then if you track it and they’re just not getting any better, sometimes you got to say, look man, we got to do something because I’m worried about you. And a lot of times just saying, I’m worried about you, by letting them know that you’re genuinely worried versus you’re talking down to them, that can be helpful. Because they know it’s coming from a place of love and caring. I’m not trying to, holier than thou, why aren’t you listening to me? Why aren’t you doing my plan? No, no. Listen, I’m a little worried about you. What’s happening? Find out. Is food their main source of comfort, and they have stress and anxiety that they’re not managing, that they’re not dealing with? Like figure out what is actually happening.

Kalea Wattles:
I think this is the time for me to put in a plug for everyone to do their health maintenance and go get your annual exam, and from a functional medicine primary care standpoint, having that touchpoint of patients coming in annually and at least being able to do some screening lab work I think can be really important in terms of catching some of these things before it’s the red flag.

Yousef Elyaman:
Right. Right, right, right.

Kalea Wattles:
Right, everybody head to ifm.org, find a practitioner, and make sure that your health maintenance is up to date. Dr. Elyaman, this has been such a great conversation, full of clinical insights. Do you have any final advice for clinicians who might be out there listening and they’re wondering how they start implementing these tools to improve their patient outcomes?

Yousef Elyaman:
Yes, I think, I think there are different groups, maybe Facebook groups out there that they could join. I think working and seeing what The Institute for Functional Medicine has to offer. I mean, yes, I do teach on the Cardiometabolic Module, but I’m only there because The Institute for Functional Medicine changed my life, changed my practice, changed my patients’ life, changed my family’s life. So it’s something that I believe in. That’s why I’m part of it. But take a look, take a look at the modules. I’ve never paid for a module and came back and felt it because there’s just so much more that you learn and so much more that you can do with patients. I’ve never went broke from paying for conferences. Let’s just say it that way. Because it comes back to you. It comes back to you. But I would say, take a look, take a course. Does IFM still have the free CME courses that they can do?

Kalea Wattles:
There’s so many free offerings to get your sea legs in functional medicine. And I think this conversation highlights so many reasons why that functional medicine approach is extremely powerful. So I wanted to thank you so much, Dr. Elyaman, for your time today and sharing your clinical experience and your passion for this topic. It’s just been a pleasure chatting with you today.

Yousef Elyaman:
No, the pleasure is all mine.

Kalea Wattles:
To join the conversation on this topic, visit IFM’s pages on Facebook and Instagram. For more information about functional medicine, visit IFM.org.

Show Notes

Select published research on diabetes subtypes:

• Ahlqvist E, Prasad RB, Groop L. Subtypes of type 2 diabetes determined from clinical parameters. Diabetes. 2020;69(10):2086-2093. doi:2337/dbi20-0001
• Veelen A, Erazo-Tapia E, Oscarsson J, Schrauwen P. Type 2 diabetes subgroups and potential medication strategies in relation to effects on insulin resistance and beta-cell function: a step toward personalised diabetes treatment? Mol Metab. 2021;46:101158. doi:1016/j.molmet.2020.101158