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Elizabeth Boham, MD, MS, RD, is board certified in family medicine with a strong background in nutrition and Functional Medicine. She graduated with a BS in nutritional biochemistry from Cornell University and an MS in nutrition education and exercise physiology from Columbia University. She is also a registered dietitian, having practiced nutrition in New York City before going to medical school. She completed her medical school training and residency in family medicine at Albany Medical College. Before joining Dr. Mark Hyman at The UltraWellness Center in Lenox, MA, she worked as an integrative physician at Canyon Ranch in Lenox, MA, and was a partner with Albany Clinical Nutrition Specialists. A prolific speaker, Dr. Boham is passionate about educating other clinicians and speaks on topics ranging from women’s health and breast cancer prevention to insulin resistance and heart health.  

Transcript

Kalea Wattles, ND:
On this episode of Pathways to Well-being, we welcome Dr. Elizabeth Boham to discuss how to create sustainable dietary intervention for patients with cardiometabolic concerns. Our conversation will take us on a deep dive into specific dietary plans and eating patterns, including fasting and time-restricted feeding. Welcome, Dr. Boham. We’re so delighted to have you today. 

Elizabeth Boham, MD, MS, RD:
Oh, thank you, Dr. Wattles. It’s great to be with you as always, Kalea. Thank you for having me. 

Kalea Wattles:
Yeah, it’s such a pleasure, and we’ll just jump into it. I think the question that we all want to know as the new year is upon us—so many of us are making these really lofty resolutions about dietary change—so from your perspective, as a starting point, what are your top recommendations for making those dietary changes really sustainably? 

Elizabeth Boham:
I think the number one thing we need to be encouraging our patients to do—ourselves to do—is just to be cooking more, getting real food and cooking more whole foods, avoiding foods with labels, getting more produce in our diet, and just getting in the kitchen. I mean, I think that’s what we, when one of the best things that we can do to help us be able to sustain the changes we want to make within our diet regimen. 

Kalea Wattles:
I love that suggestion to really return to the basics and those foundations, just getting those creative juices flowing. I think that’s a very approachable suggestion. So I really appreciate that. I would love to hear—in your clinic day to day, I’m sure patients are coming in, they’re doing their own research, and they have some diets in mind that they want to talk about—will you share with us, what are the top diets or food plans that people are coming to you with and they want to experiment? 

Elizabeth Boham:
Yeah, I think that a lot of people have questions about fasting, and we’re going to really delve into that today. People have questions about ketogenic diets, and people are wondering, “What’s going to help me feel better?” So I think the first thing we really look at when we’re trying to determine what regimen—what diet plan, what food plan we want to recommend for our patients—is we look at, right, those ABCDs of nutrition assessment. We look to see if we see signs of insulin resistance, if we see a high waist-to-hip ratio, maybe a high fasting insulin, somebody’s becoming prediabetic, their blood sugar is starting to creep up. We see that change within their cholesterol pattern. We’re saying, “Okay, we really want to encourage them to be doing more of the low-glycemic plan.” So within the cardiometabolic food plan, really reaching for that low-glycemic plan, which may have between only zero or two servings of starchy veggies or grains a day. And that can be really a sustainable food plan for a lot of people, and they can be really successful with it. 

Kalea Wattles:
I’ve always thought that the benefit of using that ABCD evaluation for our nutrition, doing our nutrition-oriented physical exam, using our functional biomarkers, that’s really how we use precision medicine to customize these dietary plans. So just reinforcing that great information that you shared. 

Elizabeth Boham:
Yeah, and it really helps us guide our patients to what’s going to be the best plan for them. What’s going to help them reach their goals. What do they need to do? And so, on the other hand, if you have a patient who doesn’t have any signs of insulin resistance, maybe they have a high LDL cholesterol, or they have one of the variations in the APOE gene of four or a four/four, and they have that high LDL cholesterol—you may really be focusing really differently on the food plan for them or what recommendations you’re going to make. You’re going to maybe not recommend lots of coconut oil, right. You may be saying, “Okay, we got to reduce saturated fats here.” And that patient may be the good person to really balance—focus on balancing animal and vegetable proteins—so you can get the benefit of both.   

