Obesity Prevention Approaches for Cardiometabolic Care

Discover effective strategies for cardiometabolic care for obesity to enhance your health and lifestyle choices.

Abstract

I am Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. In this deeply detailed educational post, I guide you through an integrated, first-person case journey that weaves modern obesity medicine, functional medicine, internal medicine oversight, and integrative chiropractic care into one cohesive roadmap for patients and clinicians. I present:
A comprehensive, stepwise protocol for managing class II obesity, insulin resistance, polycystic ovary syndrome (PCOS), binge eating disorder, and cardiometabolic risk — from diagnostic criteria to layered therapies including metformin and GLP-1/GIP agents such as tirzepatide and semaglutide.
The physiology of hyperinsulinemia, glycemic variability, ovarian hyperandrogenism, autonomic imbalance, and stress physiology, explaining how elevated insulin blocks fat loss and fuels PCOS.
An integrative model where I, as a dual-trained clinician in chiropractic and advanced practice nursing with functional medicine credentials, co-manage complex cases alongside our Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933) at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas.
Detailed patient journeys: “Eloise” (obesity, PCOS, binge eating), “George” (male metabolic syndrome, hypertension, fertility concerns), “Lynn” (perimenopause, weight gain, hypertension, mood/cognitive symptoms), “Amit/Amin” (type 2 diabetes, cardiovascular disease, sarcopenic obesity, insulin deprescribing), and “Dolores” (severe osteoarthritis, surgery thresholds, sarcopenia, health inequities).
How integrative chiropractic care enhances outcomes via pain reduction, biomechanical optimization, autonomic regulation, and adherence amplification — and why this is a critical force multiplier when combined with medical pharmacotherapy, nutrition, and rehabilitation.
Evidence-based methods from leading researchers and organizations, with clear APA-7-style in-text citations and a hyperlinked reference list.
This post is written in plain, structured language with SEO-optimized headings, clearly highlighted concepts, narrative explanations, and bullet lists to make complex physiology and treatment strategies accessible. It is a comprehensive, clinically realistic guide to restoring metabolic health, protecting fertility, managing perimenopause and sarcopenia, and building durable, patient-centered outcomes through a multidisciplinary team.
Visit my clinical observations and professional profile:
Injury Medical Clinic PA: https://chiromed.com/
LinkedIn: https://www.linkedin.com/in/dralexjimenez/

Transform Your Body!- Video

Our Integrative Team: Internal Medicine Direction and Chiropractic Functional Care Working Together

I am Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. At Injury Medical Clinic PA (also known as Mission Plaza Injury Medical Clinic) in El Paso, Texas, our care model seamlessly integrates internal medicine direction and chiropractic functional care for metabolic, musculoskeletal, and personal injury cases.
Medical Director and Collaborative Physician: Dr. Maria Guadalupe Cardenas, MD, Board Certified in Internal Medicine, NPI #1164426749, Texas MD License #J2933. With more than 40 years of experience, she ensures medical safety, guideline adherence, pharmacotherapy stewardship, and risk stratification for cardiometabolic conditions, PCOS, prediabetes/diabetes, hypertension, and liver disease.
Chiropractic and Functional Medicine: I lead biomechanical assessments, spinal and rib mobilization, myofascial care, autonomic balancing, structured exercise therapy, and nutrition-metabolic coordination aligned with IFM/CFMP frameworks.
Rehabilitation and Personal Injury Services: We deliver coordinated rehabilitation and post-injury functional restoration, common in modern integrative clinics where chiropractors and MDs co-manage patients.
Our shared mission:
Reduce pain and biomechanical friction
Normalize metabolic signaling and autonomic balance
Build capacity for sustained physical activity and nutrition adherence
Deploy evidence-based pharmacotherapies safely
Restore fertility potential and reduce cardiometabolic risk
Protect mental health and quality of life
This clinician dyad—Dr. Cardenas (internal medicine) and me (chiropractic, APRN, functional medicine)—is the structural backbone enabling comprehensive, safe, and effective integrative care.

Why Integrative Chiropractic Care Enhances Metabolic and Obesity Outcomes

Chronic metabolic conditions engage mechanics, neurology, endocrine, and immune systems all at once. Integrative chiropractic care contributes distinct and synergistic value:
Pain and Movement Efficiency: Optimizing joint mechanics, soft-tissue glide, and spinal segmental function reduces nociceptive input, making movement more comfortable. This consistency in physical activity drives skeletal muscle GLUT4 translocation and insulin sensitivity, critical for obesity and insulin resistance.
Autonomic Nervous System Regulation: Gentle spinal and rib articulations, thoracic mobility work, diaphragmatic facilitation, and guided vagal tone practices can rebalance sympathetic-parasympathetic dynamics. Patients often experience reduced stress hyperglycemia, fewer impulsive eating triggers, and improved sleep.
Inflammation Modulation: Mobilization and myofascial interventions may lower neurogenic inflammation, improving exercise tolerance and insulin signaling.
Adherence Amplifier: When pain abates and movement feels efficient, patients sustain nutrition, exercise micro-bouts, and rehab plans — amplifying pharmacotherapy effects and stabilizing outcomes.
Chiropractic care is not a medication replacement. It is a force multiplier that increases the effectiveness and sustainability of medical and lifestyle interventions.

Case Journey 1: Eloise — Class II Obesity, PCOS, Insulin Resistance, Dyslipidemia, Elevated Liver Enzymes, and Binge Eating Disorder

I present Eloise, a composite educational case consistent with modern clinical realities. Eloise is a 25-year-old fitness director with high physical activity who struggles with:
BMI 37.5 (class II obesity)
Irregular, infrequent menses since adolescence
Clinical hyperandrogenism: cystic acne and upper-lip hair
Hyperinsulinemia: fasting insulin 36.1 μIU/mL, fasting glucose 107 mg/dL, A1C 6.0%, HOMA-IR 9.5
Dyslipidemia: elevated triglycerides, low HDL, elevated LDL
Elevated liver enzymes; possible MASLD (metabolic-associated steatotic liver disease)
Acanthosis nigricans and skin tags
Binge eating episodes 1–2/week triggered by restrictive dieting
Weight cycling with repeated regain
High activity (elliptical, strength training, yoga), sleep okay except after binges; minimal alcohol; nonsmoker
Clinical impression:
Class II obesity
PCOS by Rotterdam criteria (ovulatory dysfunction + clinical hyperandrogenism), excluding secondary causes
Insulin resistance with hyperinsulinemia and prediabetes
Dyslipidemia, possible MASLD
Binge eating disorder with restriction-anxiety-binge cycles
Anovulatory infertility risk
Goals:
Reduce cardiometabolic risk and normalize ovulation/fertility potential
Stabilize insulin and lipids; improve skin/hirsutism
Resolve binge eating and stop weight cycling
Build durable lifestyle skills and protect mental health

