April 9, 2019 at 6:40 pm #2706Belle AmattParticipant
Any thoughts on this highly stressed, weight loss client much appreciated
Age 36, sex F, height 5 ft 7 and weight 11 st 5 lbs
Primary Presenting Symptoms plus aims – would like to lose weight and ‘sort out metabolism (would like more energy, thicker hair stronger nails), issue with falling asleep at work
Diagnosis – under-active thyroid, OCT 2016 – borderline PCOS (from blood tests – no cysts seen)
Duration of presenting symptoms – Hypothyroid 6 years ago
Diet –have been working on this over the last 3 months with mindful eating, reduced caffeine, alcohol and high gluten, portion control is the weight issue. Avoids lactose as believes she is intolerant – half stone weight loss
HIGH stress job – is using MIND App which helps
Current medications – thyroxine 150 mcg/day
Supplements – takes DHEA (Client has self-prescribed and feels it helps)
Has been taking Glucobalance (6 per day) and Fish oils since our last meeting.
Your own considerations for relevant antecedents, mediators & triggers – perhaps client may need further support with adaptogenic herbs, does she have the building blocks to produce hormones? I wonder if the sample 2 high was merely a stress reaction specific to that day.
lab tests –
Genova Adrenal Thyroid test results:
Cortisol – 10.15, 20.18 (H), 6.32, 2.34
DHEA mean – 1.25
DHEA:Cortisol ratio 0.192 H (but reflects her self-prescribed supplements)
Urine T3 results – T3 1,690
Your own consideration for specific nutritional intervention –
The client has lost 6 lbs and appears to have plateaued – in light of the new PCOS diagnosis we will be considering low GI diet modifications. Also to work further on low adrenal output. I am considering adding Pro-greens.
Your question(s) – any advice on further products which may be useful to support this highly stressed lady to have more energy and lose weight in line with her test results.
Posted by Belle Amatt on 08/11/2016
April 9, 2019 at 6:40 pm #2708Carrie Decker, NDModerator
Thank you for contributing this case here. I’m glad you can support this woman in bringing more balance to her state of health. It sounds like there are many different things which are primary presenting symptoms, but a high stress level which may further worsen blood sugar regulation, thyroid function, weight, and more.
I’m glad you have spent time with this woman focusing on the dietary contributions to her weight, and overall state of health. Under stress it is easy to over (or under) eat as mindfulness and connection to body and appetite is often out the window, so to speak. Focusing on filling the plate with more vegetables, with a high amount of greens including cruciferous is a recommendation that I give anyone when hormone balance is an issue. Even though portion control and mindfulness with eating is important, when the plate is more than half full with greens the overall calorie content will be low and one will experience fullness more rapidly. Although there is some dialogue around the possible anti-thyroid effect of cruciferous as goitrogens, I have done significant research around this topic and do not feel it is of concern if someone is getting adequate iodine.
Many individuals are, however, iodine deficient including the population broadly in the UK and US where iodine sufficiency is not often thought to be a concern. The United Kingdom (UK) is one of the top 10 countries having iodine deficient school-aged children. This may be associated with shifts from iodized salts to more natural sea salts, depletion of iodine from soils, and other dietary changes. Given that thyroid hypofunction is a known issue for this woman, supporting her additionally with a thyroid nutrient/conversion support formula would be appropriate particularly as she is just on a thyroxine support medication. Cortisol and insulin resistance (both of which appear to be issues for her) also increase conversion of thyroid hormone into rT3, blocking activation of receptors by T3.
Zimmermann MB. Iodine and iodine deficiency disorders. In: Erdman JWJ, Macdonald IA, Zeisel SH, eds. Present Knowledge in Nutrition. 10th ed: John Wiley & Sons; 2012:554-567. http://tinyurl.com/zjyustw
Andersson M, et al. Global iodine status in 2011 and trends over the past decade. J Nutr. 2012 Apr;142(4):744-50. http://tinyurl.com/zmgthrk
Although cortisol production can greatly vary on a day to day basis, the testing results do not suggest a state of prolonged stress-induced insufficiency. I do think you are wise to consider that there may be herbs or nutritional supplements which will help to balance her adrenal function. I’m not sure which tests have been done to assess for polycystic ovarian syndrome (PCOS), but in addition to insulin resistance being of concern, hormones as we all know are affected when someone has PCOS. Diagnostically, an increase in mean luteinizing hormone (LH) levels is one of the main hormones used for assessment of PCOS.