The benefit of the vegetable proteins, right, is they’re rich in fiber, which helps with binding to cholesterol and eliminating it out of the body. They’re also rich in plant sterols, which help with lowering cholesterol and in the beans and that sort of thing and nuts. And the benefit of animal protein is that it can help people feel more satiated, and they can get more protein per calorie. And so for some people, that’s a really good thing to focus on, that balance between the two. And then of course, when people are interested in ketogenic diets, I think they work really well for people who’ve tried everything. Maybe they’ve got pretty significant insulin resistance. Maybe they’ve tried other low-glycemic plans and haven’t been as successful as they’d like to be. And they may really benefit from a ketogenic option. And the Mito food plan ketogenic option is really a mild ketosis—a mild ketosis—which can help people with losing weight, lowering insulin. And especially, again, those patients with insulin resistance, it may be beneficial for. 

Kalea Wattles:
Well, that was a jam-packed answer full of all of these pearls that I think this really highlights the importance of working with a practitioner who’s really comfortable making nutritional recommendations because there are so many nuances, like just talked about how you might customize a food plan. 

Elizabeth Boham:
Yeah, and we have to listen to our patients and get a sense of what they have been doing, what they’ve been successful with doing, where they’ve struggled, and what they’re willing to do. And I think having that conversation’s really important. And I absolutely agree with you. I mean we have, in my practice, we have five nutritionists and health coaches, and I couldn’t do what I do without them. It’s so important to have that extra support and somebody who’s really versed in nutrition intervention to help your patients be successful. 

Kalea Wattles:
I think you just really highlighted some motivational interviewing techniques that are so important when we think about sustainable behavior change, helping patients understand their “why”: why are these behavior changes beneficial to you? And really anchoring into that meaning and purpose. And I think that you really spoke to that as we’re looking at how do we maintain these dietary choices when it gets hard and it’s holiday time and we face obstacles. 

Elizabeth Boham:
Absolutely, and I think it’s really important that our patients know that we know and our patients know that it’s normal and natural to fall off the wagon or regress. And that for very few people, do they go in a linear line when they’re making a behavioral change. For so many of us, most of our patients, most of ourselves as well, there’s more of a cyclical pattern, right? Where we regress a little bit, then we improve, and then we regress. And so, over time there’s improvement, especially when we have good support, but there’s many times where we’re not doing exactly everything we would like to do from that behavioral change perspective. And I think it’s important that we have those conversations with our patients and let them know that this is normal and natural. And that that is a time of learning, right? When we fall off the wagon, when we mess up or whatever we want to call it, that we don’t even have to put judgment to it. But that that’s a time where we learn; we learn, okay, what was it, what happened at that point where I ate that cookie at 10 pm, right. Or a box of cookies or whatever it is, right? So what was it that resulted in me not really doing what I was planning to do? Was it stress or boredom or not having the right foods available, so I could reach for those instead? What is it? And you learn from that. And then the next time you can help yourself at making the right choices. 

Kalea Wattles:
Yeah, that’s fantastic. My next question is selfish for myself as a clinician because this is an area where I struggle: as you said, healing is not linear. A behavior change is not linear. And so sometimes patients are improving over time, but because it’s been stretched out on this longer timeline, it’s kind of hard to remember where I was when I first began and all the progress that I’ve made. How do you help patients to see the progress that they’ve made over time? I know for example, I might use the medical symptom questionnaire at the very beginning of a patient’s journey, and then we repeat it later and say, “Look at all these symptoms that have improved.” But what’s your strategy for helping people really understand how far they’ve come? 