The Physiology: Why Elevated Insulin Blocks Fat Loss and Fuels PCOS

Understanding root physiology clarifies strategy.
Hyperinsulinemia and adipose storage: Insulin upregulates adipose lipoprotein lipase and suppresses hormone-sensitive lipase, decreasing lipolysis and fat oxidation during fasting. High insulin locks fat in storage.
Ovarian hyperandrogenism: Insulin synergizes with LH to increase theca cell androgen production. Elevated insulin lowers hepatic sex hormone–binding globulin (SHBG), elevating free androgens, worsening acne, hirsutism, and anovulation (Jensen et al., 2021).
Skeletal muscle and liver insulin resistance: Increases hepatic gluconeogenesis; reduces muscle glucose uptake; raises glycemia → more insulin secretion → vicious cycle (Misra & Bloomgarden, 2018).
Hepatic insulin resistance & de novo lipogenesis: Accumulation of triglycerides elevates ALT/AST and connects PCOS to MASLD risk.
Stress and sleep disruption: Elevate sympathetic drive and cortisol, worsening glycemic variability and binge vulnerability (Bornstein et al., 2018).
Restrictive dieting: Increases ghrelin (hunger), impairs leptin sensitivity (satiety), elevates allostatic load — often precipitating binges.
Therapeutic implications:
Lower insulin exposure and restore insulin sensitivity
Regularize meal timing with adequate protein and fiber to stabilize glycemia
Use exercise micro-bouts to augment glucose disposal independent of insulin
Introduce medications to improve incretin signaling and hepatic insulin sensitivity
Address autonomic balance, pain-free movement, and behavioral drivers
Align contraceptive safety and fertility planning with pharmacotherapy

Diagnostic Framework and Internal Medicine Oversight

PCOS diagnosis: Rotterdam criteria (two of three: ovulatory dysfunction, clinical/biochemical hyperandrogenism, polycystic ovarian morphology), excluding thyroid dysfunction, hyperprolactinemia, nonclassical CAH (Teede et al., 2018; ACOG, 2018).
Insulin resistance: Elevated fasting insulin, HOMA-IR, triglyceride/HDL ratio; optional CGM phenotyping.
Binge eating disorder: Validated screener like BEDS-7; assess frequency, loss of control, distress (Shafiee et al., 2023).
Dr. Cardenas’ role:
Validate diagnoses and coordinate labs/imaging
Screen contraindications
Initiate and monitor medication safely
Align with ADA 2024 and endocrine guidelines (ADA, 2024; Apovian et al., 2015; Garvey et al., 2016)

Stepwise Treatment: Phased, Safe, and Synergistic

Phase 1: Stabilize Metabolic Rhythm and Protect Fertility
Nutrition pattern shift from calorie fixation to patterned, insulin-sensitive eating:
4–5 small meals/day every 3–4 hours to smooth glycemia and reduce binge triggers
Protein 90–100 g/day; 20–30 g/meal to drive muscle protein synthesis and satiety
Fiber 50–100 g/day from vegetables and whole fruit; titrate for GI tolerance
Reduce ultra-processed foods; minimize sweets, refined starches/grains, alcohol
Exercise: Continue elliptical, strength training, yoga; add daily 10-minute walk post-meal or once daily to improve postprandial insulin sensitivity (Solomon et al., 2013)
Medication: Start metformin ER 500 mg daily, titrate to 2,000 mg daily as tolerated; insulin sensitizer with hepatic benefits and modest weight effects (Rubio et al., 2020)
Contraception: Initiate combined oral contraceptive (COC) to stabilize cycles and prevent unplanned pregnancy; counsel that 5–10% weight loss may restore ovulation (Teede et al., 2018)
Behavioral: Psychoeducation, urge surfing, structured meals, anxiety reduction; treat binge drivers (Shafiee et al., 2023)
Phase 2: Incretin Support and Binge Reduction
Once metformin tolerated: introduce tirzepatide with careful titration to minimal effective dose.
Safety counseling: With COCs, use a barrier method for the first four weeks after starting tirzepatide and for four weeks after each dose increase due to delayed gastric emptying possibly affecting pill absorption (Nauck & Meier, 2019; Perakakis & Mantzoros, 2020)
Monitor GI tolerance, hydration, bowel regularity; track satiety and binge frequency.
If binge persists: consider lisdexamfetamine (FDA-approved for binge eating) with cardiovascular/psychiatric screening (Shafiee et al., 2023)
Phase 3: Consolidation and Skill Building
Nutrition skills: meal structuring, grocery planning, protein-fiber pairing, craving scripts, evening rituals
Movement portfolio: micro-bouts (5–10 minutes) across the day; maintain resistance training to preserve muscle
Chiropractic and rehab: address pain, rib mobility, diaphragmatic mechanics, autonomic balance; sustain adherence
Sleep hygiene, stress physiology training, relapse prevention planning
Phase 4: Fertility Planning and Maintenance
As indices normalize: reassess contraception; if evaluating natural cycles, coordinate medication adjustments with OB/GYN.
Maintain lowest effective doses; consider taper with stability
Continue labs, mental health screening, supportive care to prevent regression

Integrative Chiropractic Interventions: Biomechanics, Inflammation, Autonomics

Segmental/regional mobilization: improve loading, reduce neurogenic pain; consistent movement improves GLUT4 translocation in skeletal muscle and insulin sensitivity
Diaphragmatic mobility and thoracic/rib work: enhance respiration, heart rate variability, and vagal tone, reducing stress-driven cravings and glycemic spikes
Myofascial release/fascial glide: reduce nociception, enhance proprioception, support motor control and exercise quality
Lumbopelvic alignment and hip hinge coaching: protect lifting mechanics and resistance training progression
Autonomic balancing: breath pacing, positional recovery (e.g., 90-90 breathing), gentle vagal stimulation to buffer stress-induced binge triggers
Outcome rationale: When patients feel good, they move more — compounding into better insulin sensitivity, mood, sleep, and adherence.

Medical Oversight and Safety Guardrails

With Dr. Cardenas’ internal medicine direction:
Baseline/serial labs: fasting insulin/glucose, A1C, lipid panel, liver enzymes, renal function, pregnancy testing as indicated
Comorbidity screening: thyroid function, prolactin, 17-OHP (PCOS differential); sleep apnea screening
Medication stewardship: metformin titration; tirzepatide dosing/GI safety; contraceptive guidance; lisdexamfetamine cardiovascular and misuse risk screening
Fertility counseling: medication safety windows; preconception labs; OB/GYN coordination
MASLD monitoring: track ALT/AST, consider ultrasound if persistent elevations
This dual-credentialed structure enables potent therapies within robust safety boundaries.