Between 50 and 90 percent of PCOS women have elevated serum androgen levels, which includes DHEA. DHEA-S is increased in about 16 percent of women with PCOS who have normal total and free testosterone levels. Women with PCOS also have higher levels of testosterone, and in women supplemental DHEA also tends to convert to testosterone rather than oestrogen. Thus, providing additional DHEA would not be appropriate for this woman as it will push towards further increasing these levels.
Azziz R, et al. Androgen excess in women: experience with over 1000 consecutive patients. J Clin Endocrinol Metab. 2004 Feb;89(2):453-62. http://tinyurl.com/pxhkgkp
Sex hormone binding globulin (SHBG) is a protein which binds sex hormones and in this manner helps to regulate the levels of free, unbound hormones. In women with PCOS, SHBG is often low. Hyperinsulinemia has a suppressive effect on SHBG production by the liver. The decrease in SHBG can lead to measurements of total testosterone appearing normal, yet free testosterone being high.
Nestler JE, et al. A direct effect of hyperinsulinemia on serum sex hormone-binding globulin levels in obese women with the polycystic ovary syndrome. J Clin Endocrinol Metab. 1991 Jan;72(1):83-9. http://tinyurl.com/nw9hrzt
In my practice, I have found seed and fatty acid cycling to be very beneficial for hormonal irregularities. Flax or pumpkin seeds, 2 tablespoons freshly ground and/or fish oil 2000mg combined EPA/DHA should be taken from day 1 of the cycle to ovulation (roughly day 14); and 2 tablespoons of sunflower or sesame seed and/or 2000mg of borage, black currant, or evening primrose oil (supplying approximately 200mg of gamma-linolenic acid) taken the second half of the cycle from ovulation through menstruation. In women with PCOS or significant cycle irregularity I generally instruct to follow the moon cycle with flax and/or fish in the first half and sesame / GLA in the second half.
Freshly ground flax seeds are an excellent source of phytosterols, and also serve to moderate hormones by increasing progesterone / oestradiol ratios. Flax seed also has been shown to reduce total and LDL cholesterol levels, and also supports oestrogen elimination through the gastrointestinal tract. Foods high in fibre also support the elimination of oestrogen in this manner. Sesame seed powder also has been shown to increase SHBG and urinary 2-hydroxyestrone. By increasing SHBG more hormone will exist as bound, and is thus less active.
Phipps WR, et al. Effect of flax seed ingestion on the menstrual cycle. J Clin Endocrinol Metab. 1993 Nov;77(5):1215-9. http://tinyurl.com/nw6sm5l
Wu WH, et al. Sesame ingestion affects sex hormones, antioxidant status, and blood lipids in postmenopausal women. J Nutr. 2006 May;136(5):1270-5. http://tinyurl.com/oybefx8
Bierenbaum ML, et al. Reducing atherogenic risk in hyperlipemic humans with flax seed supplementation: a preliminary report. J Am Coll Nutr. 1993 Oct;12(5):501-4. http://tinyurl.com/zeuoha4
Flax and/or sesame can be added to foods, or a smoothie, but I do find it is important to emphasize that it be an adequate amount particularly when it is being used therapeutically. I encourage patients to have a dedicated coffee grinder for this purpose. Seeds should be freshly ground, or at least not left to sit more than a day or two. I often fill a coffee grinder & use that amount for the next couple days for simplicity.