Elizabeth Boham:
Yeah. That’s so important to keep people motivated. And I think the MSQ is a really great tool to use for that. I also think other biomarkers are really helpful. When we’re talking cardiometabolic disease and insulin resistance, I always use the waist-to-hip ratio. I think that’s such a great, easy tool, inexpensive, that you can watch people’s progress. And it’s so important because it gives us so much information in terms of how they’re improving—so just looking at that waist circumference, that waist-to-hip ratio over time. And even if the pounds on the scale don’t change to the degree that they think they should change, if we see that waist-to-hip ratio improving, that’s what we want to see. And then biomarkers are great, right? So biomarkers, like insulin and blood sugar and hemoglobin A1C, and CRP, really, NMR, particle size testing of our cholesterol, all of those things really help us get a sense of how our patients are improving. 

Kalea Wattles:
Yeah, that’s really helpful as we’re looking at sustainable change that we can continue to motivate over time. And that leads me into my next question. We see all the time with patients and with ourselves that we might start some healthy practices; it seems really good for a month or so, and then it becomes more difficult. We can’t keep that momentum going. So I’d love to hear some of your strategies for helping your patients to stay consistent. 

Elizabeth Boham:
So I think one of the things that’s really helpful for me is when I have my patients fill out the three-day food diary or the lifestyle questionnaire, because then you get a lot of feedback as to where they’re tripping up, right? Where is it that they’re having a hard time with following through with the recommendations you’re making. You can really get a sense of, okay, what is it that they need to really focus on? Because it’s, as we know, it’s just different for every person. Are they making the wrong choices because of excessive stress in their life, and do they need to incorporate some more breath work and relaxation exercises into their day? So they’re not just reacting and grabbing food, for example. Do they need to get outside and get more exercise in—just, again, to help with stress and to help with insulin sensitivity? I think that getting that feedback really helps us know exactly where to focus with our patients and how to motivate them—and then taking the time to get to know them and what they’re trying to achieve, and what their goals are—so you can help them figure out what are those things that are going to help them stay motivated. 

Kalea Wattles:
I have heard you, when you teach about nutrition, give that foundational piece, that food is information, right? It’s more than just calories, it’s more than just nutrients—it’s community—and we have a whole emotional relationship with it as well. And I think one aspect of the nutritional therapeutic partnership that I found is helpful is if a patient—I know messes up is not the right term because we’re not assigning morality to food—but if someone has a hard day, and then they make their favorite pie that their grandma used to make, I kind of understand that. We return to those comfort mechanisms. And so is that kind of a conversation that you have with patients about food being more than just the calories? There’s some memories or nostalgia or other emotions we might assign to it? 

Elizabeth Boham:
Absolutely. Absolutely. And then people understand, like you said, where are they coming from? Why are they making the choices they’re making? And then that might really help them modify those choices in the future. So they’re not always eating the whole pie that it brings them down, that nostalgia. And I think that’s really important because we’re going to talk a lot about more strict food regimens or fasting and that sort of thing. But I think we do have to recognize that there’s a lot to food, in terms of community and joy and connection with others, that we don’t want to get rid of just because we’re following a regimen. And so we have to work on how does that all inter-react with each other. And so often we have to eat, it’s necessary to eat. We see as many problems with people over-restricting as not restricting enough in terms of foods. So we really—it’s really important how we talk about food with our patients. So we don’t send them on these pathways of developing a negative relationship with food. 

Kalea Wattles:
Beautifully said. And that opens the door for us to talk about fasting, which is such a hot topic in our functional medicine world, because we know it has a great therapeutic potential. So I would love to hear from you, do you find that patients are able to adhere to a fasting regimen more than some of the other diets? What obstacles are they facing? Is it sustainable? 

Elizabeth Boham:
Yeah, I mean, I feel like fasting is a really interesting path for a lot of patients. And to give you a little history, I’ve been a nutritionist prior to going to medical school. And when I was being taught nutrition, that was back in the time of three meals a day and two snacks and breakfast is the most important meal of the day. And so when a lot of this research came out about fasting and time-restricted eating, I was kind of like, “Hmm, are we sure?” I still, really, I love breakfast, and I still believe that breakfast is such an important meal of the day. And so I struggled a little bit with this, like, but what’s interesting is, when we start listening to our patients—and I think my patients have been telling me this for a long time—for many people, time-restricted eating and fasting is really beneficial for them.   