Nutrition Strategy: From Restriction to Regulation

Shift from “1,200-calorie anxiety” to physiology-first patterns:
Structured intake: 4–5 meals/snacks; protein anchor (20–30 g each), fiber emphasis, hydration and minerals (sodium/potassium/magnesium)
Glycemic smoothing: distribute carbs; pair with protein/fiber/fats; avoid long fasting gaps that provoke binge cycles
Upgrading food quality: whole-food proteins (poultry/fish/lean meats/tofu/tempeh/eggs), non-starchy vegetables, legumes as tolerated, strategic fruit, nuts/seeds, olive oil/avocado
Evening cravings protocol: pre-planned protein-fiber snack, decaf tea ritual, 10-minute walk, breathwork, coping scripts
Weekend alcohol: limit/pause to protect sleep architecture and fat oxidation
Mechanism: Protein and fiber drive satiety, attenuate postprandial glucose; frequent small meals stabilize insulin exposure and neurohormonal drivers of binge eating (Sacks et al., 2009).

Exercise Strategy: High-Value Micro-Dosing Plus Strength

Daily 10-minute walks (post-meal preferred): reduce postprandial glucose/insulin; improve mitochondrial signaling and perfusion (Solomon et al., 2013)
Resistance training twice weekly minimum: preserve lean mass and resting metabolic rate; augment insulin sensitivity via glycogen turnover
Yoga twice weekly: autonomic balance and mobility
Optional second 10-minute walk to stack metabolic benefits
Mechanism: Muscle contractions translocate GLUT4 independent of insulin, increasing glucose uptake and lowering 24-hour insulin exposure.

Pharmacotherapy Synergy: Metformin, GLP-1/GIP Agents, and Lisdexamfetamine

Metformin: reduces hepatic gluconeogenesis, improves hepatic insulin sensitivity, modest weight loss, beneficial in PCOS and MASLD risk (Rubio et al., 2020)
Tirzepatide (GIP/GLP-1): significant satiety, delayed gastric emptying, improved insulin secretion in a glucose-dependent manner, glucagon reduction, weight loss, improved A1C/triglycerides/inflammation (Frias et al., 2021)
Contraception considerations: incretin agents may delay gastric emptying; barrier method during initiation and dose escalations (Nauck & Meier, 2019)
Lisdexamfetamine: reduces binge frequency/severity; requires careful cardiovascular/psychiatric oversight (Shafiee et al., 2023)
Clinical sequencing: metformin first; tirzepatide second; reserve lisdexamfetamine for persistent binge patterns after foundational supports.

Behavioral Care: Validated Tools and Everyday Skills

Screening and monitoring: BEDS-7; track binge frequency, triggers, intensity, and recovery quality
Skills training: urge surfing, stimulus control, if-then planning, self-compassion scripts, delayed gratification drills, emotion labeling
Sleep hygiene: consistent schedule, dark/cool room, caffeine/alcohol timing, wind-down rituals
Stress/autonomic practices: paced breathing (4–6 breaths/min), micro-mindfulness, structured breaks
Social support: partner/family education, accountability check-ins, positive reinforcement
Why it matters: behavioral loops steer hormonal dynamics; lowering allostatic load improves appetite regulation and glycemic control.

Six-Month Milestones: Objective Improvements and Subjective Wins

Typical trajectory:
Weight reduction: ~11%
Fasting insulin: drop from 36.1 to ~21.4 μIU/mL
HOMA-IR: significant improvement
A1C: trending downward from 6.0%; lipids normalizing
Dermatologic/androgenic: less acne, reduced hair growth
Binges: reduced to 1–2/month; stress-triggered rather than calorie-triggered
Activity: daily walks added; resistance maintained
Sleep: improved except after rare binges
Interpretation: multi-system recovery — ovarian function likely improving; hepatic load decreasing; autonomic balance stabilizing.

Two-Year Outcomes: Risk Reduction and Fertility Readiness

Weight reduction: ~24.1%
Fasting insulin: ~8.4 μIU/mL (near-normal)
HOMA-IR: normalized
A1C: ~5.2%
Lipids: durable improvement
Liver enzymes: improved; MASLD risk reduced
Binge eating: controlled; lisdexamfetamine added/tapered as needed
Contraception: considering barrier method to assess spontaneous cycles for conception
Activity/sleep: consistently strong; minimal cravings
Clinical message: safe, sustainable path to fertility planning and cardiometabolic resilience via integrative care.

Clinic Workflows: Roles, Communication, and Monitoring

Intake and Assessment: I perform chiropractic-functional and biomechanical exams; Dr. Cardenas leads medical evaluation and labs; body composition and behavioral screeners embedded
Care Plan Conference: decide medication sequence; map nutrition/movement phases; schedule chiropractic and rehab blocks; safety intervals defined
Patient Education: written pathways, medication/contraceptive safety, binge toolkit
Follow-Up Cadence: biweekly for 8–12 weeks; monthly thereafter; labs at 3–4 months, 6 months, then semiannually
Rapid Escalation: GI intolerance, plateaus, recurrent binges, new symptoms trigger swift review
Outcomes tracking: weight, waist, strength markers, HRV if available, binge frequency, quality-of-life scores

Mechanisms in Depth: Why Each Piece Fits

Protein/fiber: increase satiety peptides (PYY, GLP-1), lower glycemic spikes; microbiome SCFAs improve insulin sensitivity and appetite regulation (Sacks et al., 2009)
Post-meal walking: reduces glucose AUC and insulin peaks; enhances skeletal muscle glucose uptake (Solomon et al., 2013)
Metformin: activates AMPK, reduces hepatic glucose output; modest microbiome shifts favor metabolic tone (Rubio et al., 2020)
Tirzepatide: dual incretin activity yields superior A1C and weight reductions (Frias et al., 2021)
Lisdexamfetamine: modulates dopaminergic/noradrenergic reward pathways in binge behavior; monitor closely (Shafiee et al., 2023)
Chiropractic-autonomic interface: thoracic/rib articulation and diaphragmatic mechanics improve HRV, linked to glycemic control and stress resilience
Resistance training: preserves lean mass; skeletal muscle is the main site for insulin-mediated glucose disposal (Wolfe, 2006)