A subsequent test that you may want to consider in the future to further assess hormone and adrenal function is the DUTCH complete hormone test from Precision Analytical – http://tinyurl.com/p34ek4l – which is now available from Regenerus Labs. This is a urine test, which includes 4 urinary samples for cortisol and melatonin profiling. This test not only looks as levels of the main hormones such as oestrogen, testosterone, and DHEA, but also their metabolites. I have used this test for more complex hormone assessment and find that it is much more informative than other hormone tests. The support provided by the company for assessment of testing results is also superb. There also is a resource they have developed to show the pathways of hormone metabolism and how factors such as herbs, insulin, and stress may affect these pathways. It is very useful and I refer to it often. It can be found here – http://tinyurl.com/p5s6swv.
Sleep apnoea is more common in individuals with PCOS, and with considerable daytime fatigue this should be considered, and possibly assessed for. In a study of 53 women with PCOS compared with 452 premenopausal controls, obstructive sleep apnoea and excessive daytime sleepiness (diagnosed by an overnight sleep study or written questionnaire) were significantly more common in the PCOS group. The odds ratio for obstructive sleep apnoea was 30.6 while for excessive daytime sleepiness it was 9.0, which show that in this population there is a very high rate of these additional issues occurring. These differences existed even when controlled for BMI, and were most strongly related to insulin resistance.
Vgontzas AN, et al. Polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness: role of insulin resistance. J Clin Endocrinol Metab. 2001 Feb;86(2):517-20. http://tinyurl.com/p8d7v6y
A garum armoricum Ling-fish-based food concentrate has been shown to balance adrenal function or dysregulated HPA function under stress as well as supporting mood and sleep. This food concentrate (http://tinyurl.com/pntrrf4) contains polypeptides that act as precursors to neurotransmitters such GABA, encephalins and endorphins. They can exert a regulatory effect on the nervous system, potentially enabling the organism to adapt to stressful conditions. It also contains the essential omega-3 fatty acids, DHA and EPA. These are precursors of the prostaglandins and prostacyclins, cellular chemical mediators which help regulate the main biological functions of the body, including the noradrenergic functions of the central nervous system. I have found this as a supplement to be very useful for balancing the adrenal axis, supporting a reduction in perceived stress and thus improving anxiety, sleep, and energy levels.
I also like to work with lipoic acid and/or N-acetylcysteine when I support patients with PCOS. Lipoic acid is a “master antioxidant” which supports regeneration of other antioxidants in the body, and has much research concerning its use in diabetic patients for the purpose of improving insulin sensitivity as well as peripheral neuropathy symptoms. Fasting blood glucose and insulin sensitivity have been shown to be significantly improved, and menstrual cycle regularity in women with PCOS (an incidental finding) was also improved with lipoic acid treatment after 8 – 16 week interventions in different studies. Dosages of lipoic acid shown to be most effective for these purposes were between 300 – 1200 mg daily.
Masharani U, et al. Effects of controlled-release alpha lipoic acid in lean, nondiabetic patients with polycystic ovary syndrome. J Diabetes Sci Technol. 2010 Mar 1;4(2):359-64. http://tinyurl.com/kk3sgel
Ansar H, et al. Effect of alpha-lipoic acid on blood glucose, insulin resistance and glutathione peroxidase of type 2 diabetic patients. Saudi Med J. 2011 Jun;32(6):584-8. http://tinyurl.com/kwy3g6c
Jacob S, et al. Oral administration of RAC-α-lipoic acid modulates insulin sensitivity in patients with type-2 diabetes mellitus: a placebo-controlled pilot trial. Free Radic Biol Med. 1999 Aug;27(3-4):309-14. http://tinyurl.com/lr5gzt6
N-acetylcysteine (NAC), another antioxidant, has also been shown to be useful in improving ovulation rate and insulin resistance in women with PCOS. Inositol is another nutritional supplement which also has been shown to have the effect of improving various markers in individuals with PCOS including ovulation, insulin sensitivity, and androgen levels.