So first of all, we have to accept the fact that we’re all individuals, and fasting regimens and time-restricted eating is not for everybody. But there is a substantial amount of patients that get a lot of benefit from this. And as I was saying, my patients have been sort of telling me this for years. “Well,” they’ll say, “well, I eat breakfast, and then, you know what, I’m just hungry earlier, and then I just want to eat more and more and more as the day goes on.” And they would say, “But if I don’t eat breakfast, it’s kind of amazing. I’m not really that hungry, and I don’t really need to overeat.” And so it’s fascinating.   

And now we’ve got all this research to—research is starting to accumulate to back this up. And so we’ve known that calories, calorie restriction with adequate nutrition—so cutting back by like, what, 25 to 40% of your calories a day—is really beneficial in terms of its anti-aging benefits, right? So it can activate Nrf2, which is a transcription factor that can help detoxification in the body and activate our antioxidant defenses. It can activate SIRT1, which has a lot of anti-aging benefits in it and lowers oxidative stress. And so we’ve known that about calorie restriction with adequate nutrition and lowering atherosclerosis, improving left ventricular function. And then, but calorie restriction for long periods of time is really hard for people. I mean, saying, “Okay, eat 25 to 40% less of your calories every day forever,” is a hard thing to maintain obviously. And so some of these ideas of, okay, intermittent fasting and time-restricted eating can be beneficial because they can potentially—or the hope is, and some of the research has started to show this—they can activate some of these pathways in the body, which are really helpful, as well as make it easier to follow. So, and potentially result in less of a drop in our resting metabolic rate, less of a drop of loss of lean muscle mass that long-term caloric restriction could potentially result in. So that’s really where people are looking at.   

We know that fasting has been shown to stimulate autophagy, which is really that process where the cells clean up debris, clean up those organelles and debris in the cells, and that can help with mitochondrial function, and DNA repair and energy metabolism. So I think that what we’re seeing is that first there’s a lot of benefit to it, and for a lot of patients it’s really, really helpful. So I guess we should talk a little bit about what some of the definitions are of time-restricted eating and intermittent fasting to make sure we’re all on the same page. 

Kalea Wattles:
That’s great, a great next step. I was just going to say, I think sometimes when I bring up fasting in the clinic, patients automatically assume this means like days of just water only, and then it’s so intimidating. So I would love to hear some of the different strategies, time-restricted feeding, intermittent fasting, and then maybe even more complete fasting. Sometimes we do go longer periods of time. So if you would give us some definitions, that would be very helpful. 

Elizabeth Boham:
Absolutely. So I think that’s a really good point, that patients can get overwhelmed and question, “Okay, I’m…” —and even like I was saying myself—“I love breakfast.” And so I’ve been exploring this time-restricted eating a little bit, and I’ve been doing okay with it, actually, you know? So what time restricted eating means is you restrict the number of hours in the day that you eat. So for example, a very typical thing is people will say, “Okay, I’m going to eat for eight hours a day.” And so they may eat between 10 am and 6 pm. And ideally, we don’t want them to just pick their eating hours too late at night. And because we know that when we eat later in the evening, that can stimulate—the same foods can stimulate a higher glucose response and a higher insulin response that can cause more insulin resistance, right? So time-restricted eating is really focused on eating for just a specific period of time. And a typical one, as I said is like eight hours a day, between 10 and 6, for example. And not so much focusing on calories during that time.  