Safety, Contraindications, and Practical Guardrails

Metformin: monitor GI tolerance, B12 over time, renal function; slow titration
Tirzepatide: counsel on nausea/emptying; pancreatitis warnings; contraceptive redundancy during dose changes
Lisdexamfetamine: cardiovascular screening; monitor BP/mood/sleep
PCOS differential: exclude thyroid disease, hyperprolactinemia, nonclassic CAH
Pregnancy planning: medication timelines, washout, preconception labs; prenatal nutrition and folate emphasized

Patient Experience: From Anxiety to Agency

Eloise’s arc:
Early weeks: meal rhythm reduces anxiety and binge triggers
Months 2–3: post-meal walks ritualized; metformin GI tolerance stabilizes; energy improves
Months 4–6: tirzepatide titration hits satiety “sweet spot”; binges diminish; acne improves; confidence rises
Years 1–2: identity consolidates — athletic, metabolically healthy, emotionally regulated; fertility options on her terms

Specific Chiropractic Techniques I Use

Cervicothoracic and thoracolumbar mobilizations: autonomic balance and trunk mechanics
Rib mobilizations and soft-tissue work: respiratory mechanics and sympathetic load reduction
Pelvic alignment, hip capsule mobilizations: gait and strength support
Myofascial techniques: thoracolumbar fascia, psoas, diaphragm to relieve tension linked to stress/overeating
Neurodynamic/proprioceptive drills: enhance motor control and reduce compensations
Breathwork coaching integrated with manual care: elevate vagal tone and calm cravings

Functional Medicine Lens: Systems Biology Integration

Gut-liver axis: reduce fructose/ultra-processed foods; fiber supports microbiota producing SCFAs that improve metabolic signaling and inflammation
HPA axis: regulate stress to prevent cortisol-driven dysglycemia and hedonic eating
Nutrient status: adequate protein, omega-3s, magnesium, micronutrients for mitochondrial and metabolic health
Inflammation resolution: movement, sleep, and whole foods modulate cytokine tone, supporting insulin signaling and ovarian function

Fertility and PCOS: Restoring Ovulation Through Metabolic Repair

As insulin normalizes:
SHBG rises; free androgens decline
Ovarian steroidogenesis rebalances; ovulatory cycles reemerge
Endometrial environment improves; preconception weight loss and glycemic control lower maternal-fetal risk

Monitoring Plan: Data-Driven Adjustments

We track:
Anthropometrics: weight, waist, body composition
Glycemic measures: fasting glucose, A1C, insulin, CGM phenotyping
Lipids/liver enzymes: MASLD risk and cardiometabolic trends
Hormonal markers: SHBG/androgens as indicated
Behavioral health: binge frequency, sleep, stress
Physical function: strength/mobility/tolerance/pain
Autonomic indicators: HRV where available

Decision Points for Plan Adjustments

Binges persist beyond 8–12 weeks: add lisdexamfetamine with screening
GI intolerance limits metformin: extend titration, adjust timing, consider alternatives
Weight loss plateaus: review meal composition, protein adequacy, micro-bouts, sleep, medication dosing
Mood/sleep deteriorate: adjust stimulant use, exercise timing, prioritize autonomic interventions
Labs stall: reassess adherence, doses, alcohol intake, comorbidities

Long-Term Maintenance: Anti-Relapse Ecosystem

Minimal effective pharmacology: maintain doses that uphold stability
Protect lean mass: never abandon resistance training
Sustain meal rhythm: protein-fiber anchors and evening scripts
Seasonal planning: holiday/travel stress playbooks
Regular touchpoints: quarterly check-ins, annual labs, chiropractic/rehab tune-ups

Case Journey 2: George — Male Metabolic Health, Hypertension, Prediabetes, Fertility Concerns, Mood and Stress

I introduce “George,” a 35-year-old nonsmoker, high-pressure tech project manager, facing fertility challenges (low sperm count) and significant stress, anxiety, occasional erectile dysfunction, elevated blood pressure, and visceral adiposity. His motivations:
Improve heart health and avoid his father’s fate with heart failure
Prevent type 2 diabetes
Improve fertility
Manage stress
Increase energy for his family

Chemical vs. Character: Reframing Shame into Physiology

George felt shame about appetite control. I explained this is not a character flaw — it is chemistry and hormones:
Aromatase in adipose converts testosterone to estrogen → reduced testosterone, increased estrogen → fatigue, mood changes, lower muscle mass, more abdominal fat, impaired sperm and erectile function
Cortisol and insulin under chronic stress and poor sleep elevate appetite (comfort foods), drive fat storage (especially visceral), and magnify insulin resistance (Bornstein et al., 2018)
Ghrelin-Leptin-GLP-1 axis:
Ghrelin increases hunger
Leptin resistance blunts satiety signals
Impaired GLP-1 signaling reduces fullness
Chronic inflammation from adipokines fuels metabolic dysfunction
His struggle is biochemical, not moral. This reframe empowers patients to act without self-blame.

Initial Plan: Multidisciplinary and Patient-Centered

Complete labs: A1C, thyroid panel (TSH, Free T4/T3, antibodies), liver function panel
Registered Dietitian (RDN) referral: personalized nutrition, address free food/drink at work, portion sizes
Blood pressure management: medication, home cuff, log for self-management
Adiposity-Based Chronic Disease (ABCD) medications: discuss tools to reset appetite circuits
Sleep medicine study: evaluate for obstructive sleep apnea (OSA) — a driver of hypertension and insulin resistance
Stress and physical activity: small starts (meditation, movement integration)

Four-Week Follow-Up: Wins and Barriers

Successes:
BP medication adherence and logging
Completed labs: thyroid/liver normal; A1C 5.9% (prediabetes)
Sleep study scheduled; dietitian visit completed
Challenges:
Could not start meditation or exercise yet
Slight weight gain; discovered large portions, stress eating, difficulty switching from soda to water
We normalized the experience, reframed the scale, and focused on behavior wins. We explored barriers: meditation felt “silly,” exercise energy low.

Plan Refinement

Increase BP medication dose for better control
Bupropion-naltrexone after sleep study:
Bupropion: supports mood and energy (dopamine/norepinephrine)
Naltrexone: modulates reward pathways, reduces cravings
Stress management: three-minute guided meditation via phone app in car after commute, twice weekly
NEAT: stairs at work, hourly movement breaks — build activity without “gym requirement”
Continue dietitian and sleep study

Integrative Chiropractic Care for George

Chronic stress manifests physically: muscle tension, spinal subluxations, pain, and autonomic imbalance. My care plan:
Spinal adjustments: reduce neurological stress; down-regulate sympathetic, elevate parasympathetic; aid cortisol normalization
Soft tissue therapies: myofascial release, trigger point therapy for neck/shoulders/lumbar tension
Postural/ergonomic education: commute and desk setup; specific counter-sitting drills and stretches
Support movement goals: improve joint function, balance, coordination to reduce injury risk as activity increases
Close communication with Dr. Cardenas ensures medical oversight for non-musculoskeletal alerts and supports comprehensive care.