Oner G, Muderris II. Clinical, endocrine and metabolic effects of metformin vs N-acetyl-cysteine in women with polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol. 2011 Nov;159(1):127-31. http://tinyurl.com/pek22l6
Sacchinelli A, et al. The Efficacy of Inositol and N-Acetyl Cysteine Administration (Ovaric HP) in Improving the Ovarian Function in Infertile Women with PCOS with or without Insulin Resistance. Obstet Gynecol Int. 2014;2014:141020. http://tinyurl.com/p9dfmqc
Iuorno MJ, et al. Effects of d-chiro-inositol in lean women with the polycystic ovary syndrome. Endocr Pract. 2002 Nov-Dec;8(6):417-23. http://tinyurl.com/nkun5lx
Unfer V, et al. Effects of myo-inositol in women with PCOS: a systematic review of randomized controlled trials. Gynecol Endocrinol. 2012 Jul;28(7):509-15. http://tinyurl.com/nycksnf
Endothelial dysfunction has also been shown in individuals with PCOS. Dietary agents such as flavonoids (found at high levels in foods such as berries and cocoa) and the antioxidant lipoic acid have been shown to improve endothelial function. Blueberries also support healthy blood sugar metabolism, and thus I encourage them as a fruit in this population.
Sprung VS, et al. Endothelial function measured using flow-mediated dilation in polycystic ovary syndrome: a meta-analysis of the observational studies. Clin Endocrinol (Oxf). 2013 Mar;78(3):438-46. http://tinyurl.com/nn4xd4n
Rodriguez-Mateos A, et al. Intake and time dependence of blueberry flavonoid-induced improvements in vascular function: a randomized, controlled, double-blind, crossover intervention study with mechanistic insights into biological activity. Am J Clin Nutr. 2013 Nov;98(5):1179-91. http://tinyurl.com/nytvj4f
Heiss C, et al. Sustained increase in flow-mediated dilation after daily intake of high-flavanol cocoa drink over 1 week. J Cardiovasc Pharmacol. 2007 Feb;49(2):74-80. http://tinyurl.com/nc7c5r4
Sola S, et al. Irbesartan and lipoic acid improve endothelial function and reduce markers of inflammation in the metabolic syndrome: results of the Irbesartan and Lipoic Acid in Endothelial Dysfunction (ISLAND) study. Circulation. 2005 Jan 25;111(3):343-8. http://tinyurl.com/o4z3xmj
The following supplements are suggested for you to consider in light of your relevant expertise and understanding of the needs of your client or patient. They may be used in isolation or as part of a multi supplement strategy, but at all times the consideration of their use should be tied into the specific needs of the individual you are responsible for.
Flax seed, freshly ground: 2 Tbsp/day in first half of cycle.
Sesame seed, freshly ground: 2 Tbsp/day in second half of cycle (roughly days 15 – 30).
Meda Stim (BRC): 1 – 2 caps with breakfast & dinner. http://tinyurl.com/k79e25h Nutrient support for thyroid function. Includes iodine and selenium.
ALA Release (ARG): Gradually increase up to 3 capsules twice a day. http://tinyurl.com/n7fl8l7
Lipoic Acid Plus (BRC): 3 capsules twice daily with food. Each capsule provides 100 mg of alpha lipoic acid with 50 mg of vitamin C. http://tinyurl.com/njz6kv5
NAC Enhanced Antioxidant Formula (ARG): 1 tablet three times daily. http://tinyurl.com/p2o6k85 Provides NAC and lipoic acid.
For support of response under stress consider:
Stabilium® 200 (ARG): 4 capsules once daily on an empty stomach for 4 weeks, decreasing to 2 -3 capsules after this. http://tinyurl.com/pm5ou44 Garum armoricum concentrate that reduces anxiety response under stress.
Casein Concentrate (BRC)(formerly De-Stress): 1 caps twice daily. http://tinyurl.com/ax5t7vp
Please consider these suggestions in light of the other clinical information pertaining to this individual. If you have any more information about the specific problems this individual is experiencing, further refinement of these suggestions may be considered. I hope this information is helpful, and if you have any further questions or information specific to the problems this individual is experiencing, please do provide feedback.
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