Intermittent fasting is a time period where you don’t eat, and the idea is that you don’t really make up those calories during the time where you are eating. And intermittent fasting can be anything from 16 hours to 48 hours of not eating. And I definitely work, just when people are hesitant to get started, I say, “Okay, let’s try at least not eating after dinner and try at least 12 to 13 hours.” And people start to do it, and they sit there like kind of amazed at how good they feel with it. I think, again, it’s not across the board, but a lot of people will notice, like I was mentioning earlier, less hunger, probably because of the lower ghrelin and lower insulin that has been shown with when people have shortened that eating window; they can see. They can have lower ghrelin and lower insulin. And that may be what’s helping our patients with, some of our patients, with weight loss and becoming more metabolically flexible. And so I think that there’s a lot of ways we can explore this. And the other thing that I often use with my patients is the 5:2 plan. I really like this. I think it’s a great regimen that has worked well for a lot of my patients that have gotten stuck and not seeing—they’ve been trying to lose weight and not seeing the improvements they would want to see, or they got to a certain point and then they didn’t continue to see improvements. And so I said, “Okay, let’s try something like the 5:2 plan.” And what that is, you pick two days a week, usually not two days in a row, and you say, “Okay, on those two days, I’m going to only eat 500 to 600 calories that day.” And for some people, they split those calories for two to three meals, but other people say, “Okay, that’s just going to be one meal on those days.” And for many people, they found that to help with getting that weight loss going again, helping to kind of break through a plateau, and improve their metabolic flexibility. So I find that to be really helpful.   

And then some people do things called—which you can actually morph this 5:2 into—that alternate daily fasting, where essentially you don’t eat for 24 hours. So let’s say you have lunch, and then you don’t eat again until the next day at lunch, or if you did dinner and then not eat again for the next day at dinner, and that would be like a 24-hour time of not eating or alternate daily fasting, whether you do this once a month or once a quarter. But that can also potentially help patients with maintaining their weight, helping improve their metabolic flexibility. And so that’s, I think, another option to use with your patients. So I guess what it really comes down to is getting to know your patients, and what have they tried, and what has worked, and what kind of works for them with their lifestyle and how they like to eat. 

Kalea Wattles:
Well, the beautiful part about this is look how many options there are. We can really individualize and tailor this treatment plan based on the patient’s preferences and what’s realistic for them. So I love that you just outlined all of these different structures that we can utilize because that’s what this is all about, personalized medicine. So thank you for summarizing all of those for us. I have so many follow-up questions, but the one I’ll start with is when we look at time-restricted eating, is it okay that someone would kind of put the bulk of their hours at the front of the day? So say they might eat breakfast, but then they don’t eat dinner. 

Elizabeth Boham:
Absolutely. I mean, I think in an ideal world, right—if you look at our circadian rhythm, in an ideal world—it would be better to front load our calories because we do know that as the day goes on we become more insulin resistant. So if we took the same meal at noon and ate it at 9, we might get a higher blood sugar spike and a higher insulin spike, if we ate that food at 9. So, or maybe it’s midnight, right? So the later in the day that we eat food, that can have a worsening impact on our risk of insulin resistance. So you’re absolutely right, in an ideal world, if we did time-restricted eating, it may be best to do 7 to 2. I’m just guessing at the top of my head, like 7 to 2. The problem with that is just for a lot of people in the world—I was going to say in this country, but really in the world—we do so much communal eating in the evening. And so a lot of times people feel left out or like they’re missing something, but if people wanted to adapt something like that, a couple of days a week where they’re not really having family dinners or getting together with others, that may be a great way to really help with improving their insulin resistance, their metabolic syndrome, or their weight. 

Kalea Wattles:
Yeah. Thank you for, I was waiting for the question to come up about, like, “Well, I have to cook for my family. So how do I skip dinner?” That’s always, I think, one of the obstacles we face. The next question I have, which I work in a primarily women’s health setting, and the question always comes up, “If I do fasting, will this impact my menstrual cycle and hormones?” How do you address that question, especially for women? Is there certain modifications we need to make during the menstrual cycle? What counseling do you give around that? 

Elizabeth Boham:
I think that’s really interesting to pay attention to. And what we do know is that fasting is a stress on the body. I mean, some of the reasons why it’s so beneficial to us is because of it’s a stress on the body, right? And it can activate that adaptive cellular stress response, which can help our mitochondria and DNA repair and autophagy. And so there’s a lot of benefit to that. But is everybody—can everybody handle that level of stress at certain times of their life? And that’s a really, really, really great and important question to address. And I think depending on what’s going on in terms of your overall health, your adrenal health, that HPA axis, I think there is potential. fasting could result in changes to a menstrual cycle, changes to fertility, depending on where that person is. And I think that’s what we’ve really got to pay attention to. So it may not be right for everyone.   