Four-Month Follow-Up: New Tools and Progress

Blood pressure controlled
OSA treated with CPAP — game-changer for BP, insulin sensitivity, cortisol
Mood and habits improved; daily lunch-break walks
Weight and nutrition improved
Persistent challenge: hunger persists despite progress. He asks about injectable medications (GLP-1 agonists). He plans to try for a second child in a few months.
Updated plan:
Semaglutide initiation: 0.25 mg weekly titration; potent appetite suppression, slowed gastric emptying, improved insulin response (Wilding et al., 2021)
Taper naltrexone; continue bupropion for mood/energy
Body composition monitoring: BIA/DEXA or home scale trend tracking
Add resistance training: protect lean mass during weight loss

One-Year Transformation: Data and Outcomes

Family joy: spouse pregnant
BP controlled; semaglutide effective at 1.7 mg maintenance dose
Waist circumference down; visceral fat reduced
Sleep improved with CPAP; stress tools sustained
Key markers:
HOMA-IR formula: HOMA-IR = (Fasting Insulin [μU/mL] × Fasting Glucose [mg/dL]) / 405
Initial HOMA-IR 3.1 → 1.64
A1C 5.9% → < 5.7%
Fasting insulin and glucose normalized
He met all goals: cardiometabolic improvement, diabetes prevention, fertility, stress management, energy.

Case Journey 3: Lynn — Perimenopause, Hypertension, Cognitive/Mood Symptoms, Weight Gain, Tirzepatide Layered After MHT

“Lynn,” 45 years old, presented with fatigue, brain fog, poor sleep, mood swings, hot flashes, and a 20-pound weight gain. Her goals:
Manage perimenopause symptoms
Reduce blood pressure
Prevent further weight gain and reduce visceral fat

Why Start with Menopausal Hormone Therapy (MHT) Before Obesity Medication

We engaged in shared decision-making and root-cause analysis:
Primary driver appears hormonal — estrogen decline impairs insulin sensitivity, promotes visceral fat, disrupts neurotransmitters affecting mood and sleep (NAMS, 2022)
Patient preference: She wanted cognitive clarity and mood stability; MHT directly targets this
Start low, go slow; one-at-a-time: To avoid polypharmacy confusion, we began with transdermal estradiol (preferred for lower thromboembolism risk) plus oral micronized progesterone for endometrial protection and sleep benefit (Vinogradova et al., 2019)
Lifestyle anchors: hydration, BP monitoring, sleep hygiene, and initial movement plans. We planted seeds for phased metabolic therapy.

Six-Week Follow-Up: Early Wins

Dramatic cognitive and mood improvements; sleep quality improved
Began a consistent walking routine; explored new activities
Initial weight loss and BP trending down
We transitioned into Phase Two.

Phase Two: Tirzepatide to Strengthen Metabolic Control

Tirzepatide 2.5 mg weekly initiation:
GLP-1 agonism: glucose-dependent insulin secretion, reduced glucagon, slowed gastric emptying, hypothalamic appetite reduction
GIP agonism: synergistic insulin effect and improved adipose lipid handling; superior weight and A1C reductions compared to GLP-1 alone (Frias et al., 2021; Jastreboff et al., 2022)
Continued MHT, dietitian and therapist collaboration, and new exercise routines
Monitoring muscle mass and body composition:
Baseline BIA/DEXA
Protein intake 1.2–1.6 g/kg ideal body weight spread through the day
Resistance training added for sarcopenia prevention

Side Effects: Expect, Educate, and Manage

Common GI effects (nausea, constipation/diarrhea) are transient, dose-dependent, and manageable with smaller meals, hydration, and dietitian guidance.
Red flags (severe abdominal pain) prompt urgent assessment

Three-Year Horizon: Stability, Muscle Preservation, and Lifestyle Integration

Lynn stable on 15 mg tirzepatide
Continues MHT for cognitive/mood stability
Body composition: majority of weight loss from fat; muscle mass maintained/increased
Physical exam: strong gait, easy sit-to-stand, firm handshake — functional strength indicators
Exercise: found enjoyable cardio and weights class; consistent participation
Ongoing dietitian and therapist tune-ups; proactive mental health care during family stress
Lynn achieved and exceeded goals: symptom control, BP normalization, healthy weight loss emphasizing muscle preservation — and a thriving outlook.

Case Journey 4: Amit/Amin — Type 2 Diabetes, Prior MI, PAD, MASLD, Sarcopenic Obesity; Semaglutide for Cardiovascular Risk Reduction and Insulin Deprescribing

“Amit” (also presented as “Amin” in some summaries), 57, North African ancestry, with:
Type 2 diabetes on basal-bolus insulin
Prior myocardial infarction (MI)
Peripheral artery disease (PAD) Stage 2A with claudication
Obstructive sleep apnea (CPAP), hypertension, hyperlipidemia
Stage 2 MASLD
Low testosterone on therapy; erectile dysfunction
Family history: obesity, diabetes, hypertension, MI, severe PAD
Key findings:
BMI 38.4 kg/m²
Waist 51.25 inches
A1C 6.9% (appears controlled but driven by high exogenous insulin)
Lipids: elevated triglycerides, HDL 29 mg/dL
Liver enzymes elevated
Body composition: total body fat 56.7%, skeletal muscle 20.7% (4th percentile), visceral fat 4.4 L
Physical exam: acanthosis nigricans, skin tags, enlarged liver, lower extremity edema
Diagnosis: sarcopenic obesity — severe cardiometabolic and functional risks.

Treatment Goals

10% body weight reduction
Improve body composition: increase muscle mass; reduce adiposity (visceral fat priority)
Reduce cardiovascular/metabolic risk
Improve PAD symptoms and physical conditioning
Increase energy and quality of life

Pillar 1: Nutrition for Muscle Synthesis and Insulin Sensitivity

Mediterranean-style diet compatible with culture
Protein 90–100 g/day, spread every 3–4 hours:
Stimulates muscle protein synthesis (MPS) repeatedly via leucine threshold dosing
Emphasize complete proteins; plant strategies can be structured effectively with dietitian support
Carbohydrate intolerance counseling: minimize ultra-processed foods, sweets, refined grains; reduce alcohol given liver and metabolic considerations

Pillar 2: Physical Therapy for Function and PAD

Functional assessment: strength, balance, mobility
PAD walk-rest-walk protocol: stimulate collateral vessel growth and pain-free walking distance
Resistance training prescription: begin safely with supervision
Home program: stationary bike; light weights twice weekly

Pillar 3: Semaglutide and Insulin Deprescribing

Semaglutide 2.4 mg (Wegovy) choice — cardiovascular risk reduction:
SELECT trial: Secondary prevention benefit — 20% reduction in major adverse cardiovascular events (MACE) in patients with obesity and established cardiovascular disease without diabetes (Lincoff et al., 2023). FDA-recognized indication.
Amit is a perfect candidate: prior MI, PAD, obesity.
Insulin deprescribing rationale:
Insulin is anabolic and lipogenic, promotes fat storage and prevents lipolysis. With severe insulin resistance, escalating insulin increases hyperinsulinemia, locking fat in storage and fueling inflammation.
Goal: break the cycle by augmenting incretin pathways and tapering insulin. Use CGM to guide safely; individualize taper speed based on glycemic stability.