And that younger woman who is looking to get pregnant, for example, maybe for them you just focus on those 12, 13 hours at night, right, of not eating. And that can be enough because it can help with improving our microbiome and improving digestion and some of the real benefits. But not putting too much stress on the body. It really is a balance. I find also with young men—either, of course, our children, but then those men in their teens and their twenties—they’re really working to put on a lot of lean muscle mass, and their metabolisms are so strong. And so they need to eat a lot of calories, and they need to eat a lot. And sometimes, it’s hard to get that in eight hours, and maybe they don’t have to get it in eight hours, right? So I think we have to look at somebody’s activity level, their metabolism, and I think that’s important to pay attention to. 

Kalea Wattles:
Very helpful. And you already have spoken to the fact that individualizing the plan is really helpful, and I’m just thinking about for women, especially who have insulin resistance, this might actually be helpful for their, for example, ovulatory function, so it’s all about customization. 

Elizabeth Boham:
Yep. You’re absolutely right, right? So if you’ve got that patient on the other end, right: so we were just talking about maybe adrenal issues, maybe a patient who is not overweight or doesn’t have sign of insulin resistance, if you’re not reaching for a fasting regimen. But then on the other hand, you’ve got that patient with PCOS, high levels of insulin, irregular cycles; for them, that’s an absolute. That’s a great point, Kalea. You’ve got them—you put them on some sort of a time-restricted eating or intermittent fasting—and you may really see that their cycles actually then become regular because you’ve just lowered insulin. Great point.  

Kalea Wattles:
Let’s tie this in because we’re kind of going down the road of cardiometabolic disorders. What changes are induced during fasting that might be helpful, especially for those who have active cardiovascular disease, are at risk for cardiovascular, or actually just cardiometabolic disease. 

Elizabeth Boham:
So fasting can activate that adaptive cellular response, which can help our mitochondria, which can help with energy production and DNA repair. We talked about autophagy; we talked about how it can cause lower levels of insulin, which really helps people with weight loss and losing weight around that belly. It can help with decreasing risks of cardiovascular disease. They did a study with women who had elevated blood pressure and elevated cholesterol—they were actually on medication for both—and they had them do some time-restricted eating and said, “Okay, you can only eat for 10 hours a day.” And they noticed that the women who implemented that actually had further—they had improvement in hemoglobin A1C, they had improvement in percentage of body fat, they had improvement in that visceral adiposity, they had lower levels of insulin. And so all of these things lead to decreased risk of cardiovascular disease. 

Kalea Wattles:
The research here seems really favorable, that we can improve cardiometabolic health. All these things you said—we can reduce risk for obesity and hypertension and dyslipidemia and diabetes. One thing that I’d like to get better at personally is utilizing these tools in a more preventive manner, in a preclinical stage, so that we can… we’re not waiting until someone is symptomatic or their biomarkers are looking really scary. Is this something that you’re using in clinic: really trying to catch those patients who are on the cardiometabolic disease spectrum in an early stage of disease so that you can really use some proactive tools? 

Elizabeth Boham:
Absolutely. I mean, I think that this is an incredible tool for that. I mean, one of the things we know is, for people with prediabetes, in terms of prevention of them becoming diabetic, one of the biggest things we know that impacts whether that happens or not is whether that patient loses weight. And so I think everybody, again, is an individual in what’s going to work for them, but these are some great tools that you can have in your toolbox to help your patients achieve their goals, lose weight, and then prevent that progression into metabolic syndrome. Absolutely.  

And if patients are, I mean, I think the other thing is, patients are like, “I just feel great,” and you look at their biomarkers, and they look great, and you’re like, “Should they implement fasting just for prevention prevention?” I mean, that’s a really good question. And they’ve looked at women with breast cancer, and they note that if they don’t eat for 13 hours overnight that they have a decreased risk of recurrence. And so I think that that 12 to 13 hours of not eating a day is something that really pretty much, most everybody can implement. And you can get then, as I said, some of those benefits of fasting and maybe prevention of vascular disease and cardiovascular disease and metabolic syndrome and insulin resistance. And so I think that’s a great place to start. And I think the other area that we kind of had gotten into this pattern of—as I was talking earlier about, that three meals a day and the two snacks—a simple place to start also with those patients from a prevention standpoint is saying, “Well, maybe we can pull away some of these snacks. Maybe they’re not really that necessary.” Again, it depends on the patient and their energy level, their adrenals, their insulin and blood sugar, and all those things. But saying, “Okay, let’s experiment with pulling away some of these snacks and see how you feel without them. Making sure at every meal, you’ve got a really good, healthy fat source and protein source and fiber source, so your blood sugar stays stable,” and see how they do with that. 

Kalea Wattles:
So if I can just summarize my clinical takeaway there and make sure I’m on the right track here, it sounds like for most people, a fast that’s maybe 12 or 16 hours is going to be pretty healthy and realistic for them. And I think this is going to come up as we explore all these topics in longevity and anti-aging medicine that are really at the top of mind right now. So it seems like there’s some baseline fasting strategies that most people can implement. 

Elizabeth Boham:
Absolutely. And then what we’ve kind of also reviewed is those more aggressive fasting strategies that help people as well. Yeah, absolutely. 

Kalea Wattles:
Before we move on from this topic, it’s important to know, as you have already, that fasting is not necessarily suitable for everyone. Are there any preexisting conditions that automatically you say, “This is not a great candidate for fasting”? 

Elizabeth Boham:
Yeah, I mean, I think that if you’ve got any signs—when you gather your history from your patient—that they have some disordered eating or they have a history of an eating disorder, adding more restrictions just doesn’t make sense. And you don’t want to talk about food in that way. And I think that it’s… you want to be really careful with that area. Those patients don’t necessarily need to be counting hours or looking at their blood sugar response, necessarily. It’s maybe healthier to really focus on it a different way. Our patients who are underweight or really struggling to gain weight, many times it’s hard for them to get in enough calories, enough fat, enough protein, if the eating window is too low. And I also spoke about our young men that are working to really increase or they’re gaining lean muscle mass; for them, it may be hard as well. So again, it depends on the individual. And our growing children. We definitely want to move away from breakfast foods being so high in sugar and refined carbs, absolutely; for our kids, that is not helpful. But many times, kids really do well when they’ve got a good, healthy breakfast that’s rich in protein and fats, and it helps them with learning during the day and energy and growth. And so I think those are just a few people that we—we’re a little bit more cautious with. And pregnant women. Again, it depends on the woman, but you want to make sure they’re getting sufficient nutritional, sufficient nutrients and calories for the health of themselves and the baby. 

Kalea Wattles:
Great. You have given us so many really practical takeaways. That’s something I always appreciate about your teaching; it feels very practical. I know what I can do tomorrow differently, so I so appreciate that. For our listeners, what’s your top takeaway coming out of this conversation about sustainable dietary change and cardiometabolic health? What if you could impart one final suggestion for us about how we actually make this work? We’d love to hear that. 

Elizabeth Boham:
I mean, I think it’s all about that gathering stage with your patient. Get to know them. Where are they coming from? What have they used before? Listen to your patient. Really understand what they’re looking for and what they’ve tried and what’s worked and hasn’t worked. And then get to know what might be helpful for them. And so you can then, through that interviewing process, get to know, okay, maybe fasting is going to be really helpful here. And you can then explore some of those different options. 

Kalea Wattles:
Beautifully said. Well, I just wanted to thank you so much for sharing your insights—not only about nutrition but also about how we foster that therapeutic partnership and really help guide our patients successfully through their stages of change and their behavior modification. So thank you so much for being with us. It’s been such a pleasure talking with you today. 

Elizabeth Boham
Thank you so much, Kalea. It’s great being with you all. 

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. 

IFM’s Intermittent Fasting: Therapeutic Mechanisms & Clinical Applications course provides an evidence-based overview of several of the fasting methods listed above and outlines potential contraindications and points of personalization for each patient’s unique health needs and goals.