Six-Month Follow-Up: Liberation from Hunger and Insulin

Titrated to 2.4 mg semaglutide maintenance
Insulin fully tapered off
Subjective “food noise” dramatically reduced; better portion control; ~75% nutrition adherence
Alcohol reduced naturally (possible reward pathway modulation)
Functional gains: 15 minutes daily on exercise bike; strength training twice weekly; less claudication pain
Weight reduction 10.2% — outstanding given diabetes, prior insulin, and limited initial activity

Go-Forward Plan and Biological Pushback

Increase diet adherence to 85%
Gradually extend bike sessions to 30 minutes daily
Progress strength training weights
Increase NEAT
Expect biological pushback (ghrelin ↑, leptin ↓, satiety hormones ↓) — normalize experience and consider second obesity medication if necessary:
Phentermine
Naltrexone/bupropion
Phentermine/topiramate
We weigh risks versus ongoing adiposity and insulin resistance — often favoring careful pharmacologic support (Garvey et al., 2016; Bray et al., 2018)

One-Year Transformation: Data and Function

Nutrition adherence 85%
Beer consumption down to three per week
Bike 30 minutes most days; increased resistance loads; enjoys exercise
Energy, stamina, minimal claudication pain
Objective measures:
Weight loss: 16.3%
Fasting insulin: 22.4 → 13.1 μU/mL
HOMA-IR: 5.8 → 3.4
A1C: 6.3% → 6.0%
Body fat: 56.7% → 41.1%
Skeletal muscle: 20.7% → 29.1% (percentile jump to 25th)
Visceral fat: 4.4 L → 2.3 L
He successfully reversed sarcopenic obesity, built muscle, and halved visceral fat — transforming cardiovascular and metabolic risk.

Case Journey 5: Dolores — Severe Osteoarthritis, Surgical Thresholds, Sarcopenia, Health Inequities, Weight Loss Tools and Rehab

“Dolores,” 72-year-old retired advisor, with:
Hyperlipidemia, insomnia, severe knee osteoarthritis limiting mobility
Surgical barrier: BMI must be < 40 for total knee replacement
Weight gained since perimenopause; repeated weight-loss/regain cycles
Medications: rosuvastatin, trazodone, diclofenac, multivitamin
Nutrition: loves fruits/vegetables; low protein; sweets at night
Physical activity: swimming 20 minutes, 3 times/week
Sleep: improved with trazodone; occasional alcohol; nonsmoker
Baseline:
Fasting insulin: 8.4 μU/mL (early insulin resistance)
BMI: 41.5 (just above surgical threshold)
Body fat: 56.8%
Skeletal muscle: 15.1% (2nd percentile) — severe sarcopenia
Visceral fat: 2.3 L
Waist: 43.1 inches
Body shape: gynoid with central adiposity — higher risk with sarcopenia

Health Risks and Inequities

We are concerned about cardiometabolic decline, functional deterioration, and obesity complications. We must also confront weight bias and health inequities affecting older women with obesity (Puhl & Heuer, 2009; Tomiyama et al., 2018). These patients often face dismissive care and internalized stigma, which harms outcomes.

Stepwise Plan: Function, Empowerment, and Surgery Readiness

Primary goal:
Reduce weight by ≥3.9% (~10 lb) to cross BMI < 40 threshold
Broader goals:
Improve mobility, reverse sarcopenia via body composition, enhance quality of life
Plan:
Nutrition
Protein 90–100 g/day, every 3–4 hours
Favor animal proteins where acceptable; use eggs, seafood, cottage cheese, Greek yogurt, hard cheeses, and high-quality protein shakes.
Reduce sweets/starches to address insulin resistance.
Refer to an obesity-informed Registered Dietitian
Physical activity
Continue swimming
Physical therapy referral: geriatrics and obesity expertise; exercise bike for low-impact cardiovascular work; tailored strength training to build muscle
Medication options
Tirzepatide or semaglutide for weight loss
Naltrexone/bupropion, phentermine, or phentermine/topiramate as alternatives based on tolerance, access, and goals

Addressing Barriers: Empathy, Education, Advocacy

Dolores feared PT due to weight-related judgment and failure. We validated her concerns, advocated to orthopedics, and reframed surgery requirements:
BMI cutoffs are blunt tools; we must examine body composition, metabolic health, and function
We coordinated with a female PT experienced with obesity
We coached Dolores to communicate proactively with PT and surgeons, reframing from a position of strength
We followed up frequently to sustain support

One-Year Outcomes: Mobility and Freedom

Weight reduction: 8.7%
Fasting insulin normal; labs improved
Body fat: 56.8% → 49.8%
Skeletal muscle: 15.1% → higher percentile (2nd → 10th)
Visceral fat and waist: lower
Medication path:
Started naltrexone/bupropion for cravings and portion control to reach surgery threshold
Paused naltrexone perioperatively to allow opioid analgesia; continued bupropion
Successful first knee replacement with no complications
Post-surgery, mobility improved; switched to semaglutide, titrated to 1.7 mg
Protein intake increased to 75 g/day; sweets reduced
Began PT and found it positive; plans in place for second knee replacement
Dolores is ready to travel — achieving mobility, dignity, and autonomy through integrated care.

How Our Multidisciplinary Team Integrates Care

I lead chiropractic/functional rehabilitation, and Dr. Cardenas provides medical oversight. Together we coordinate:
Internal medicine direction: cardiometabolic risk management, pharmacotherapy safety, lab monitoring, sleep, and comorbidity screening
Chiropractic functional care: biomechanical optimization, autonomic balancing, soft-tissue interventions, coaching for exercise safety and efficiency
Functional medicine: root-cause analysis — gut-liver axis, HPA axis, nutrient sufficiency, inflammation resolution
Personal injury and rehabilitation: integrated physical therapy protocols, progressive resistance training, pain management strategies
Behavioral health: binge tools, stress physiology training, sleep hygiene, relapse prevention scripts
Patient education: clear written pathways, medication safety, contraception guidance, body composition literacy
Visit my clinical observations and professional profile:
Clinic: https://chiromed.com/
LinkedIn: https://www.linkedin.com/in/dralexjimenez/

Physiology Deep Dive: The Metabolic Web We Untangle

To deliver consistent results, we treat causes, not just symptoms. Below is a deeper explanation of the physiological frameworks that guide our protocols.

Insulin Resistance and Hyperinsulinemia: The Energy Lock

Skeletal muscle insulin resistance decreases glucose uptake; more glucose remains in circulation, prompting the pancreas to over-secrete insulin
Hepatic insulin resistance elevates gluconeogenesis and de novo lipogenesis, which raises triglycerides and contributes to MASLD
Adipose tissue insulin signaling shifts toward storage; high insulin blunts hormone-sensitive lipase and lipolysis, locking fat in adipocytes
GLUT4 translocation depends both on insulin and muscle contraction; repeated contractions provide an insulin-independent path to glucose uptake — hence micro-bouts and resistance training are essential (Solomon et al., 2013; Wolfe, 2006)
Clinical reasoning:
We lower insulin exposure via meal rhythm, protein/fiber intake, micro-bouts, and pharmacotherapy
We improve insulin sensitivity via metformin, GLP-1/GIP agents, and resistance training
We emphasize adherence by using chiropractic to reduce pain and movement friction

PCOS: Metabolic-Hormonal Crosstalk

High insulin synergizes with LH to increase ovarian theca androgens
Lower SHBG increases free androgens → acne, hirsutism, anovulatory cycles
Weight loss and insulin normalization raise SHBG, reducing androgenic symptoms and restoring ovulation (Jensen et al., 2021; Teede et al., 2018)
Clinical reasoning:
Nutrition rhythm, micro-bouts, metformin, and incretin therapies reverse hyperinsulinemic drive
Contraception early; fertility planning later as cycles normalize

Autonomic Balance: Stress Physiology and Appetite Regulation

Chronic sympathetic dominance elevates cortisol; increases appetite for energy-dense foods; worsens glycemic variability
Chiropractic manual care, diaphragmatic mobilization, thoracic rib work, and breath pacing enhance vagal tone and HRV
Improved autonomic balance lowers “food noise” and binge triggers; increases sleep quality — crucial for leptin sensitivity and insulin regulation (Bornstein et al., 2018)
Clinical reasoning:
We embed autonomic balancing within manual therapy and home practices to steady appetite regulation and glycemia

Sarcopenia and Sarcopenic Obesity: The Muscle Imperative

Muscle is metabolically active, central to glucose disposal and resting metabolic rate
Aging accelerates muscle loss; perimenopause and menopause exacerbate due to reduced estrogen
Weight loss without resistance training risks sarcopenia; medications that reduce appetite can blunt protein intake, making planning essential (Bauer et al., 2013; Wolfe, 2006; Ponti et al., 2020)
Clinical reasoning:
We mandate resistance training, protein distribution, and regular body composition checks
We titrate medications while coaching nutrition to protect muscle

Cardiovascular Risk Reduction: Why Semaglutide Matters in Secondary Prevention

SELECT trial: Semaglutide 2.4 mg reduced MACE by 20% in patients with obesity and established cardiovascular disease without diabetes (Lincoff et al., 2023)
Mechanisms include weight loss, improved glycemic control, reduced inflammation, and possible improvements in endothelial function
Clinical reasoning:
In patients like Amit with MI and PAD, semaglutide carries a dual role: weight loss and cardiovascular risk reduction
Insulin deprescribing lowers hyperinsulinemia-driven lipogenesis and inflammation

Patient Education: Making Complex Science Simple and Actionable

We teach patients concepts they can use. Here is how we translate complexity into practical steps.

Key Concepts We Emphasize

n locks fat”: Meal rhythm, protein/fiber, post-meal walking, metformin, and incretin therapy help “unlock” stored fat
“Muscle protects metabolism”: Resistance training and regular protein prevent sarcopenia and sustain weight maintenance
“Autonomics drive appetite”: Breath pacing, rib/diaphragm work, and sleep hygiene help control cravings and stabilize glycemia.
“Progress over perfection”: We measure trends, not daily fluctuations; we celebrate adherence to behaviors that produce physiological wins.

Practical Scripts and Tools

If-then decision trees for high-stress days: “If I feel overwhelmed at 5 pm, then I take a 10-minute walk and have a protein-fiber snack.”
Evening ritual: decaf tea, breathwork, short walk, then pre-planned snack
Grocery strategy: protein-first list, vegetables and fruit variety, healthy fats for satiety
Social support: involve family or partners; schedule check-ins; set environment cues to reduce ultra-processed food exposure

Clinic Structure: How We Sustain Safety and Outcomes

Our workflows are designed around safety, clarity, and momentum.
Baseline labs: insulin, glucose, A1C, lipids, liver/renal function; pregnancy testing as indicated
Comorbid screening: thyroid, prolactin, 17-OHP; sleep apneas; cardiovascular risk
Pharmacotherapy sequencing: metformin then GLP-1/GIP; deprescribe insulin as appropriate; consider lisdexamfetamine in binge eating
Contraception safeguards: barrier redundancy during incretin initiation/uptitration
Body composition monitoring: baseline and periodic BIA/DEXA; ensure fat loss > lean loss
Manual care blocks: chiropractic sessions for movement efficiency; autonomic tuning; soft-tissue work; neurodynamic drills
Physical therapy: gait/strength progression; PAD walk-rest-walk; home plans
Check-in cadence: biweekly early phase; monthly later; labs at planned intervals
Documentation: weight, waist, HRV where available, strength markers, binge frequency, QoL indices

Clinical Observations: My Perspective as DC, APRN, FNP-BC

I observe repeatedly:
Pain relief and rib/diaphragm mobilization increase willingness to move; movement increases insulin sensitivity and stabilizes mood
Micro-bouts across the day often outperform single long workouts for glycemic smoothing in busy patients
Body composition conversations create insight — patients understand why muscle matters and commit to resistance training
Clear contraceptive guidance during incretin changes prevents unexpected risks
Coaching for stigma and fear in older women is essential — empathy and advocacy unlock access to PT and surgery
Semaglutide’s cardiovascular indication changes the risk-benefit conversation in secondary prevention patients
Integrative chiropractic with internal medicine oversight is not only viable — it is often the missing link in sustainable outcomes
Explore more of my clinical work and insights:
Clinic: https://chiromed.com/
LinkedIn: https://www.linkedin.com/in/dralexjimenez/

Practical Takeaways for Clinicians and Patients

Hyperinsulinemia locks fat; target insulin exposure with meal rhythm, protein/fiber, micro-bouts, metformin, and incretin therapy.
PCOS is a lifelong cardiometabolic risk phenotype; early and sustained follow-up matters; fertility planning should be careful and coordinated
Binge eating thrives on restriction and stress; stabilize rhythm and nervous system first; consider lisdexamfetamine if symptoms persist after foundational changes.
Integrative chiropractic care boosts adherence and physiology by reducing pain and rebalancing autonomics.
Multidisciplinary internal medicine-chiropractic collaboration delivers safety, speed, and durability for complex metabolic cases.
Muscle preservation is non-negotiable; resistance training and protein distribution should be embedded in every plan.
Secondary cardiovascular prevention: semaglutide 2.4 mg is a powerful ally for patients with established CVD and obesity
Advocacy beats bias: challenge unhelpful surgical thresholds with data and empathy; coach patients to reclaim their voice.

References

• American College of Obstetricians and Gynecologists. (2018). Polycystic ovary syndrome.
• American Diabetes Association. (2024). Standards of medical care in diabetes—2024.
• Apovian, C. M., Aronne, L. J., Bessesen, D. H., McDonnell, M. E., Murad, M. H., Pagotto, U., Ryan, D. H., & Still, C. D. (2015). Pharmacological management of obesity: An endocrine society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism, 100(2), 342–362.
• Bornstein, S. R., Schuppen, D., Mussig, K., & Jauch-Chara, K. (2018). The cortisol, insulin and glucose axis in the sleepy brain. Sleep, 41(1).
• Bray, G. A., Heisel, W. E., Afshin, A., Jensen, M. D., Ryan, D. H., & Klein, S. (2018). The science of obesity management: An endocrine society scientific statement. Endocrine Reviews, 39(2), 79–132.
• Frias, J. P., Davies, M. J., Rosenstock, J., Pérez Manghi, F. C., Fernández Landó, L., Bergman, B. K., Liu, B., Cui, X., & Brown, K. (2021). Tirzepatide versus semaglutide once weekly in patients with type 2 diabetes. New England Journal of Medicine, 385(6), 503–515.
• Garvey, W. T., Mechanick, J. I., Brett, E. M., Garber, A. J., Hurley, D. L., Jastreboff, A. M., … & Reviewers of the AACE/ACE Obesity Clinical Practice Guidelines. (2016). American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for comprehensive medical care of patients with obesity. Endocrine Practice, 22(Suppl 3), 1–203.
• Jastreboff, A. M., Aronne, L. J., Ahmad, N. N., Wharton, S., Connery, L., Alves, B., … & SURMOUNT-1 Investigators. (2022). Tirzepatide once weekly for the treatment of obesity. New England Journal of Medicine, 387(3), 205–216.
• Jensen, M. D., et al. (2021). Insulin resistance and its implications in PCOS. Nature Reviews Endocrinology.
• Lincoff, A. M., Brown-Frandsen, K., Colhoun, H. M., Deanfield, J., Emerson, S. S., Esbjerg, S., Hardt-Lindberg, S., Hovingh, G. K., Kahn, S. E., Kushner, R. F., Lingvay, I., Oral, H., Rasmussen, S., Steg, P. G., Torekov, L., Viljoen, A., & Buse, J. B. (2023). Semaglutide and cardiovascular outcomes in obesity without diabetes. New England Journal of Medicine, 389(24), 2221–2232.
• Misra, A., & Bloomgarden, Z. (2018). Obesity and cardiometabolic risk. Endocrine Reviews, 39(3), 295–321.
• Nauck, M. A., & Meier, J. J. (2019). Incretins and their role in glucose homeostasis and obesity treatment. Nature Reviews Endocrinology, 15, 262–279.
• Perakakis, N., & Mantzoros, C. S. (2020). The role of GLP-1 and GIP in metabolic regulation and obesity therapies. Diabetes, 69(3), 457–464.
• Ponti, F., Santoro, A., Mercatelli, D., Gasperini, C., Conte, M., Martucci, M., … & Franceschi, C. (2020). Aging and imaging assessment of body composition: from fat to facts. Frontiers in Endocrinology, 10, 861.
• Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity: a review and update. Obesity, 17(5), 941–964.
• Rubio, M. A., et al. (2020). Metformin mechanisms beyond glucose lowering. Current Diabetes Reports, 20(10), 1316–1327.
• Sacks, F. M., et al. (2009). Dietary strategies for weight loss—Comparative effectiveness. New England Journal of Medicine, 360(9), 859–873.
• Shafiee, M., et al. (2023). Lisdexamfetamine for binge eating disorder: Efficacy and safety. The Lancet Psychiatry.
• Solomon, T. P. J., et al. (2013). Postprandial walking and glycemic control. Diabetes Care, 36(10), 3389–3394.
• Teede, H. J., et al. (2018). International evidence-based guideline for the assessment and management of PCOS. Monash University/ESHRE/ASRM.
• Vinogradova, Y., Coupland, C., & Hippisley-Cox, J. (2019). Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ, 364, k4810.
• Wilding, J. P. H., Batterham, R. L., Calanna, S., Davies, M., Van Gaal, L. F., Lingvay, I., … & STEP 1 Study Group. (2021). Once-weekly semaglutide in adults with overweight or obesity. New England Journal of Medicine, 384(11), 989–1002.
• Wing, R. R., Lang, W., Wadden, T. A., Safford, M., Knowler, W. C., Bertoni, A. G., Hill, J. O., Brancati, F. L., Peters, A., & Wagenknecht, L. (2011). Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes Care, 34(7), 1481–1486.
• Wolfe, R. R. (2006). The underappreciated role of muscle in health and disease. American Journal of Clinical Nutrition, 84(3), 475–482.

SEO tags: integrative chiropractic care, internal medicine collaboration, Dr. Alex Jimenez, Dr. Maria Guadalupe Cardenas, PCOS treatment, insulin resistance, hyperinsulinemia, binge eating disorder, metformin, tirzepatide, semaglutide, GLP-1 GIP therapy, cardiovascular risk reduction, SELECT trial semaglutide, sarcopenic obesity, resistance training, protein distribution, autonomic balance, vagal tone, diaphragmatic mechanics, postprandial walking, HOMA-IR improvement, MASLD NAFLD, fertility planning in PCOS, perimenopause hormone therapy, MHT, body composition analysis, physical therapy PAD, El Paso multidisciplinary clinic, Injury Medical Clinic PA